Australasian Emergency Nursing Journal (2012) 15, 9399

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/aenj

RESEARCH PAPER

The development of clinical nursing practice

guideline for initial assessment in multiple injury
patients admitted to trauma ward
Wipa Sae-Sia, RN, PhD a,
Praneed Songwathana, RN, PhD a
Pornpen Ingkavanich, RN, MNS b

a
School of Nursing, Prince of Songkla University, Thailand
b
Trauma Ward, Songkhla Hospital, Thailand

Received 20 May 2011; received in revised form 29 February 2012; accepted 29 February 2012

KEYWORDS Summary
Initial assessment; Background: Missed diagnoses are very common in patients with multiple injuries. To help nurses
Trauma nursing; identify missed injuries, this study aimed to develop and evaluate a clinical nursing practice
Clinical practice guideline (CNPG) for the initial assessment of multiply injured patients admitted to the trauma
guideline; ward in a provincial hospital in southern Thailand.
Evidence-based Method: The CNPG was developed using evidence-based knowledge of trauma assessment and
practice; the Advanced Trauma Life Support guideline. The CNPG was used by 18 nurses working in the
Multiple injuries; trauma ward. They implemented the CNPG with 34 multiply injured patients. The outcome
Missed injury measures of the CNPG use were the nurses self-reported compliance with the use of the CNPG,
the nurses satisfaction with using the CNPG, and the percentage of missed injuries detected
as a result of the use of the CNPG.
Results: Most nurses (83.33%) reported complying with the CNPG and 72.2% of them indicated
that their satisfaction with using the CNPG was at a high level. Missed injuries were discovered
at a rate of 14.6% of the total injuries diagnosed in the injured patients within 24 h of ward
admission.
Conclusion: Further research needs to be conducted to establish if the CNPG could be more
widely applied to improve the quality of care and increase the safety of those with multiple
injuries.
2012 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights
reserved.

Introduction
Corresponding author. Patients with severe injuries in road accidents especially
E-mail address: [email protected] (W. Sae-Sia). those with head injuries and multiple trauma injuries are
1574-6267/$ see front matter 2012 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.aenj.2012.02.003
94 W. Sae-Sia et al.

