Dataset Information

Giving ourselves a head start: improving the quality of documentation of referrals to neurosurgery.

ABSTRACT: Referrals to neurosurgical units are regularly made by doctors in the emergency department (ED), intensive care and acute medicine, following brain injuries sustained by both traumatic and non-traumatic processes. Although some centres accept electronic referrals, many still rely on telephone conversations with a specialist registrar. The flaw in this style of communication is that only information volunteered or requested is relayed. Furthermore, documentation of these dialogues is often incomplete, omitting specific and vital details. Inconsistent advice from referral centres on the management of such brain injury cases had been highlighted, prompting a review of practices at local level in order to improve quality of patient care. The aim of this project was to identify the current level of documentation and improve this through departmental education and implementation of a referral proforma. National guidelines and a literature review were used to formulate the gold standard for high quality documentation. ED patient notes were retrospectively reviewed over a three month period, assessing adequacy of referral documentation to a neurosurgical centre against the parameters previously set. Initial audit results and specific case studies were presented to ED team members at an educational meeting. A "record of telephone referral to neurosurgery" (RTRN) form was also introduced. Re-audit against the same set of standards was conducted to assess any change in level of documentation and use of the form itself. The results of this project have shown that, although departmental education improves clinical practice, following the introduction and use of a protocol such as the RTRN there was a significant improvement in the level, and therefore quality of, documentation.

SUBMITTER: Storey M

PROVIDER: S-EPMC4645841 | biostudies-other | 2015

REPOSITORIES: biostudies-other

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Giving ourselves a head start: improving the quality of documentation of referrals to neurosurgery.

Storey Madeleine M Webster Simon S

BMJ quality improvement reports 20150312 1

Referrals to neurosurgical units are regularly made by doctors in the emergency department (ED), intensive care and acute medicine, following brain injuries sustained by both traumatic and non-traumatic processes. Although some centres accept electronic referrals, many still rely on telephone conversations with a specialist registrar. The flaw in this style of communication is that only information volunteered or requested is relayed. Furthermore, documentation of these dialogues is often incomp ...[more]

PMID: 26734334

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Project description:Record keeping for patients on non-invasive ventilation (NIV) at St. Georges Hospital is poor. The initial NIV prescription is often not recorded, and changes to the NIV prescription or the rationale for the changes (ABG results) are also poorly documented. This leads to confusion for nurses/doctors as to what the correct settings are, meaning patients could receive ineffective ventilation. The use of NIV is also poorly recorded by nursing staff meaning that doctors are unsure if the prescribed NIV is being achieved. This can lead to treatment being escalated unnecessarily in the event of treatment failure. Non-invasive ventilation (NIV) is the provision of ventilatory support in the form of positive pressure via the patient's upper airway using a mask or similar device. NIV is indicated for treatment of acute hypercapnic respiratory failure, of which there are many causes, though COPD is the indication in up to 70% of cases.[1] British Thoracic Society (BTS) guidelines for NIV suggest that the rationale for commencing a patient on NIV and the proposed settings should be clearly documented.[2] Clinicians cannot effectively tailor changes to the patients NIV settings if this information is not clearly recorded, which could lead to increased time requiring NIV or NIV failure. Three main areas were considered important to measure for this project. The initial prescription of the NIV, changes to the NIV settings, and nursing documentation surrounding NIV. A baseline measurement of NIV documentation for two weeks found NIV documentation to globally very poor. NIV was formally prescribed 29% of the time, full detail of intended settings were documented 57% of the time, the decision to commence NIV was discussed with the respiratory consultant/SpR just 29% of the time and on no occasion was a decision regarding escalation of treatment recorded. Eighteen changes were made to the NIV settings. These were formally prescribed 22% of the time and detail of the intended settings was recorded 44% of the time. Nursing documentation included detail on the length of NIV use just 21% of the time, and comments on the NIV use were left just 33% of the time. The intervention was a unified four page NIV prescription chart. Page 1: An area for the NIV to be initially prescribed with reminder questions for important considerations. Page 2: An area for changes to be made to the NIV settings. Page 3: An area for the most up to date NIV/respiratory plan to be documented. Page 4: Nursing documentation, with prompts for the time NIV was put on/off and for comments. The chart was printed at St Georges print services and paid for by the respiratory ward. A further two weeks of monitoring followed after implementation of the new chart. Improvements were seen in all areas of documentation surrounding NIV. The NIV was formally prescribed 86% of the time compared to 29% pre-intervention. The NIV settings were stated 100% of the time in the initial prescription. An escalation decision was recorded 71% of the time. Changes to the NIV settings improved to 92%. Nursing documentation improved greatly. The length of the NIV use was recorded for 91% of NIV days compared to 21% previously (p<0.001), and comments on the use of NIV improved from from 33% to 98% (p<0.001). Cases where the documentation remained poor were in those patients for whom the new chart had not been used. The implementation of a unified NIV prescription chart to be kept in the bedside notes on the respiratory ward greatly improved documentation surrounding NIV. Further work must be done to ensure that the chart is used 100% of the time. This will include adjusting the chart to reduce the workload to use it, rolling the chart out on the acute medical ward, and submitting the chart to the trust board for its acceptance as an official trust chart.

Dataset Information

Giving ourselves a head start: improving the quality of documentation of referrals to neurosurgery.

Publications

Giving ourselves a head start: improving the quality of documentation of referrals to neurosurgery.

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