Trauma centers need to maintain a concurrent trauma registry. For ACS-verified centers, that means at least 80% of trauma cases must be entered in the registry within 60 days of patient discharge. In many hospitals, however, the trauma registry is months behind on chart abstraction. Hiring more staff is usually not an option, so how can registry teams keep up?
One solution is to make existing registry staff more efficient. According to Christina Wargo, MSN, CRNP, the key is to weed out time-wasting processes so that registrars have more time to abstract charts.
Wargo served as trauma program manager at Geisinger Medical Center in Danville, Penn., from 1995 to 2015. During her tenure, she led a team effort to streamline trauma registry processes.
Wargo and colleagues described their work in “Trauma Registry Reengineered,” which was published in the Journal of Trauma Nursing. The paper showed that process improvement can increase registry productivity while maintaining data accuracy.
Trauma registry benchmarking study
The starting point was a 2011 study conducted by the Pennsylvania Trauma Systems Foundation. The goal of the study was to create a registry staffing benchmark for state trauma centers. Registrars across Pennsylvania tracked their work minutes by category for 30 days. The categories were:
- Patient identification
- Report submission
- Emergency system record request
- Autopsy request
- Follow-up letter development
- Data submission
- Meetings
- Conference and training
- Informatics issues
- Interrater reliability
- Other
On a statewide basis, the study showed the average Pennsylvania registrar spent more than 8 hours per week on non-abstraction duties. At Geisinger, this finding spurred trauma program leaders to take a close look at their registry processes.
“Our big concern was the ‘other’ category,” Wargo said. “We started looking at what was going on in that time period, and that started a lot of discussion about how we could take the time back. We looked at every single piece in our registry processes because we wanted to get as many minutes as possible devoted to abstraction.”
Starting in 2013, the team held weekly meetings focused on registry process redesign. Their experience highlights seven registry efficiency strategies:
1. Eliminate obsolete processes
The Geisinger team began by drilling down on the “other” category. They discovered that a big chunk of this time period was devoted to an obsolete process that no longer provided value.
“When we first transitioned to an electronic medical record five years earlier, the EMR did not always include the entire medical history. So registrars would request paper charts in order to include more detail in the abstraction,” Wargo said.
By 2013, however, most charts were built electronically and paper charts included only limited medical history. “We recognized that we no longer needed to request and abstract those paper charts, so we got rid of that process,” Wargo said. Eliminating paper chart requests saved 120 minutes per week.
2. Look for opportunities to combine activities
The study found that Geisinger registrars spent more than 2 hours per week performing interrater reliability activities. These activities are critical to data validation, but they also take away from chart abstraction time.
After reviewing processes step-by-step, the team hit upon a way to increase abstraction time while maintaining data integrity checks. They realized the program could fulfill a portion of interrater reliability requirements by leveraging the staff onboarding process. Now, charts are double-checked for accuracy during the “abstraction review” segment of new staff orientation.
The team further streamlined data validation by focusing the process on areas of concern. “So if a registrar’s abstract was reviewed and it was perfect except for diagnosis coding, their next review would focus on diagnosis coding only,” Wargo said.
3. Consolidate discussion time
Registrars in all trauma centers spend a lot of time clarifying issues related to coding and reporting. Again, this activity is critical to an accurate registry, but making the process more efficient will help increase productivity.
The Geisinger team made two changes. First, they channeled complex discussions to the weekly registrar meeting. According to the Journal of Trauma Nursing paper, weekly sessions were used to discuss “coding questions, decisions on state reportable cases, syntax to achieve the highest scoring, Trauma Quality Improvement Program reporting, and National Trauma Data Base reporting.” Detailed meeting minutes provide discussion highlights and decisions for staff who are unable to attend.
Second, the team created a more efficient digital forum for routine conversations. “For daily discussions, a group e-mail and instant messaging were utilized,” according to the paper. “All registrars and coordinators are included in the group; everyone benefits from the on-line discussion and final decision.”
