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Project Scope and Plan (PSP

)

General Information:
Project name: _Improving Trauma Documentation in the ER______________
Project Manager Name: _Holly Leveille______________________________
Site: _North Ottawa Community Hospital (NOCH)_Location:_Grand Haven, MI____

Project Overview: Describe the product or service of the project, the reason project will be
undertaken, and the purpose of the project. Discuss the problem or opportunity this project
addresses. Include the quality and safety issue this project will address. Support with current
evidence-based practice literature or data specific to the project.

Patients must receive optimal care during their critical “golden hour,” therefore adult and
pediatric triage and transport guidelines must be established on a statewide level. Data is
collected and entered into a statewide trauma data bank through a program called ImageTrend,
which then feeds into the National Trauma Data Bank. The State of Michigan requires that
every hospital, throughout the state, enter trauma that meet certain criteria into ImageTrend.
Each hospital in Michigan will undergo an inspection and required training for their American
College of Surgeons (ACS) Trauma Program certification rating. If NOCH does not meet
certain criteria, we will have to divert every ambulance that is carrying a trauma patient, which
could have a long term financial consequence for our small community hospital.

Problem:
Emergency department nurses continually struggle to properly chart during major trauma
resuscitations (Wilshaw, Day, & Hansen, 2000). Currently our hospital is in need of
improvement of our trauma documentation, especially in the area of documenting a Glasgow
Coma Scale (GCS) and in maintaining accurate times.

Patients that are logged into the statewide trauma data bank and National Trauma Data Bank
must have a GCS documented along with the time the injury occurred, the time the patient
presented to the emergency room, along with the time every test was performed.

Nurses currently document Priority 1 (emergency) traumas on paper form and while other
injuries or traumas are documented electronically. On the paper form there is a place for GCS
documentation and a place for times of procedures and tests. When documenting electronically
the “GCS” is not a triggered box or indicator to document, which leaves GCS forgetting to be
documented. Also, current process has the unit clerk or nurse manually advancing the status of
the patient, such as when the patient leaves the department for a test or when the patient is ready
for the doctor to reassess them. There are times when the status is not updated reguarly.

Improving patient outcomes:
By collecting patient data, gathering GCS, and accurate times, our ER will be able to compare
ourselves with other ER’s of similar size and ACS ratings. We can take our data gathered and
compare it to evidence based studies to see what and where we need to improve ourselves. This
will benefit the patient in the long run and definitely improve the patients “golden hour.”

B. Project Goal(s): Describe the project goal(s) using SMART (specific, measurable, accurate
and agreed to, realistic, and time bound) formula. These goals will be used to measure and
determine the project’s success at its conclusion.

1) The nurses at NOCH ER will document a Glasgow Coma Scale on 40% of cases that are
reportable to the statewide trauma data bank and National Trauma Data Bank by July 27,
2014. This will be measured in the program ImageTrend during a chart review.
2) The emergency room charts included in the statewide trauma data bank and National
Trauma Data Bank will have consistent times for procedures. Nurses and unit techs will
work together to keep the times accurate by July 27, 2014. These can be measured by
comparing times of actual procedures in other departments to documented times in the
ER.

C. Project Objectives/Deliverables: List the specific items or services that must be produced in
order to fulfill the goal of the project. Objectives/deliverables should be measurable results,
measurable outcomes or specific products or services. List and number in a logical order to
complete the project.

1) Glasgow Coma Scale (GCS)
a. Meet with Meditech information systems RN by June 15, 2014
b. Provide education to coworkers in ER on why it is important to log GCS on any
and all injuries (or possibly all patients) by July 1, 2014
c. Beginning logging data into ImageTrend software to track data for the statewide
trauma data bank and National Trauma Data Bank by July 1, 2014
2) Accurate times
a. Provide education to department on what data collection is and why accurate
times are important by July 1, 2014
b. Meet with department manager to develop a strategy to improve accurate times by
June 15, 2014

D. Comprehensive List of Project Requirements/Activities/Tasks: List by corresponding
objective the necessary specifications of the objective/deliverable. Example 1.1, 1.2, 1.3, 1.4, etc
This is a breakdown of the objectives/deliverables into their most basic components. Consider
this the action plan of the project.

