883 A Closed-Loop Audit to Improve Admissions Documentation in A Busy ENT Department. (12th October 2021)

• Record Type: Journal Article
• Authors: Connelly, A; Law, K; Williamson, A
• Is Part Of: British journal of surgery. Volume 108:Supplement 6(2021)
• Publication Date: 2021-10-12
• Subjects: Surgery -- Periodicals; 617.005
• DOI: 10.1093/bjs/znab259.108
• Languages: English
• ISSNs: 0007-1323

Abstract

Abstract: Aim: Accurate and thorough admissions documentation is crucial for patient safety and effective care. We amended the admissions pro-forma used on a busy adult ENT ward to improve adherence to a modified version of Royal College of Surgeons of England guidelines. Method: Baseline documentation of the 25 parameters of interest was assessed using electronic medical records for all emergency and pre-operative admissions over a 4-week period (n = 75). A new pro-forma was introduced, and the documentation over the following 4 weeks (n = 75) was assessed in the same way. Statistical analysis was done using Excel and RStudio (z-test for two proportions, p-value ≤ 0.05). Results: The two groups were similar in age, gender, length of stay, and presenting complaint. The new pro-forma was completed for more admissions than the prior version (91% vs 77%) and resulted in documentation improvements in 19 out of 25 parameters. 9 of these were statistically significant, including initial vital signs and differential diagnosis. Parameters that improved, but not significantly, include admission source, medication history, and cognitive assessment. Across the 8 weeks, using a pro-forma (n = 126) significantly improved documentation of 11 parameters compared to freehand clerking (n = 24). Conclusions: Adequate documentation at admission can help with immediate patient care, and act as a point of reference during extended stays. We were able to increase use of a pro-forma and produce meaningful documentation improvements quickly. Further work is required to assess why certain parameters are infrequently completed, and how future pro-forma iterations can become more user-friendly.