Document Type
Conference Proceeding
Publication Date
11-2025
Abstract
Introduction:
The purpose of the tertiary survey is to ensure that traumatic injuries that may be missed during the primary and secondary survey are identified and treated accordingly. After a review, our trauma program identified a quality gap where tertiary surveys were not being documented. The purpose of this study is to evaluate whether the use of an electronic medical record tool, in conjunction with a reporting process, improved documentation of the tertiary survey in pediatric trauma patients.
Methods:
A review of the pediatric trauma database was performed. Patients < 16 years old who were admitted after level 1 or 2 activations or trauma evaluations were included. The study period was between January 2023 and January 2024. An Epicâ„¢ SmartPhrase was developed with input from the pediatric surgery team, pediatric trauma nurse manager, and the general surgery residents. The residents and pediatric surgery attendings were educated and the smartphrase was implanted July 2023. Reviews were made on a month-to-month basis and if a patient did not have a tertiary survey documented, emails to the trauma attending and residents of record were sent, notifying them of missed documentation of a tertiary survey.
Results:
Tertiary survey documentation compliance in the six months prior to implementation of the Epicâ„¢ SmartPhrase was only 45%, with only 28% of patients having a tertiary survey documented in June 2023, the month prior to implementation. July and August compliance was significantly higher at 89% in each month. Six months post implementation, compliance was found to be 78%. In 2024, compliance increased to 86% for the full year. In 2024, patients that were admitted after a trauma consult, as opposed to an activation, had a higher proportion of missed tertiary survey documentation, 23.6% vs. 3.3%, p< .01.
Conclusions:
Use of an Epic smartphrase, in conjunction with reminder emails, helped increased tertiary survey documentation in our pediatric trauma center. Standardized documentation practices help provide consistent care through the constant change of residents of the pediatric trauma service. The tertiary survey has the potential to identify missed injuries and ensure quality trauma care and is an important step in the care of a trauma patient.
Recommended Citation
Davis RT, Surman E, Akay B, Novotny N, Stallion A, Brahmamdam P. Use of an electronic medical record tool to ensure tertiary survey compliance in pediatric trauma patients. Poster presented at: Pediatric Trauma Society 11th Annual Meeting; 2025 Nov; Austin, TX. Available from:https://pediatrictraumasociety.org/meeting/Program/2025/P38.cgi
Comments
Pediatric Trauma Society 11th Annual Meeting, November 5-8, 2025, Austin, TX