TY - JOUR
T1 - Documentation of paediatric head injuries in a mixed metropolitan emergency department
AU - Lee, Sean Shi-Jie
AU - Manivel, Vijay
AU - Vignakaran, Suganya
AU - Hochholzer, Karina
AU - De Alwis, Chamila
AU - Espinoza, David
AU - Teo, Stephen Sze Shing
PY - 2022
Y1 - 2022
N2 - 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 ≥1Â 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 <1Â 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.
AB - 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 ≥1Â 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 <1Â 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.
UR - https://hdl.handle.net/1959.7/uws:69406
U2 - 10.1111/1742-6723.13967
DO - 10.1111/1742-6723.13967
M3 - Article
SN - 1742-6731
VL - 34
SP - 738
EP - 743
JO - Emergency Medicine Australasia
JF - Emergency Medicine Australasia
IS - 5
ER -