TRU-IT Coding schemes_v5
TRU-IT Project
Coding schemes for analyzing trauma resuscitations
In this document, we present two types of coding schemes: (1) medical coding scheme, and (2) interaction coding scheme.
The medical coding scheme categorizes a variety of medical interventions and events during trauma resuscitations. The interaction coding scheme categorizes tasks and communicative actions performed by the trauma team during trauma resuscitations.
The layout and description of a coding worksheet:
Trauma resuscitations will be videotaped and transcribed. Transcripts will then be transferred into a coding worksheet which will be used for entering codes from both the medical and interaction coding schemes.
Table I shows an example from a coding worksheet after the coding has been completed.
For example, the above table can be read as follows: In line 197, a team leader (TL) has asked (Q) the team if they finished inserting the chest tube (B4). In line 198, team leader, based on his observations (SEN = simple sensing: sight) realized that the chest tube is in, praised the team (JU = judgment) and asked them (DIR = directive) to connect the chest tube (B4) to a pleural bag. In line 199, primary nurse (PNR) relays (RLY) this information to the rest of the team.
Note that the Mode code for all three lines reads “BRE,” which denotes step B in the ATLS protocol (Breathing).
a) TRU Actors: Actors within categories are ordered based on their expertise.
b) TRU Medical Coding Scheme (captures primary and secondary examinations, vital signs, fluids, transfer to another hospital unit, and so on.)
1 Includes giving medications for anesthesia and detection of CO2 in exhaled gas.
2 If a team member reports a numeric measurement for pulse, the action code is “Reporting,” same as the heart rate. A qualitative assessment “weak pulse” is coded as “Assessment.”
3 These are felt on touch; when BP is low, you cannot feel them physically; carotid pulse is checked rarely, only if the patient is almost dying.
4 Includes femoral cordis and infuser.
5 Tasks include holding pressure, stapling head, putting pelvic sling, giving plate lits, blood products, etc.
6 Three categories: best eye opening (cannot open eyes, 1; 2 if you open eyes; 4 points if they open eyes spontaneously), best verbal score (no words at all -- 1), motor score (if you don’t move at all, 1point) – lowest score 3; e.g., questions such as “What’s today’s date?” are asked to assess verbal score…
GCS is to check for brain injury – tells words but they don’t make any sense = 3; not knowing their name or where they are = 4; normal = 5; we often hear paramedics saying “alert and oriented x 3” (a-and-o-times-three) = highest score, means patients is able to talk and aware of surrounding -- know who they are, where they are and what’s today’s date; if the team hears this, there is no need to do the rest of GCS
Alternative to GCS is AVPU (assessment of mental status), which stands for Alert Voice Pain Unresponsiveness – we don’t hear this at all, but just in case…
7 Motor/sensory exams to check for spinal cord injury – motor exam for movement, reflexes, e.g., asking patient if she or he can lift up their leg or arm against gravity, wiggle toes, squeeze hands, etc.; sensory exam for sensation, e.g., asking patient if touching feels normal or less than normal
8 Taking the clothes off
9 Includes auscultation of bowel sounds and asking the patient about feeling any tenderness
10 Checking if there are broken legs or arms, bumps, etc.
11 To check if there is blood in ear canal – blood implies there is a scull fracture
c) TRU Interaction Coding Scheme (involves both tasks and communication)
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Other potential categories – ambiguous/unresolved issues:
- Cases when they call each other by name to get each others’ attention – e.g.,
TL: Hey John…
John: Yeah…
TL: Have you put the orders in?
Etc.
- Should we also include in transcription every time we see REC recording/writing down something on the trauma sheet – also, what matters here? – time when she records, content (note: this is hard to see, but can be deduces based on conversation going on, although REC might be writing down something from previous reports and then asking again for clarification in order to write down the new stuff…); there are also cases when interns/medical students are making reports… how should this be addresses in both transcription and coding?