ED11 due to the particularly high work load of ED staff in

What is known Thailand.
There has been little work done to date in the early Currently, there is no existing nursing assessment guide-
detection of missed injuries in patients with multiple line for multiple trauma patients admitted to the trauma
trauma injuries admitted to wards in Thailand. ward at Songkhla Hospital which is a provincial hospital
located in southern Thailand. Nurses perform their assess-
What this paper adds ments based on individual experience, so there is variability
in individual decision making. Observation of recent cases
The implementation of the CNPG used in this study has shown that missed injuries, such as clavicle fractures, rib
could help the early detection of missed injuries fractures, or abdominal injuries are still detected in patients
by nurses in patients with multiple trauma injuries admitted to the Trauma Ward (Pornpen Ingkavanit, personal
admitted to wards in Thailand. communication, September, 15, 2010).
Clinical practice guidelines are a tool used to stan-
dardize care for a specic group of patients.12 In trauma
patients, clinical practice guidelines have been reported,
in a study in the United States, to reduce the incidence
more likely to experience a missed injury.1,2 A missed of delayed assessment or missed injuries from 2.4% to
injury has been dened as a clinically signicant injury that 1.5%.13 Although several guidelines and manuals have been
was not identied on admission to the emergency depart- developed in Thailand, those guidelines were developed
ment (ED), not documented in ED records, but is identied for implementation in tertiary hospitals and included man-
after the patient is transferred from the ED to the trauma uals for the treatment of patients with traumatic brain
ward.3 The international published literature suggests that injuries,14 liver injuries,15 and a nursing guideline for
the incidence rate of missed injuries ranges from 1.3% to patients with head injuries.16 Only one manual for the
13%. 2,46 Missed injuries cause adverse effects on patient physical assessment and discharge planning for patients
outcomes including increased length of hospital stay and with injuries has been developed in a tertiary hospital
cost, and an increased mortality and morbidity rate. 3,7 in Thailand and that manual has not been tested for its
In Thailand, multiple trauma injury is a leading cause of effectiveness.17
death particularly following road accidents which are them- Advanced Trauma Life Support (ATLS) is a well-known
selves a major cause of death in the Thai population.1 guideline that was developed in the United States of
The death rate between 1993 and 2002 ranged from 16.3 America.18 and has been translated into many languages
to 20.9 per 100,000 people. The trafc accident statis- around the world. ATLS was developed to guide physicians
tics for the period 19952002 showed that between 70 and nurses in accurately performing the assessment and
and 75% of the injuries resulting from trafc accidents treatment of multiple trauma patients. There are four steps
were suffered by males, with between 25 and 30% being included in ATLS: primary survey, resuscitation, secondary
suffered by females. The numbers of injured males in survey, and denitive care.18 However, there are currently
the period ranged from 33,854 in 1999 to 49,063 in 2002 no guidelines for the rapid assessment and management
and the number of injured females ranged from 12,633 in of patients with multiple trauma admitted to secondary
1995 to 20,250 in 2002.8 Approximately 75% of the peo- hospitals, such as provincial hospitals, in Thailand. The pur-
ple admitted to hospital are victims of motor cycle and pose of this study was therefore, to develop and evaluate
car accidents suffering from serious or moderate injuries.8,9 the effectiveness of a clinical nursing practice guide-
Since there has to date been no reporting of missed injuries line (CNPG) for the initial assessment of multiple trauma
in Thailand, information about their existence could only patients admitted to the trauma ward in Songkhla Hos-
hitherto be based on the individual experience and obser- pital in southern Thailand. The main outcome measures
vations of trauma nurses, and the authors have noticed were: (1) compliance with the use of the CNPG, (2) nurses
that missed injuries, such as fractured ribs or extremi- satisfaction in implementing the CNPG, and (3) the per-
ties, dislocated joints or internal organ hemorrhage have centage of missed injuries detected through the use of the
been diagnosed in patients with multiple injuries in the CNPG.
trauma ward even though they had been assessed in
the ED.
One strategy to reduce the incidence of missed injuries
is rapid initial assessment and the management of multi- Methods
ple trauma patients is a gold standard of care that can
save a patients life and reduce mortality.3 In Thailand, Design
rapid assessment and management is rstly performed at
the ED by nurses using primary and secondary surveys as A two-step exploratory approach was employed in this
described in the Advanced Trauma Life Support Manual.10 study. The rst step was the development of the con-
After initial assessment and management at the ED, the tents of the initial assessment guideline for multiply injured
patient is transferred to the trauma ward, the intensive patients. The second step was to evaluate the effective-
care unit, or an operating room. Despite this structured ness of the CNPG developed. The process of developing
approach to the assessment and management of multiple the guideline was based on the process published by the
trauma patients, severe or mild injuries may not be diag- Australian National Health and Medical Research Council
nosed in either the primary or the secondary survey in the (NHMRC).12
The development of clinical nursing practice guideline for initial assessment in multiple injury patients 95

