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Problem Statement: Staff turnover and lack of standardized processes led to missing documentation and inefficient management of trauma patients. The RNs in the ED at HFWH need education, support, consistency, and prompt feedback to ensure high quality trauma care that meets American College of Surgeons (ACS) national benchmarking standards. In previous years, overall trauma documentation for vital signs and GCS were below the national trauma standard of 90% and trauma processes were not hard wired into everyday practices.

Goals: To establish high reliability and improve trauma patient care by developing a structured approach to improve trauma documentation and the overall management of injured patients of all ages in the downriver community. This is an ongoing project which was revised in collaboration with Trauma and ED Nursing Leadership. Continue to require all new ED RNs to participate in a Trauma orientation session with the Trauma PI Coordinators. Provide ongoing education through education days, bimonthly huddles, feedback letters, bedside support, and the involvement of the ED Trauma Champions team. Improve the documentation compliance for vital signs and GCS to ≥ 90% by the end of 2023. Continue to require the use of the trauma activation checklist to help improve required documentation and standardize trauma care in the ED.

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Henry Ford Health


Detroit, Michigan


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Project #42: Improving Documentation for Trauma Patients in the Emergency Department



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