Conrad Lee, CT2

July 2014- Sep 2014

T&O, BSUH

Wardround documentation auditJune - Aug 2014

Section 1: Background

Background Aims /Method Results Discussion Conclusion

Current literature / guidelines

Why is good documentation important?

• Support safe and effective patient care

• Medical-legal

Current literature / guidelines

Documentation in wardrounds

• Crucial part in continuity of patient’s care.

• Written communication to colleagues

Current literature / guidelines

“You must keep clear, accurate and legible records”

- GMC Good Medical Practice 2013

Current literature / guidelines

Current Standards / guidelines

- Health informatics Unit, Royal College of Physicans, April 2008

“The standards should be used for all hospital patient records”

Current literature / guidelines

But it’s not always that simple ...• Time pressure

• Accessibility of notes

• Number of staff on the round

• Staff experience

• Who is leading the round

BackgroundBackground

Section 2: Aims & Method

Aims /Method Results Discussion Conclusion

Aims:

1. Assess our current standards of wardround documentations

2. Compare current practise with best practice guidelines

3. Explore and suggest ways to improve current practice

4. Define an agreed action plan and implement improvement changes

Methods:

• Concurrent observational study

• 8 weeks – 23rd June to 17th Aug

• Exclusions: paediatric, orthogeri

• Random selection of wardround entries

Variables 1. Wardround details2. Clinical details3. Management and

Investigations 4. Clinical assessment 5. Management plan 6. Documenting doctor

Wardround details

Clinical details

Management and investigations

Clinical assessment

Management plan

Documenting doctor

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

86.00%

11.60%

12.70%

42.30%

92.00%

62.80%

On average

Section 1: Background

BackgroundBackgroundBackground

Section 3: Results

Aims /Method Results Discussion Conclusion

Results:

74 wardround entries reviewed

• 9 weekend entries

• 7 outliers

57

3

12

2

lower limb

polytrauma

spine

upper limb

P.T.O…

Wardround details

Name of consultant leading wardround

Entry date

Entry time

Patient identification

96%

97%

86%

66%

% documented

P.T.O…

Clinical details

Active issues

Resus status

Sig PMH

Diagnosis

Admission date

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

34%

1%

5%

18%

0%

% documented

P.T.O…

Management and investigations

Radiology report

lab results

Management undertaken

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

5%

9%

24%

% documented

P.T.O…

Clinical assessment

Clinical impression

Discussion with patient

Observations

Examination findings

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

34%

35%

62%

38%

% documented

48%38%

14%

obs stable apyrexia (n=36)not documented (n=28)actual obs reading (n=10)

P.T.O…

Management plan

Dicharge plans

weightbearing status*

Ongoing managment plan

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

19%

14%

92%

% documented

P.T.O…

Documenting doctor

contact bleep

grade

signature

name of doctor

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

70%

45%

82%

54%

% documented

Wardround details

Clinical details

Management and investigations

Clinical assessment

Management plan

Documenting doctor

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

On average

Section 1: Background

BackgroundBackground

Section 4: Discussion

Aims /Method Results Discussion Conclusion

Yeah.. The results are pretty poor, so what?

Wardrounds have always been like this and it has worked “fine”, why change now and create hassle???

We should not just look at the figures, but focus on why good documentation is really important for ours patients and staff.

Who are the stake holders?

Example scenario:

What is in the literature?

checklists / proforma Electronic wardrounds

Proformas

4) Using a proforma to improve standards of documentation of an orthopaedic post-take ward round - BMJ Qual Improv Report. 2013

2) Do post-take ward round proformas improve communication and influence quality of patient care? - Postgrad Med J. Nov 2004

3) A Considerative Checklist to ensure safe daily patient review- The Clinical Teacher. August 2013

1) Why patients need leaders: introducing a ward safety checklist- J R Soc Med. September 2012

Proformas BSUH Surgical department – wardround proforma

Initial resistance from consultants and some registrars, but highly favoured by junior doctors and nursing staff

6 week reaudit showed improved documentation

Proforma to be made more user friendly

limiting factors to complete documentation - Time pressure - Variability between juniors

Proformas

Pros Cons

Improve standard of documentation

Better written communication

Promote patient safety

Educational value for students

More sheets of paper

?longer wardrounds

We don’t know unless we try

Electronic wardrounds

Electronic wardrounds

Birmingham Women’s Hospital’s neonatal unit, 2013

• Wardround with portable laptop

• Self-programmed wardround spreadsheets, prepopulated lists, can be wirelessly printed

• Reduction of WR time from 5 hours to 4 hours

• Improved documentation (100% legible) and handover standards

Electronic wardrounds

“There were a lot of staff who were sceptical and the NHS is set in its ways. I believe the system we developed could be of benefit to everywhere that does an in-patient ward round.”

- Dr Sarah Steadman

Electronic wardrounds

ELECTRONIC WARDROUNDS!? Sounds like a distant future for us at BUSH…

Electronic wardround:

Pragmatic solutions:

1. Education 2. Improve ease of patient note access and navigation3. MDT wardrounds 4. Wardround “checkers”5. Be conscientious of the limits of juniors (a human being)6. Proformas 7. Electronic wardround

BackgroundBackground

Section 5: Conclusion

Aims /Method Results Discussion Conclusion

• Wardround documentations are substandard

• Causes of poor documentation is multifactorial, but can be improved

• We should aim for EMR, but we need to take small steps by step improvements to reach this using a MDT approach

Conclusion:

Action plan

References• Why patients need leaders: introducing a ward safety checklist - J R Soc Med. September 2012

• Do post-take ward round proformas improve communication and influence quality of patient care? - Postgrad Med J. Nov 2004

• A Considerative Checklist to ensure safe daily patient review - The Clinical Teacher. August 2013

• Using a proforma to improve standards of documentation of an orthopaedic post-take ward round - BMJ Qual Improv Report. 2013

• Electronic Ward Rounds and #HandoverProject – improving quality while increasing efficiency - Arch Dis Child 2014

Background Aims /Method Results Discussion Conclusion