Documentation of paediatric head injuries in a mixed metropolitan emergency department

Sean Shi-Jie Lee; Vijay Manivel; Suganya Vignakaran; Karina Hochholzer; Chamila De Alwis; David Espinoza; Stephen Sze Shing Teo

doi:10.1111/1742-6723.13967

Documentation of paediatric head injuries in a mixed metropolitan emergency department

Emerg Med Australas. 2022 Oct;34(5):738-743. doi: 10.1111/1742-6723.13967. Epub 2022 Apr 5.

Authors

Sean Shi-Jie Lee¹, Vijay Manivel^{2

3

4}, Suganya Vignakaran^{5

6}, Karina Hochholzer^{3

7}, Chamila De Alwis^{3

7}, David Espinoza⁸, Stephen Sze Shing Teo^{3

5

6}

Affiliations

¹ Westmead Hospital, Sydney, New South Wales, Australia.
² Emergency Department, Nepean Hospital, Sydney, New South Wales, Australia.
³ Emergency Department, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia.
⁴ Nepean Clinical School, The University of Sydney, Sydney, New South Wales, Australia.
⁵ Paediatrics and Neonatology Department, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia.
⁶ Paediatrics and Child Health, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia.
⁷ Emergency Department, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia.
⁸ NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia.

PMID: 35384296
DOI: 10.1111/1742-6723.13967

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.

Keywords: documentation; emergency services; head injuries; hospital; medical transcription; paediatric emergency medicine.

MeSH terms

Adolescent
Australia / epidemiology
Child
Craniocerebral Trauma* / diagnosis
Craniocerebral Trauma* / epidemiology
Documentation
Emergency Service, Hospital
Humans
Infant
Retrospective Studies