電子期刊 |
ISSN:1684-193X
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Updated
Feb 25, 2003
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Contents:
Volume 1, Nomber 2; Jan, 2003 |
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Preliminary
Pre-Hospital Use of Personal Digital Assistance-Based EMT Pre-Hospital
Patient Care Records (PCR) |
Tzong-Luen Wang, MD, PhD and Hang Chang, MD, PhD |
From the Department of Emergency Medicine(Wang
TL, Chang H), Shin-Kong Wu Ho-Su Memorial Hospital.
Correspondence to Dr. Hang Chang, Department
of Emergency Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95
Wen Chang Road, Taipei, Taiwan. E-mail M001043@ms.skh.org.tw
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Abstract
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To investigate if the use of personal
digital assistance (PDA) with wireless transmission could provide
more pre-hospital information before arrival to the emergency departments,
we implemented the PDA system with wireless transmission and web-based
recording system in the EMS of Taipei City since August 1st 2002.
All pre-hospital records were posted in PDA software. The PDA was
hanged on the legs of the EMTs. The time elapse from information
received to the arrival to the ER was recorded. The completeness
of pre-hospital recording was evaluated by two independent physicians.
In addition, a questionnaire for EMTs was used to evaluate the possible
difficulties in PDA use. There were 145 pre-hospital records enrolled
in the study. Sixty eight records were posted in PDA files whereas
the other 77 records were listed as traditional method. Among the
cases used with PDA recordings, the mean time interval between the
information received in our institute and arrival to hospital was
1.6+0.3 min. Eight of the 68 files (12%) were incomplete,
especially the recording of vital signs (6/8, 75%). On the other
hand, 9 of the 77 traditional records were incomplete (12%, P=NS
vs. PDA files). According to the questionnaire, lack of personnel
operating the PDA (28/35, 80%) and unfamiliarity with PDA processing
(22/35, 63%) were the main factors affecting the completeness of
PDA files. PDA-based EMT pre-hospital recording may have the benefit
of early information received before arrival to the hospital. More
humanistic design may be needed to promote the use of the system
and its efficiencies. (Ann Disaster Med. 2003;1:97-103)
Key words: Emergency Medical Technician; Personal Digital Assistance;
Prehospital care |
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Introduction
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To establish well-defined prehospital
medical records, prehospital personnel such as paramedics, emergency
medical technician (EMT) and first responders shall manage the medical
care of the patient within their scope of practice and in coordination
with all other responding personnel. They should provide patient
care according to the EMS Section treatment protocols appropriate
for the level of care of the responder. In the United States, an
approved prehospital patient care record (PCR) would be completed
by each prehospital provider agency for each response.1 The individual
evaluating the patient’s condition and providing emergency care
shall complete the PCR.1 The report is to be distributed as follows:
medical record as an original top copy (legal document) to be retained
by the provider agency; provider copy to be retained by provider
agency for billing and/or quality assurance purposes; and hospital
copy that forward with the patient to hospital for inclusion in
the patient’s chart. If the PCR is incomplete at the time of transport
and/or arrival at the hospital, the provider must complete the PCR
and take to the receiving hospital before the end of their shift.
With the advancement of electronic medical records, a well-informed
clinician or a emergency medical technician (EMT) can respond to
specific patient needs in a knowledge fashion and may therefore
avoid possible errors such as those in recording.1 Portable devices
such as personal digital assistance (PDA) may further assist the
receiving hospitals and physicians to access all available information
including patients’ data and drug database before arrival. We therein
evaluated the adequacies of PDA software in pre-hospital EMT recordings
in Taipei city. |
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Methods |
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We implemented the PDA system with
wireless transmission and web-based recording system in the EMS
of Taipei City since August 1st 2002. All pre-hospital records that
had been presented in the traditional form were posted in PDA software.
