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Trauma care systems deal with patients who have an infinite variety of injuries requiring complex treatment. The assessment of such systems is a major challenge in clinical measurement and audit. Which systems are most effective in delivering best outcomes? Implementing recommendations for improved procedures will often incur additional costs – will the expense be worthwhile? Clearly, case-mix-adjusted outcome analysis must replace anecdote and dogma. Outcome prediction in trauma is a developing science that enables the assessment of trauma system effectiveness. This chapter will review some of the commonly used scoring systems and their particular applications in patients with traumatic brain injury.
Improving medical record keeping is a key part of the World Health Organization’s (WHO’s; Geneva, Switzerland) drive to standardize and evaluate emergency medical team (EMT) response to sudden onset disasters (SODs).
In response to the WHO initiative, the UK EMT is redeveloping its medical record template in line with the WHO minimum dataset (MDS) for daily reporting. When changing a medical record, it is important to understand how well it functions before it is implemented.
The redeveloped medical record was piloted at a UK EMT deployment course using simulated patients in order to examine ease of use by practitioners, and rates of data capture for key MDS variables.
Some parts of the form were consistently poorly filled in, and the way in which the form was completed suggested that the flow of the form did not align with the recorder’s natural thought processes when under pressure.
Piloting of a single-sheet triplicate medical record during an EMT deployment simulation led to significant modifications to improve data capture and function.
Jafar AJN, Fletcher RJ, Lecky F, Redmond AD. A pilot of a UK emergency medical team (EMT) medical record during a deployment training course. Prehosp Disaster Med. 2018;33(4):441–447.
Medical records are a tenet of good medical practice and provide one method of communicating individual follow-up arrangements, informing research data, and documenting medical intervention.
The objective of this review was to look at one source (the published literature) of medical records used by foreign medical teams (FMTs) in sudden onset disasters (SODs). The published literature was searched systematically for evidence of what medical records have been used by FMTs in SODs.
The style and content of medical records kept by FMTs in SODs varied widely according to the published literature. Similarly, there was great variability in practice as to what happens to the record and/or the data from the record following its use during a patient encounter. However, there was a paucity of published work comprehensively detailing the exact content of records used.
Without standardization of the content of medical records kept by FMTs in SODs, it is difficult to ensure robust follow-up arrangements are documented. This may hinder communication between different FMTs and local medical teams (LMTs)/other FMTs who may then need to provide follow-up care for an individual. Furthermore, without a standard method of reporting data, there is an inaccurate picture of the work carried out. Therefore, there is not a solid evidence base for improving the quality of future response to SODs. Further research targeting FMTs and LMTs directly is essential to inform any development of an internationally agreed minimum data set (MDS), for both recording and reporting, in order that FMTs can reach the World Health Organization (WHO) standards for FMT practice.
JafarAJN, NortonI, LeckyF, RedmondAD. A Literature Review of Medical Record Keeping by Foreign Medical Teams in Sudden Onset Disasters. Prehosp Disaster Med. 2015;30(2):1-7.
In the UK, hen harriers (Circus cyaneus) are illegally killed on moorland that is managed for red grouse (Lagopus lagopus scoticus), and they produce fewer young per female on grouse moorland than on either unmanaged moorland or forestry. However, those breeding attempts on grouse moorland that escape nest destruction produce more young than in other land-use classes. One explanation for this difference is that food is more available to harriers on managed moorland than elsewhere. To examine this hypothesis, we compared the capture rates of hunting male harriers on sites across Scotland. Four of these sites were managed for grouse whilst the remaining three consisted of either unmanaged moorland or a mixture of unmanaged moorland and young forestry plantations. We found a significant difference in capture rates, with harriers on managed grouse moorland capturing prey at a greater rate than elsewhere, supporting the idea that prey were more available on grouse moorland. However, there was no difference in strike rates between the land-use classes, suggesting that prey were not necessarily more abundant on grouse moors. Males on unmanaged moorland tended to catch larger prey, though this was insufficient to compensate fully for the reduced capture rates. The improved hunting success on grouse moorland means that this habitat is likely to be more attractive to breeding harriers, thereby increasing the conflict between those interested in maximizing grouse numbers and those interested in conserving rare raptors.
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