- Cases when team member make announcements about what is their next action/activity, e.g.,
REC: I am taking the blood now for tests…
[REC is announcing this to the whole team, i.e., she is not talking to anyone in particular – this should be connected somehow to the concept of situation awarenees?!]
- Cases when they ask questions about their schedule, or if they are still needed in the room, e.g.,
ORT: Do you need anything else from me?
[ORT can be addressing the whole team or say TL or ATP in this case]
- How would you code polite TA – e.g., Can you please give me another gauze? Or questions that sound like TA – Blood pressure please – so is this a question or an implicit assignment to a member of the team to provide blood pressure…
- Cases when a team member asks for an instrument, e.g.,
TL: (talks to PNR):Can I borrow your stethoscope?
(this is some kind of a question, but it’s different from other questions that we usually code with Q code)
- What about codes for administrative activities, e.g., Did registration come in?
- Cases when they cry out for help, e.g.,
ANST: (…) I’ll have to call the backup help here – could this be some kind of situation assessment?
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In addition to the main interaction coding scheme (presented in Table IV), we will use the MODE codes which will serve to mark types of information that is being communicated in inquiries, responses, task assignments, or assertions, as well as the steps in ATLS protocol to which they belong (see Table V).
TRU Interaction Coding Scheme Description
Six main categories are identified:
I. Observing: Actions include monitoring vital signs by reading various instruments, assessing patient’s status using various tools (e.g., manual measurement of blood pressure), etc.
II. Deciding: Identifies behaviors that lead to decision making. Communication exchange reflects: gaining control over the problem solution, allocation of resources and efforts to achieve or establish or change a goal, assigning tasks to other team members, providing feedback regarding treatment plans, judging a decision, and demonstrating or explaining a technical procedure to the training members.
(This category was developed by consulting the following literature: Thomas et al., 2006; Xiao et al., 2004; Klein et al., n.d.; Xiao et al., 2003; Velez et al., 2004)
III. Communicating:Team members verbally exchange and share information that relates to patient status, assessment, and planned treatment of the patient. Statements include information requests or inquiries, responses to information requests, reports regarding vital signs or patient history, clarifications, i.e., requests for re-transmission of information, and so on. (This category was developed by consulting the following literature: Thomas et al., 2006; Velez et al., 2004.)
IV. Information retrieval / Memory lookup: needs work
V. Intervening: Identifies therapeutic interventions done by team members.
VI. Other: not sure if this is needed.
These six major categories are further divided into (number) subcategories:
NOTE: Examples are shown in tables, in bold and italic type.
I. OBSERVING
- Assessment/Diagnosis: A team member assesses patient status, and immediately interprets the measurement. The assessment is usually done with the aid of a specific instrument (e.g., stethoscope, ultrasound). This type of behavior is typically followed by a Report. Assessment isdifferent from Manual measuring scenario (which also includes the use of an instrument) because it involves interpretation of the measurement, and this requires expert knowledge. Assessment is also different from Sensing because of interpretation; i.e., any team member can do Sensing, whereas Assessment is typically done by a physician (whether it be a TL, ATP, JR, ORT, etc.)
Example:
TL((listens to breath sounds)): / I hear something on the right.- Manual measuring: A team member obtains information about the patient status by using a specific tool/instrument. This is different from Instrument reading scenario because the information is obtained manually, not automatically/electronically.
Example:
((JR examines eyes with the pen light))JR: / Pupils 4 mm, non-reactive
- Simple sensing: sight, sound, touch, time: A team member acts based on his or her immediate observations in the trauma bay, i.e., a team member is aware of situation in the trauma bay. (Note: this category refers to the notions of awareness, and I wonder if it should be called/viewed/explained differently?)
Example:
TL / Chest tube in?TL ((looks at the patient and inserted chest tube)) / Excellent, great! Connect to pleural bag.
- Instrument reading: A team member obtains information visually by looking either at the vital signs monitor or other instruments/tools in the emergency room.