1.a.1-Call Deb Macomber and schedule a meeting
1.a.2-Put together a handout for Deb explaining project
1.a.3-Determine what can be done with Meditech

1.b.1-Gather current trauma sheet and highlight where GCS is documented
1.b.2-Take info from 1.a.3 and apply here
1.b.3-Send email to coworkers with managers support and put together a poster on GCS and why
it needs to be documented

1.c.1-Meet with ER manager to determine when hours are available to start logging trauma data
into website
1.c.2-Start gathering data immediately on how many patients currently have GCS documented

2.a.1-Gather articles on data collection, National Trauma Data Registry, ACS certification
2.a.2-Show what our current data shows with inaccuracy (times)
2.a.3-Poster on accurate times (possible with GCS?) for the staff

2.b.1-Meet with Janee to determine what methods should be used to communicate with unit techs
and nurses
2.b.2-Brainstorm ideas

E. Timeline: Identify time estimates by hours for each objective/deliverable in hours. These are
estimates only and will be updated as project progresses.

1) Glasgow Coma Scale (GCS)
a. Meet with Meditech information systems (2 meetings @ 2 hours a piece)
b. Provide education to coworkers in ER on why it is important to log GCS on any
and all injuries (or possibly all patients) (6 hours prep time, 2 hours presentation
time)
c. Beginning logging data into ImageTrend software to track data for the statewide
trauma data bank and National Trauma Data Bank (20 hours/week)
2) Accurate times
a. Provide education to department on what data collection is and why accurate
times are important (10 hours prep time, 2 hour presentation)
b. Meet with department manager to develop a strategy to improve accurate times (4
meetings @ 2 hours a piece)

F. Assumptions & Constraints: Identify all project assumptions and constraints.

Assumptions:
 GCS
o IT will be able to add a GCS checkbox to the mandatory documentation for nurses
for all patients
o Nurses will now have to document GCS on all patients when documenting
electronically
o Nurses will have to document GCS on patients when documenting on paper
 Times
o Unit techs will be required to update the tracker board
o If the unit tech is unable to update the tracker board then it is the nurses
responsibility to update the tracker board on the patient’s status
Constraints:
 Budget
o In order to start logging data into ImageTrend, a position needs to be created.
Currently 2 employees are trained in our ER department to enter data. One
employee is full-time and I am part-time. Our manager is working on getting
additional FTE’s approved to allow this to go through within the next week.

 Quality
o All data that is entered into the ImageTrend website for data collection must be
accurate and concise. If both employees are entering data that is different, the
data will not be accurate and produce usable results.

G. Success Criteria: Provide the “value” of the project. Why is this project important and of
what benefit it is? What impact will it have on client care and client outcomes including aspects
related to quality and safety? How will you know if the project was a success? Support with
evidence-based literature or nursing data.

Emergency nurses are responsible for initial and ongoing patient assessment (Considine, Potter,
& Jenkins, 2006), this includes recording an initial mental status on a patient. Many times
patients can experience delays while waiting to be seen for a physician. It is the nurses’
responsibility to continually monitor patients for changes. Facilities that see a large number of
traumas have the abilities to use electronic medical records (EMR’s) successfully, however our
facility does not have the large frequency of trauma patients, therefore we are better off
documenting on paper.

The data that is required by the State of Michigan to be entered into the trauma website is
required for American College of Surgeons for trauma center certification. If our hospital does
not receive a certification, our financial reimbursement from insurance companies could be
affected. In order to get this certification, our ED physicians will all undergo Advanced Trauma
Life Support and our ED nurses will all have to have Trauma Nurse Core Course’s also. Some
of the data that is monitored by the trauma website that our hospital is currently scoring low on is
Glasgow Coma Score documentation and inconsistencies in procedure times.

Project Success:
This project’s success will be measured by looking at data gathered in ImageTrend. I will be
gathering measurable data on the amount of patients that are entered into the system that have
documented GCS scores documented. I will also be gathering subjective data on how easy it is
to gather time collection data on procedures that are performed in the emergency room.

H. Signatures: (no electronic signatures)

Project Manager:_Janee Carney_____________________________________

Nurse Manager/Supervisor/________________________________________
Phone: 616-844-4503 email: jcarney@noch.org


Considine, J., Potter, R., & Jenkins, J. (2006). Can written nursing practice standards improve
documentation of initial assessment of ED patients?. Australasian Emergency Nursing
Journal, 9(1), 11-18.


Curtis, K., Murphy, M., Hoy, S., & Lewis, M. (2009). The emergency nursing assessment
process---a structured framework for a systematic approach. Australasian Emergency
Nursing Journal, 12(4), 130-136. doi:10.1016/j.aenj.2009.07.003
D'Huyvetter, C., Lang, A. M., Heimer, D. M., & Cogbill, T. H. (2014). Efficiencies Gained by
Using Electronic Medical Record and Reports in Trauma Documentation. Journal Of
Trauma Nursing, 21(2), 68-71. doi:10.1097/JTN.0000000000000031
Wilshaw, R., Day, S., & Hansen, K. (2000). Sharing our best: designing a trauma flow sheet.
Journal Of Trauma Nursing, 7(3), 58-63.