In detail, the record forms were displayed in 4 different pages
and included the items such as call date and time, identification
of the EMS agency/vehicle, patient identification, pertinent history
of present illness/injury, relevant past medical history, chief
and associated complaints, patient assessment findings, care rendered
before arrival, clinical observations including responses to interventions,
rescue/extrication information for trauma patients, facts supporting
the intensity of the patient evaluation and treatment, including
thought processes and the complexity of medical decision making,
legible signatures and names of medical control personnel, communication
method, notation of other agencies on scene.
The PDA was hanged on the legs or around the waists of the EMTs.
The time elapse from information received to the arrival to the
ER was recorded. Two independent physicians evaluated the completeness
of pre-hospital recording. In addition, a questionnaire for EMTs
was used to evaluate the possible difficulties in PDA use. |
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Results |
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There were 145 pre-hospital records
enrolled in the study. Sixty eight records were posted in PDA files
whereas the other 77 records were listed as traditional method.
Among the cases used with PDA recordings, the mean time interval
between the information received in our institute and arrival to
hospital was 1.6+0.3 min. Eight of the 68 files (12%) were
incomplete, especially the recording of vital signs (6/8, 75%).
On the other hand, 9 of the 77 traditional records were incomplete
(12%, P=NS vs. PDA files). According to the questionnaire, lack
of personnel operating the PDA (28/35, 80%) and unfamiliarity with
PDA processing (22/35, 63%) were the main factors affecting the
completeness of PDA files. PDA-based EMT pre-hospital recording
may have the benefit of early information received before arrival
to the hospital. More humanistic design may be needed to promote
the use of the system and its efficiencies. |
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Discussion |
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Emergency department (ED)-based
surveillance offers a way to collect data on those consulting the
ED. The completeness of data collection should include pre-hospital
medical records. Establishing a hospital ED surveillance system
has several advantages for corresponding research. 1
First, because the incidence of ED-treated events is substantially
greater than the incidence of fatal episodes, ED surveillance systems
are extremely useful in monitoring pre-hospital management, detecting
event clusters, and serving as endpoints of evaluation studies where
the occurrence of more severe injuries would be too rare. 2
Second, the ED is usually the first place a patient visits after
an acute event. Therefore recall of the external cause of the event
is likely to be more accurate at the ED than it is later in the
treatment process. On the other hand, the minimum data required
for out-of-hospital documentation should accordingly include the
following: call date and time, identification of the EMS agency/vehicle,
patient identification, pertinent history of present illness/injury,
relevant past medical history, chief and associated complaints,
patient assessment findings, results of diagnostic tests such as
capillary glucose readings and EKG rhythm if possible, care rendered
before arrival, any hospital-generated orders, clinical observations
including responses to interventions, which are as important as
the intervention itself, final disposition and estimated time of
arrival, mechanisms of injury, Glasgow Coma Scale score, and trauma
scores; rescue/extrication information for trauma patients, facts
supporting the intensity of the patient evaluation and treatment,
including thought processes and the complexity of medical decision
making, legible signatures and names of medical control personnel,
communication method, notation of other agencies on scene (i.e.,
police). 3
PDA-based PCR provides at least two benefits to hospitals. First,
it requires personnel at EDs to collect and maintain certain data
elements on all patients, including patient identification, time
and means of arrival, relevant history, prehospital care, diagnosis,
tests ordered, and disposition. 4 The
PDA is designed to meet the requirement, and all essential pre-hospital
data are included. Second, hospitals can use the system for quality-improvement
activities. 5-9 For example, case load
may be determined by provider, diagnosis, outcome, and demographic
characteristics of patients. A well-documented Ustein style survey
may also be established. 10
However, the PCR should be met with the following criteria: 11,12
1) Factual: The log should chronicle objective information reported
by emergency medical technicians (EMTs)--what they observe about
the scene, glean from their assessment, or treatments rendered to
the patient. Resist the impulse to speculate, judge character, or
to label behaviors by using slang or demeaning statements abbreviated
as code initials (such as TNT or PRH). On the other hand, using
appropriate medical abbreviations increases the amount of information
that can be noted in a limited space and in the short time span
taken by most telemetry calls. Charting generally should maintain
a sense of profession detachment. 2) Accurate: Even factual records
will be subject to scrutiny if they look inaccurate or unreliable.