Example:
[PNR ((after looking at the monitor, talking to REC)): / Margie, he's got heart rate 110, 19 sat]II. DECIDING
- Judgment: Approval vs. Disapproval vs. Praising:
- Approval/agreement: In this form of communication exchange a team member gives the directions for performing an action and receives confirmatory feedback from another team member, that is, another team member expresses his agreement with the proposed action. Approval typically follows Task assignment, Assertion, or Strategic planning scenarios.
Example:
TL: / Can we do FAST?[ATP1: / Let's do FAST]
TL((looks at ATP1 and ATP2)): / We do FAST?
ATP: / Let's do FAST.
- Disapproval/disagreement: In this form of communication exchange a team member gives the directions for performing an action and receives negative feedback from another team member, that is, another team member expresses his disagreement with the proposed action. As with the Approval, Disapproval typically follows Task assignment, Assertion, or Strategic planning scenarios.
Example:
JR / Let’s roll him.TL / You got to have blood pressure before you roll him!
- Praising (effective performance): In this form of communication exchange a team member (typically the team leader or attending physician) expresses satisfaction with members of the crew when they do their job well.
Example:
TL: / Chest tube in?JR: / Yes.
TL: / Excellent, great! Connect it to pleural bag.
- Strategic planning: In this form of communication exchange, a team member tells the other team members the overall plan or strategy for treating the patient, prioritizing possible interventions, and revising the treatment plan as new information becomes available.
Example:
PNR: / Heart rate 128, sat 78 pulse (sacks)TL: / Let's get him intubated, then upstairs.
- Directives (Task assignment/Instruction/Command): In this form of communication exchange, one team member is leading the conversation and telling the other team members what actions to perform. Typically, this is done by the team leader. However, as leadership may be shared, other team members may engage in this type of behavior. This is different from Strategic planning scenario because it is followed by an immediate action, whereas action(s) requested by strategic planning can take place later in resuscitation.
Example:
ATP: / Do we have access to IV fluid?PNR: / We have 18 and 16 in his (right) arm.
ATP: / Go ahead and give him a liter.
- Takeover/Handover of leadership role: In this form of communication exchange a team member counters the orders given by another team member and, instead, gives his own orders and acts on them. Following such a takeover, the two team members often switch roles and engage in mitigated conversation. Thus, this mode reflects a status exchange.
Example***:
PNR: / Let's do EKG, he is having chest pain.PTN: / Oh I can't breath and my chest hurts.
ATP2: / He's actually got abdominal pain.
TL: / Now he's got abdominal pain? ((reaches to check abdomen))
PTN: / Oh I can't breathe and my chest hurts.
*** This example is the closest one to Takeover scenario that we see in the simulation run on May 6, 2006. Klein et al. (n.d.) define role shifts as follows: “A shift in active leadership occurs when a senior leader (the attending or the fellow) takes over strategic direction of the team, assuming a more active and influential role in the team, or, conversely, when a senior leader recedes from strategic direction, assuming a more passive and less influential role.”
Literature (e.g., Xiao et al., 2003), as well as our interviews and focus groups suggest that nurses can often play an active role in leadership status changes; because of this, we don’t want to assume that leadership shifts only happen on attending—resident axis, but involve other team members as well.
- Coaching/Educating: In this form of communication exchange a team member demonstrates or explains a technical procedure to other members, either when a member performed the procedure incorrectly, or when there was a training need to demonstrate/explain a procedure. Communication exchanges also include instructions on how to perform specific medical procedures.
Example:
ATP1((asks JR)): / Can you put the chest tube?ATP2: / Just tell us verbally how you are going to put the chest tube.
((JRexplains how to put the chest tube))
ATP2: / You didn't tell us what's the size of the chest tube.
JR: / Oh, 32 inches (?)
ATP2: / Alright, let's assume the chest tube is in, what you are going to do next?
- Group decision making: needs work
III. COMMUNICATING
- Report: In this form of communication exchange team members provide facts about the patient status. These are self-initiated reports related to vital signs, mechanisms of injury, and so on. When reporting, team members typically raise their voices so that the whole team can hear them. This is different from a Response scenario because provided information is not requested, but self-initiated.