Any issues not resolved in the digital forum are referred to the weekly registry meeting. Cumulatively, efforts to consolidate discussions saved more than 3 hours per week.
4. Keep up with system changes
When IT systems change, registry processes need to change too. “Years ago, we began building queries so that everything we submitted to the state was also submitted internally as ‘information leaving the hospital’,” Wargo said. “This was a hospital requirement related to protecting patient information under the HITECH Act.”
Since this process was put in place, however, changes in the registry information system made the query structure obsolete. “The system had changed, but we never changed with it,” she said. “We were building these queries weekly, and it was taking about 150 minutes every single week.”
The chief registrar worked with IT staff to take advantage of new capabilities to create built-in queries. “The new process was more automatic, so it cut the time spent on this task by about 90 minutes per week,” Wargo said.
5. Optimize interactions with other departments
Trauma registries depend on data provided by other departments. Unfortunately, when outside departments change their data recording or submission processes, the trauma registry may fail to keep pace.
“Over the years, the ED and the flight crew changed their processes for patient logging, but the registry was still doing things the way they had been set up years before,” Wargo said. As a result, data collection took longer than necessary. “We fixed this issue by simply working with ED and flight staff to understand where they were entering patient information and where our registrars should be looking for it.”
The discussions also uncovered new ways to coordinate efforts. “We also arranged with these departments that they would enter certain information into the EMR,” Wargo said. “That saved more time that registrars were spending collecting data.”
Wargo recommends reviewing interactions with other departments at least annually. “If they change their process, that can affect your process,” she said. “The change could be great for them, but it might add work and represent additional time for you.”
6. Spin off non-core activities
One major inefficiency in many registries is staff misallocation. Registrars are given many administrative and secretarial duties, taking away from the time they can devote to chart abstraction.
“A big part of our effort was comparing job duties to staff roles,” Wargo said. The team identified several registrar tasks that could easily be transferred to an administrative assistant. They included logging patient identification data, maintaining calendars and scanning paper documentation. “This change gave a lot of time back to registrars. It was huge.”
In addition, some data collection duties were spun off to other program staff. Previously, trauma registrars collected trauma flow sheets, EMS paperwork and outside transfer documentation. Under the new workflow, these paper records are now collected and scanned by trauma case managers.
7. Cross-train for greater flexibility
At Geisinger, individual registrars specialized in specific tasks. For example, one registrar handled data submission, another requested EMS records, etc. The problem with specialization, however, was that when a staff member was absent, key processes could slow down or stop altogether.
To fix this issue, program leaders decided to cross-train registrars in multiple tasks. “Shared responsibilities include data submissions, orientation for new staff members, patient identification, and EMS record request,” according to the Journal of Trauma Nursing paper. “Each registrar is currently competent in all responsibilities; thus, staff turnover and time off do not obstruct timely completion of responsibilities.”
“Rotating responsibilities made it a lot easier for everyone to take part in the total workflow,” Wargo said. “The team just had more time to abstract.”
Speed up submission, maintain data accuracy
Process redesign saved 7 hours per week for Geisinger’s 5-person registry team, according to the Journal of Trauma Nursing paper. Increasing abstraction time enabled registrars to speed up throughput. Before the process changes, “time to submission” for registry cases was 4 – 5 weeks. After the redesign, case submission time was cut to 2 – 3 weeks. Most important, the team has maintained data accuracy at greater than 95%.
“Registry process reengineering will help you stay current while maintaining data accuracy,” Wargo said. “In addition, involving your entire team in the effort can help improve job satisfaction and potentially reduce staff turnover.”
Streamlining the trauma registry can also help program leaders persuade hospital administration to hire additional staff. “If you run a tight registry with as many minutes as possible spent on chart abstraction, and you don’t have any waste, you can make a stronger case for additional hiring,” Wargo said.
The key to the entire process is to look at trauma registry workflows with fresh eyes, she said. “It’s a matter of not just doing the same thing you do every day, but actually evaluating whether processes and ways of doing things are appropriate anymore or even necessary.”
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