Setting developed by the AGREE collaboration committee to evalu-

ate the quality of practice guidelines. The AGREE instrument
Songkhla Hospital, a 500-bed provincial hospital located in is composed of six domains with a total of 23 items. Those
the South of Thailand, is a secondary care level hospital domains are scope and purpose of guidelines, stakeholder
catering for both walk-in and referral patients from nearby involvement, rigour of development, clarity and presenta-
primary hospitals. Approximately 50% of trauma patients are tion, applicability, and editorial independence. The ATLS
referred to the ED from nearby primary hospitals. About guidelines quality score exceeded 60% based on the AGREE
160200 patients visit the ED per day and approximately six criteria, which is considered to be an acceptable score.21
to eight multiply injured patients aged 15 or over are admit- However, a major gap in ATLS18 is that it does not include
ted to the trauma ward each day.19 The trauma ward is a the assessment of the psychological status of multiple
36-bed unit and most of the patients admitted to the trauma trauma patients. Psychological problems are an important
ward are patients with trauma or multiple trauma problems aspect of the initial assessment of patients suffering multi-
related to trafc accidents. The major challenges in caring ple trauma.22,23 Therefore, a psychological assessment was
for these patients are the treatment of crush injuries, blunt included in the draft of the guideline used in this study.
injuries, fractures, and head injuries. The psychological assessment included assessments of fear,
anger, paranoia, anxiety, and uncertainty,22,23 based on level
5 evidence.20
Intervention (CNPG) Next, a draft CNPG for the initial assessment of mul-
tiply injured patients was prepared. This draft CNPG was
There were two steps in developing the intervention (CNPG). reviewed by the same group of six experts. After revi-
The rst step was the development of the guideline based sion of the draft CNPG based on the recommendations
on the NHMRC12 process. The process of validating the con- of the experts, the draft guideline was assessed for con-
tents of the guideline began by assembling an expert panel. tent validity. The universal agreement content validity
The expert panel consisted of one physician, two Master- index among the same six experts was 0.90. The draft
prepared nurses working in the trauma ward, a head nurse CNPG was also checked for inter-rater reliability by three
from the trauma ward, and two nursing researchers working pairs of registered nurses and was found to be 0.86. The
in the trauma area. CNPG was then ready for its effectiveness to be evalu-
The content of the guideline was then developed based ated. The sections of the CNPG consisted of (1) demographic
on a review of relevant literature published in the English data, (2) patients history, using AMPLE (allergies, medica-
language between 1993 and 2011 from four databases tion, past history, last meal, event/environment related to
(PubMed, CINAHL, Science Direct, and Ovid), the use of an injuries), (3) operational procedure/treatment, (4) head to
internet search engine including a manual search of Mas- toe physical examination, (5) estimated blood loss, (6) pain
ters theses, doctoral dissertations, as well as articles in assessment, (7) laboratory information, (8) psycho-social
Thai journals. The search terms used were multiple trauma, assessment, (9) functional health assessment, and (10) nurs-
polytrauma, missed injuries, missed diagnoses, and delayed ing diagnosis identication. The CNPG developed is shown in
diagnoses. The results showed that no single research study Fig. 1.
had examined the initial assessment of multiple trauma The second step was to evaluate the effectiveness of
patients and there was only one clinical practice guide- the CNPG. The following aspects of the effectiveness of
line for the assessment and treatment of multiple trauma the guideline were evaluated: (1) compliance rate with the
patients,18 Advanced Trauma Life Support (ATLS), the well- use of the CNPG, (2) nurses satisfaction in implementing
known guidelines utilized in several countries including the CNPG, and (3) percentage of missed injuries detected
Thailand. through the use of the CNPG.
However, it was found that in a previous study conducted
in Thailand at a tertiary hospital, the contents of the sec-
ondary survey step of ATLS had been modied to develop a Sample
comprehensive and documented nursing assessment as well
as discharge planning for multiply injured patients after
The CNPG was implemented by all 18 registered nurses who
being admitted to the ward.17 However, that nursing guide-
worked in the trauma ward, Songkhla Hospital with 34 mul-
line had not been tested for its effectiveness. Therefore,
tiple trauma patients between the middle of May and the
the contents of the guideline developed in the current study
rst week of June, 2009.
were based only on the secondary survey section of the
ATLS.18
A working group consisting of the members of the expert
panel analyzed the levels of evidence used in the ATLS. Research ethics statement
It was found that the evidence used for recommenda-
tions for secondary assessment in the ATLS were Level 2 This paper presents the ndings of a research study that
to Level 5 in which Level 2 evidence is from random- adhered to the National Statement on the Conduct of Human
ized control trial studies either with or without a control Research issued by the Thai Ministry of Public Health and has
group and single prospective studies, and Level 5 evidence been approved by the Ethics Committee, Faculty of Nursing,
is expert opinion.20 In addition, the ATLS was evaluated Prince of Songkla University and the Director of Songkhla
using the Appraisal of Guidelines Research and Evaluation Hospital, Thailand. Participation in this study was voluntary
(AGREE) instrument21 which is a set of assessment criteria and responses were anonymous.
96 W. Sae-Sia et al.

Patient
Name..
Initial Assessment for Multiple Trauma Patients
Trauma Ward, Songkla Hospital
1. Admitted from ED ( ) Ward () OR ( ) at am/pm
Diagnosis..
2. Chief complaint..
3. History of injury (AMPLE)
Contact Person ..
History of Injury No Yes (please specify)
A= Allergies Telephone No
B = Medications
P = Past history Admied me.
L = Last meal Time.am/pm
E = Events V/S: TC, P./min BP...mmHg
RR. /min, O2 saturaon.