Example:
TL: / Roll him towards me. ((TL moves to the top of the patient head))CCT: / Blood pressure is 98 over 56, and heart rate is 111.
TL: / Can we give another liter of fluid?
- Inquiry/Request for information retrieval: In this form of communication exchange explicit information requests are made regarding patient status, i.e., team members question each other about the patient’s clinical status, their assessment, and treatment plans.
Example:
ATP: / What's the blood pressure?CCT((looks at the monitor)): / Blood pressure is 98/56, heart rate is 109.
- Response to an inquiry: In this form of communication exchange explicit answers are given to information requests or inquiries, i.e., team members provide information that is being requested.
Example:
ATP: / What's the blood pressure?CCT ((looks at the monitor)): / Blood pressure is 98/56, heart rate is 109.
- Clarification/Request for re-transmission of information: In this form of communication exchange a team member does not understand information given by another team member. A team member repeats, in a questioning manner, what he/she thinks is the information given and waits for the answer before executing any action. In most cases there is little or no feedback after the action is performed.
Example:
REC ((talking to ORT)): / Are you ortho?ORT: / Yes.
REC: / Name?
ORT: / Wilson.
REC: / Wilson?
ORT: / Yeah.
- Relay: In this form of communication exchange a team member simply transfers information that she or he heard.
Example:
TL / Excellent, great! Connect to pleural bag.PNR / Connect it to pleural bag.
- Acknowledgment: This form of communication exchange is simply confirmation that the request has been heard and understood often through a simple repeat of the request or remarks such as “okay” and “yeah.”
Example:
REC ((talking to ORT)): / Are you ortho?ORT: / Yes.
REC: / Name?
ORT: / Wilson.
REC: / Wilson?
ORT: / Yeah.
- Task coordination: needs work
- Establishing link with remote unit/consultant: In this scenario, a team member makes a phone call or is trying to contact a remote unit or consultant in the hospital.
Example:
JR ((makes call to OR))IV. MEMORY LOOKUP / INFO RETRIEVAL
- Knowledge recall: In this form of non-communicative action a team member is using his or her knowledge as a source of information when responding to questions and other requests from team members.
Example: provide an example
- Situation recall: In this form of non-communicative action a team member is using his or her “short-term memory” as a source of information when responding to questions and other requests from team members. (Note: this one is tricky, research on short term memory says exactly how long does information stays in short term memory and at what point does it transfer to long term memory – check this out!!!)
Example:
ATP / What's- what's the story here?TL / MVA
ATP / That's it? MVA, nothing else?
- Info retrieval from artifacts (trauma flow sheet, notes, etc.): In this form of non-communicative action a team member (usually scribe nurse/recorder or EMS paramedic) uses artifacts such as flow sheet or notes as a source of information.
Example:
CCT / What's the story?PNR / He hit a (polo?)
REC ((reading from TAFS)) / Restrained driver who's driving from police, car (?), airbags deployed, restrained driver.
V. INTERVENING
11. Intervention/Treatment: A team member performs medical intervention, e.g., administers fluid, drugs, performs intubation, etc. There are two types of interventions: brief and lengthy. Brief Interventions last for a short period of time and are presented in a single line in the coding worksheets. Lengthy Interventions last for a longer period of time (e.g., couple of minutes) and can run through several lines in the coding worksheets. To distinguish between these, different codes should be put (see Interaction coding scheme). In case there are two or more lengthy interventions happening in parallel, they need to be distinguished by putting an order number at the end of a code (e.g., INT_B1, INT_B2, etc.)
Example for Brief Intervention:
PNR ((administers atomidate via IV access))Example for Lengthy Intervention:
ANST ((starts intubation))… / …
… / …
… / …
… / …
… / …
Aid nurse, ANST, PNR ((still working on intubation))
… / …
… / …
… / …
… / …
ANST ((finishes intubation))
Nonverbal communication