During the discovery period, attorneys from both sides will examine
all charts or logs and compare the actual notations to written standards.
Every word and time frame may be meaningful. Inaccurate or incomplete
entries, without just cause, diminish the reliability of the record.
3) Complete: The communications log should stand alone as a chronologic
recording of all out-of-hospital events. It is helpful if boxes
are present that allow quick checkmarks noting either "within
normal limits" or other locally customized notations suggesting
a pathologic condition (nausea, vomiting, cough, etc.) Equally helpful
are check boxes for routine assessments, such as quantification
of pain, pupil size and reactivity, breath sounds, skin color, temperature,
moisture, level of consciousness, Glasgow Coma Scale scores and
trauma scores. Forms constructed to facilitate quick notations of
care rendered in the field, destination, and estimated time of arrival
are also beneficial provided local protocols define the applicable
standards of practice. 4) Timely: The EMT should document as much
as possible during the run. 7 If this
cannot be done contemporaneously, jot down shorthand notes so that
details remain fresh until you can finish the record. All vital
signs, rhythm interpretations, assessments, and out-of-hospital
interventions should be timed unless local protocols indicate otherwise.
In this study, lack of personnel operating the PDA (28/35, 80%)
and unfamiliarity with PDA processing (22/35, 63%) were the main
factors of incompleteness of PDA files. Besides personal training
in exercising the PDA, adequate arrangement of personnel in ambulances
and improvement in imputing mode of PDA may another measures in
resolving the problem.
In our study, the limitations of PDA-based PCR include the following
three. First, data were not entered while the patient was in the
ED as the PCR was originally designed. This means that the additional
information not contained in the logbook was written down and subsequently
entered into the computer. Second, the PCR is used without any communication
to other hospital information systems and still cannot be merged
into a part of the hospital medical chartings. Finally, these were
just preliminary results and more large-scale data would be needed
to ascertain the role of PDA in pre-hospital EMT medical recordings.
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References |
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1. |
Garrison HG, Runyan CW, Tintinalli JE, et al. Emergency
department surveillance: An examination of issues and a proposal for
a national strategy. Ann Emerg Med 1994;24:849-56 |
2. |
Schootman M, Zwerling C, Miller E, et al. Method to Electronically
Collect Emergency Department Data. Ann Emerg Med 1996;28:213-9 |
3. |
Mattera CJ. Principles of EMS Documentation for Mobile Intensive
Care Nurses. J Emerg Nursing 1995;21:231-7 |
4. |
Joint Commission on Accreditation of Healthcare Organizations:
Accreditation for Hospitals. Chicago, 1988 |
5. |
Fowler DL, Hogle NJ, Martini F, Roh MS. The use of a personal
digital assistant for wireless entry of data into a database via the
Internet. Surg Endosc 2002;16:221-3 |
6. |
Bird SB, Zarum RS, Renzi FP. Emergency medicine resident patient
care documentation using a hand-held computerized device. Acad Emerg
Med 2001;8:1200-3 |
7. |
PDA response: electronic records; electronic signatures. Parenteral
Drug Association. PDA J Pharm Sci Technol. 1995;49:207-11 |
8. |
8. Wang TL, Chang H. Benefits of personal digital assistance in
decreasing prescribing errors: preliminary experience from a tertiary
care hospital. Ann Disaster Med 2002;1:20-8 |
9. |
Carroll AE, Saluja S, Tarczy-Hornoch P. Development of a Personal
Digital Assistant (PDA) based client/server NICU patient data and
charting system. Proc AMIA Symp 2001:100-4 |
10. |
Gallagher EJ, Lombardi G, Gennis P. Cardiac arrest witnessed by
prehospital personnel: intersystem variation in initial rhythm as
a basis for a proposed extension of the Utstein recommendations. Ann
Emerg Med 1997;30:76-81 |
11. |
Anderson CW. Patient-care documentation. Emerg Med Serv. 1999;28:59-62 |
12. |
Balaban D. Data entry on the run. Health Data Manag. 1998;6:49-50 |
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