Date of Publication


Project Team

Academic Advisor: Stuart Whitney, Ed.D., RN, CNL; Agency Mentors: Jessica Cullen, RN, CEN & Javad Mashkuri, MD


Purpose: Poor trauma documentation has negative consequences on continuity of care, results in errors related to treatment, and yields increased time to order completion2, 3. Nursing staff at a community hospital emergency department (ED) expressed frustration when utilizing the existing trauma flow sheet. The purpose of this project was to redesign and implement an evidence-supported emergency department trauma flow sheet for efficient and comprehensive documentation of trauma encounters.

Methods: A new trauma flow sheet was developed through a focus group session and semi-structured interviews. A PDSA model for improvement was introduced to facilitate future initiatives to improve trauma documentation and workflows. Qualitative thematic analysis was the primary method of analysis, while descriptive statistics and frequencies were utilized to report data related to the operationalization efforts of the project.

Results: Nearly 29% of nursing staff and 72% of provider staff participated in the iterative process (n=28). The five most frequent themes from the focus group included: recommendations, standard of care, ease of use, use patterns, and foresight. The trauma flow sheet was adopted into clinical practice on January 1st, 2020.

Conclusions: An interprofessional approach of seeking, analyzing, and presenting stakeholder input is an effective strategy for the development of documentation tools. The introduction of the PDSA model for improvement allows for future improvements to trauma documentation and care to be sustained. Implications for practice related to this project include: mitigation of cumbersome documentation, opportunities for cognitive offloading, and empowerment of stretcher-side nurses to lead critical scenarios in the ED1.

Document Type