[Admission documentation of multiple trauma patients using the Zurich Trauma Protocol--initial experiences]

Area of Science:

• Trauma care documentation
• Medical record systems
• Injury assessment

Context:

• Multiply injured patients require standardized documentation for effective care.
• Existing medical record systems may lack specific trauma-focused structures.
• Efficient data acquisition is crucial in emergency and intensive care settings.

Purpose:

• To present a novel 23-page trauma protocol for documenting multiply injured patients.
• To structure documentation based on the Abbreviated Injury Scale (AIS) for comprehensive injury classification.
• To enhance data entry efficiency and provide standardized overviews of patient diagnosis, therapies, and investigations.

Summary:

• The protocol utilizes checklists and templates aligned with AIS categories (head/neck, face, thorax, abdomen, extremities/pelvis, integument).
• Analysis of 22 residents' experiences after one year indicated ease of learning and acceptance.
• The protocol facilitated improved information exchange between emergency and intensive care units.

Impact:

• The trauma protocol supports prospective data acquisition and retrospective analysis for intensive care patients.
• It serves as a valuable tool for enhancing quality control and quality assurance in trauma care.
• While generally well-received, some users found data entry more time-consuming than traditional methods.