Operation: No ( ) Yes ( ) Please specify Retained NG tube: No ( ) Yes ( ) ICD: No ( ) Yes ( )

Retained Foleys catheter: No ( ) Yes ( ) Cutdown: No ( ) Yes ( ) Suture: No ( ) Yes ( ) please
specify.
4. Head to toe physical examination
Organ Physical Examination
Head Conscious: Full ( ) Unconscious ( ) Dizziness ( ) Stupor ( ) Alcohol drunk ( )
Wound: No ( ) Yes ( ) please specify..
GCS: EVM. Total score .. Pupils size: Rt.mn RTL..Lt..mn RTL
Eye swelling: Rt eye: No ( ) Yes ( ) LT eye: No ( ) Yes ( )
Motor power: Rt arm Lt arm Rt leg.. Left leg
Eye Visual acuity: Normal ( ) Abnormal ( ) please specify.
Injury: No ( ) Yes ( ) please specify..
Ears Hearing ability: Normal ( ) Abnormal ( )please specify. Injury: No ( ) Yes ( ) please
specify..
Face and teeth Abnormal shape: No ( ) Yes ( ) please specify
Teeth: Normal ( ) Abnormal ( ) please specify..
Neck Injury: No ( ) Yes ( ) please specify. Appearance: Normal ( ) Abnormal ( ) please
specify..
Movement: Yes ( ) No ( ) please specify ..
Fracture of the spine: No ( ) Yes ( ) please specify
Thoracic, lung, Injury: No ( ) Yes ( ) please specify. Clavicle shape: Normal ( ) Abnormal ( ) please
and circulation specify..
Rib shape: Normal ( ) Abnormal ( ) please specify
Rt Br Rt Breath sound: Normal ( ) Abnormal ( ) please specify.
Lt breath sound: Normal ( ) Abnormal ( ) please specify .
Pattern of breathing: Normal ( ) Abnormal ( ) please specify.
Skin: color: Pink ( ) Pallor ( ) Temperature: Warm ( ) Cold ( )
Skin lesion: No ( ) Yes ( ) please specify
On respirator
Abdomen Inspection: Contour: ( ) Symmetry ( ) Asymmetry
Palpation: Tenderness: No ( ) Yes ( )
Percussion: Tympanics: No ( ) Yes ( ) Dull: No ( ) Yes ( )
Auscultation: Bowel sounds: No ( ) Yes ( ) please specify the frequency./ min
Retained NG tube : No ( ) Yes ( ) Gastric content .cc
Wound: No ( ) Yes ( ) Please specify

Genitourinary Wound: No ( ) Yes ( ) Please specify.

Musculoskeletal Muscle strength: Motor power: Rt armLt armRt leg..Left leg
Sensory: Normal ( ) Abnormal ( ) Please specify
Wound: No ( ) Yes ( ) Please specify..
On Cast/or splint: No ( ) Yes ( ) On collar: No ( ) Yes ( )
5. Organ(s) being actively bleeding: No ( ) Yes ( ) Please specify Estimated blood losscc
6. Pain intensity for verbally communicating patients
0 1 2 3 4 5 6 7 8 9 10
7. Pain intensity for non verbal patients ( )facial grimacing ( )moaning ( ) groaning ( )rubbing a body part
8 Common nursing diagnosis:
Ineffective tissue perfusion (please specify type: renal, cerebral, cardiopulmonary,
gastrointestinal, or peripheral) due to hypovolemea
Potential risk for increase intracranial pressure due to (brain swelling, brain injury)
Ineffective airway clearance due to (thoracic injury, brain injury, spinal cord injury)
Acute pain due to tissue trauma (please specify organ..)
Stress/fear/anxiety due to unfamiliarity with hospitalized environment, sensory and /or motor impairment
Others diagnosis please specify

Figure 1 The CNPG used for initial assessment for multiple trauma patients admitted to the Trauma Ward, Songkla Hospital.
The development of clinical nursing practice guideline for initial assessment in multiple injury patients 97

Outcome measures Table 1 Injury diagnosis in trauma patients.

Compliance with CNPG use Diagnosis n (%)

