Documentation of paediatric head injuries in a mixed metropolitan emergency department. (5th April 2022)

• Record Type: Journal Article
• Authors: Lee, Sean Shi‐Jie; Manivel, Vijay; Vignakaran, Suganya; Hochholzer, Karina; De Alwis, Chamila; Espinoza, David; Teo, Stephen Sze Shing
• Is Part Of: Emergency medicine Australasia. Volume 34:Number 5(2022)
• Page Start: 738
• Page End: 743
• Publication Date: 2022-04-05
• Subjects: documentation -- emergency services -- head injuries -- hospital -- medical transcription -- paediatric emergency medicine; Emergency medicine -- Periodicals; Emergency medicine -- Australasia -- Periodicals; 616.025
• DOI: 10.1111/1742-6723.13967
• Languages: English
• ISSNs: 1742-6731

Abstract

Abstract: Objective: Head injuries are a common presentation of children to Australian EDs. Healthcare documentation is an important tool for enhancing patient care. In our study, we aimed to assess the adequacy of paediatric head injury documentation in a mixed ED. Methods: A retrospective analysis of presentations to a mixed ED between 2017 and 2018. Children aged <16 years old with a primary diagnosis of head injury were included. Documentation items based on local head injury guidelines were assessed in both medical and nursing documentation. We compared cases aged <1 and ≥1 year. Results: There were 427 presentations that met the case definition. Medical documentation was present in 422 cases and nursing documentation in 310 cases. In combined medical and nursing documentation, items poorly documented include blood pressure (BP; 21.3%) and secondary survey (16.9%). In solely medical documentation, least commonly documented items are high‐risk bony injuries (22.5%), high‐risk soft tissue injuries (22.3%), seizure (22.0%) and non‐accidental injury (3.6%). Glasgow Coma Scale (GCS) was poorly documented in cases aged <1 year (10.9%, P < 0.001). Conclusions: The largest gaps in the documentation of paediatric head injuries were BP and paediatric GCS in infants. Future audits and educational strategies should focus on targeting clinically relevant items that are predictive of serious outcomes. Abstract : This retrospective analysis of paediatric head injury presentations in a mixed ED over a 12 month period aimed at evaluating the adequacy of documentation. We demonstrated that the largest gaps in documentation were blood pressure and paediatric GCS in infants, and future research should target clinically relevant items that are predictive of serious outcomes.