Occam's Razor and Prehospital Documentation: When the Simpler Solution Resulted in Better Documentation.

Introduction: The Tactical Combat Casualty Care (TCCC) card has undergone several changes since its first introduction in 1996. In 2013, updates to the card included more data points to increase prehospital documentation quality and enable performance improvement. This study reviews the proportions of data collected before and after the implementation of the new TCCC card.

Methods: This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry (DODTR) focused on prehospital medical care. In this sub-analysis, we defined the pre-implementation period as 2009-2013 followed by a 1-year run-in with the post-implementation period as 2015-2019. Our primary outcome was documentation of a pulse rate and our secondary outcomes included documentation of other vital signs. We used multivariable logistic regression models to adjust for confounders.

Results: There were 18,182 encounters that met inclusion for this analysis-14,711 before and 3,471 after the update. Across all vital signs, there was a peak around 2012-2013 with a drop noted in 2015. Comparing the preimplementation and post-implementation groups, there were higher proportions with documentation of a pulse rate (62% versus 49%), respirations (51% versus 45%), systolic pressure (53% versus 46%), diastolic pressure (49% versus 41%), oxygen saturation (55% versus 46%), and pain score (27% versus 19%, all p is less than 0.001) in the pre-implementation group. When adjusting for injury severity score (ISS), casualty category, and year of injury, the odds ratio of documentation of a pulse after implementation was 0.01 (95% CI: 0.00-0.01). When adjusting for ISS and casualty category, the odds ratio was 0.64 (95% CI: 0.60-0.70). When adjusting for ISS only, the odds ratio was 0.58 (95% CI: 0.54-0.63).

Conclusions: Implementation of the new TCCC card resulted in overall lower documentation proportions which persisted after adjusting for measurable confounders.