Compliance with CNPG use was dened as the percentage
Traumatic brain injuries 23 (41.82)
of nurses whose patient assessments complied with each
Facial injuries 9 (16.30)
component of the CNPG. This parameter was evaluated by
Thoracic injuries 3 (5.45)
a questionnaire asking the nurses whether they complied
Abdominal injuries 8 (14.55)
with each component of the CNPG. The response format of
Injuries to extremities 12 (21.82)
the questionnaire was in the form of a yes/no answer.
The questionnaire was composed of seven questions, so the
possible score ranged from 1 to 7. The scores were con-
trauma ward was 13.22 years (SD = 8.1). A trauma train-
verted into percentages, with a higher percentage indicated
ing course had been completed by ten (55.6%) of the
a higher compliance rate.
nurses.
It was found that 15 nurses (83.33%) felt that overall
Nurses satisfaction the ten sections of the CNPG were easy to comply with.
This parameter was dened as the percentage of nurses However, 13 (72.22%) reported that only eight sections of
who were satised with implementing the CNPG. A score the CNPG were feasible to be implemented in practice.
of 110 was used to determine the nurses rate of satisfac- Fourteen nurses (77.8%) indicated a lower feasibility for
tion. Higher scores indicated a higher level of satisfaction the implementation of the pain assessment component,
and the levels of satisfaction were classied as low (score particularly in traumatic brain injury patients who were
13), moderate (score 46), or high (score 710). unconscious. In addition, ve (27.8%) reported that the
requirement of performing a head to toe physical examina-
Percentage of missed injuries tion was not easy to comply with, especially when many new
The percentage of missed injuries was determined by patients were admitted during their shift. Most of the nurses
the third co-author reviewing the information assessed (72.22%, n = 13) reported that their satisfaction in imple-
in the CNPG. It was calculated by counting the numbers menting the CNPG was at a high level (scores = 7 or 8) with
of injuries detected by nurses observations within 24 h three (16.67%) reporting their satisfaction at a moderate
after initial admission into the trauma ward divided by the level (scores = 46).
total numbers of injuries diagnosed in the patients dur- Of the 34 patients with 55 diagnosed injuries included
ing the study period (one patient might have had multiple in this study, 29 were male (85.29%), 17 (50%) had minor
injuries). injuries (severity score: ISS = 19), seven (20%) had moder-
ate to severe injuries (ISS = 1624) and 10 (30%) had severe
Data collection to critical injuries (ISS greater than or equal to 25). The most
common diagnosis was traumatic brain injury (41.8%, n = 23:
see Table 1). Of the 55 diagnosed injuries, eight (14.6%),
Before implementing the CNPG, the third co-author who is a
were missed injuries detected while using the CNPG within
head-nurse in the trauma ward in which the study was con-
24 h of ward admission. The most common missed injuries
ducted, instructed all the nurses who were to be involved in
were clavicle fractures (5.9%, n = 2), fractured ribs (5.9%,
the study regarding the implementation of the CNPG. The
n = 2), ruptured spleen (5.9%, n = 2), a facial fracture (2.9%,
10 sections of the CNPG were required to be completed
n = 1), a lacerated wound in the scalp (2.9%, n = 1), and bro-
within 24 h by the nurse who was working when the patient
ken teeth (2.9%, n = 1).
was admitted. Each nurse in the trauma ward experienced
using the CNPG with at least one multiple trauma patient.
Finally, the nurses were asked to complete questionnaires Discussion
and to return them within three days. The return rate was
100%. To gain better information about some issues aris- The issue of missed injuries in multiply injured trauma
ing from the CNPG implementation, a few nurses were also patients is certainly an important one. The incidence of
interviewed. missed injuries found in the present study (14.6%) was
slightly higher than those found in studies at trauma centers
Data analysis in the United States and the United Kingdom which ranged
from 1.3% to 13%.2,57 These studies found that missed
injuries occur at both secondary and tertiary care levels and
The data were analyzed using SPSS version 11.5 (Chicago,
missed injuries are also an important issue in secondary level
IL). Descriptive statistics (frequency, percentage, mean,
hospitals in Thailand.
and standard deviation) were used to summarize the study
This study also found that the limbs and the intra-
data.
abdominal organs were the most common organs to suffer
missed injuries. This nding is similar to those of previous
Results studies.4,5,11,24 Injuries to these organs are commonly missed
because the aim of caring for multiple trauma patients is
All the 18 nurses involved in the implementation of to focus on the problems that pose a threat to life, such
the CNPG were female with a mean age of 35.67 years as cardiac arrest, active bleeding, chest injuries, or open
(SD = 8.22). The average experience of working in the fractures; therefore, injuries to the limbs, the spine, or
98 W. Sae-Sia et al.

intra-abdominal organs might easily miss early detection in Implementation to practice, recommendations,
the ED. In addition, a decreased level of consciousness or and future research
intubation can also cause a delayed diagnosis in the ED. 5,25
Moreover, inadequate initial physical examinations and the The CNPG developed in this study is specic to one trauma
late objective presentation of symptoms are also factors in ward of a provincial hospital in southern Thailand. The
missed injuries.25 implementation of this CNPG could be benecial to other
Signicant injuries can be missed during the initial pri- trauma wards in Thailand where the care system is simi-
mary and secondary survey in the ED.11 It has been suggested lar to the hospital studied. Replication of this study with a
that secondary re-assessment and tertiary assessment when larger sample in other trauma wards at other institutions
patients are admitted to the intensive care unit or ward and with less experienced and more junior nursing staff is
could help healthcare providers in the early detection of recommended to establish if the ndings of this study are
missed injuries during the initial admission.6,11,23 The CNPG generalizable to other contexts. Future studies should inves-
for the initial assessment of multiple trauma patients devel- tigate the factors which cause injuries to be missed and
oped in the present study provides a structured assessment should measure patient outcomes, such as the length of stay
related to trauma care and therefore, provides a structure in hospital, and the morbidity and mortality rate of multi-
for nurses to re-assess patients within 24 h of admission to ply injured patients after the use of the CNPG. It is also
the ward. A re-assessment without such a structure is likely recommended that future studies should employ documen-
to focus on what has already been assessed on admission tation audits to conrm the results of self-reported data on
to the ED, rather than on identifying missed injuries.26 It compliance with the CNPG.
has been found that inadequate clinical assessment is prob-
ably the most common reason for injuries to be missed.4
The current study found that 14.6% of the injuries even- Limitations
tually diagnosed in patients admitted to the trauma ward
during the study, were injuries missed in the ED, which were Some limitations to this study should be considered when
detected early by nurses in the trauma ward when the CNPG interpreting its results. First, the study did not investigate
was used. Therefore, the CNPGs structured approach to the health outcomes of the patients who were assessed using
the initial assessment of multiply injured patients on admis- the CNPG, including their length of stay in hospital and
sion to the trauma ward is useful for the early detection of whether they were re-admitted to hospital within 28 days,
missed injuries allowing prompt nursing interventions to be nor were their mortality and morbidity outcomes monitored
employed. in this study. In addition, the CNPG was developed to be
The results show that the registered nurses self-reported implemented in the specic context of a trauma ward in
compliance rate with the use of the CNPG was at a high level southern Thailand and the results cannot be generalized
(83.33%). Two factors could explain this result, the working across other trauma wards either in other regions of Thailand
experience and the training experience of the nurses. Pre- or in other countries. Finally, the small number of subjects
vious studies have shown a signicant positive relationship who used the CNPG might limit the extent to which the
between previous experience and clinical problem man- effectiveness of the use of the CNPG in this study would
agement and clinical skills.27,28 In the present study, the be reproduced in wider use. Therefore, future studies are
average working experience of the participating nurses was recommended to measure the patients health outcomes to
13.22 years with approximately 50% of them having attended ensure the effectiveness of the CNPG with larger sample
a trauma training course. Therefore, they are skilled at sizes and at other sites which would improve the generaliz-
and have hands-on experience of performing head-to-toe ability of the use of the CNPG.
physical examinations, and establishing the patients history
and related clinical information. Consequently, the com- Conclusion
pliance rate with the use of the CNPG was quite high.
This high compliance rate also led to most of the nurses Multiple injuries may initially be missed despite primary
(72.2%) having a high level of satisfaction with using the and secondary surveys in EDs. The CNPG used for the ini-
CNPG. tial assessment of multiple injury patients admitted to the
However, 17.2% of the nurses did not comply with the use trauma ward, which was developed in this study, was found
of the CNPG. There were two aspects of the CNPG where the to be useful in promoting the early detection of missed
nurses indicated a lower rate of compliance. The rst was injuries. The nurses compliance with the use of the CNPG
pain assessment of semiconscious or unconscious patients and their satisfaction rate in its use were found to be at
which caused the nurses to have difculty in assessing pain high levels. Therefore, further studies at other institutions
using the numerical rating scale. The second aspect was as well as with more junior nursing staff are recommended
poor compliance in performing a head-to-toe physical exam- to establish if this CNPG could be more widely used for the
ination within 24 h of the initial ward admission. This poor initial re-assessment of multiple injury patients admitted
compliance may have been due to the high workload of to trauma wards providing secondary level trauma care in
nurses when there were large numbers of newly admitted Thailand.
patients during evening or night shifts when only two reg-
istered nurses were on duty in each shift. Therefore, the
nurses were often busy doing paperwork and providing bed- Funding
side nursing care when many multiply injured patients were
admitted during their shift. This study was funded by Prince of Songkla University.
The development of clinical nursing practice guideline for initial assessment in multiple injury patients 99

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