Improving critical care discharge summaries: a collaborative quality improvement project using PDSA

Strategies to Improve Compliance with Clinical Nursing Documentation Guidelines in the Acute Hospital Setting: A Systematic Review and Analysis

Introduction

This systematic review attempts to answer the following question - which strategies to improve clinical nursing documentation have been most effective in the acute hospital setting?

Methods

A keyword search for relevant studies was conducted in CINAHL and Medline in May 2019 and October 2020.Studies were appraised using the Joanna Briggs Institute (JBI) critical appraisal for quasi-experimental studies. The studies were graded for level of evidence according to GRADE principles.The data collected in each study were added to a Summary of Data (SOD) spreadsheet. Pre intervention and a post intervention percentage compliance scores were calculated for each study where possible i.e. (mean score/possible total score) × (100/1). A percentage change in compliance for each study was calculated by subtracting the pre intervention score from the post intervention score. The change in compliance score and the post intervention compliance score were both added to the SOD and used as a basis for comparison between the studies. Each study was analyzed thematically in terms of the intervention strategies used. Compliance rates and the interventions used were compared to determine if any strategies were effective in achieving a meaningful improvement in compliance.

Results

Seventy six full text articles were reviewed for this systematic review. Fifty seven of the studies were before and after studies and 66 were conducted in western countries. Publishing dates for the studies ranged from 1991 to 2020.Eleven studies included documentation audits with personal feedback as one of the strategies used to improve nursing documentation. Ten of these studies achieved a post intervention compliance rate ≥ 70%.

Conclusion

Notwithstanding the limitations of this study, it may be that documentation audit with personal feedback, when combined with other context specific strategies, is a reliable method for gaining meaningful improvements in clinical nursing documentation. The level of evidence is very low and further research is required.

Improving communication of patient issues on transfer out of intensive care

The written medical handover document is frequently poor in quality and highly variable which raises concerns about patient safety. Intensive care unit (ICU) patients have complex medical and social issues which increases the risk of errors during ongoing hospital treatment. Our project team of four doctors and two nurses aimed to improve the documentation of patient problems as they leave the ICU.

A literature review and process mapping of both medical and nursing transfer documentation helped in understanding the current process. Current problems (CP) were defined as any patient issues which require ongoing thought, management or follow-up.

Our progress was tracked using a measure of the number of CPs listed in the free-text field titled ‘Current Problems’ in 50 medical transfer documents. This was graphed on a control chart showing a process in statistical control. Means and control limits were recalculated whenever a process shift occurred.

There was no relationship between the number of CPs listed and length of ICU stay, age of patient, or severity of illness on presentation (Acute Physiologic Assessment and Chronic Health Evaluation II score). An inter-relationship graph identified the key drivers which were amenable to change: (1) the doctors completing the clinical summary at the time of discharge did not have all the information readily available to them and (2) the doctors were uncertain of the types of problem which should be communicated.

Improvements were designed and trialled using Plan-Do-Study-Act cycles to address these two key drivers. At baseline, the average number of CPs per patient was 1.8. After implementation of a paper problem list at the patient bedside, with supporting education, the average increased to 2.7. This was further improved by the addition of a checklist of common patient problems. This increased the average to 3.85.

These improvements were permanently implemented and ongoing audits have shown sustained improvement using statistical process control methods.

Intensive care discharge summaries for general practice staff: a focus group study

BACKGROUND

Understanding how patients and relatives can be supported after hospital discharge is a UK research priority. Intensive Care Unit (ICU) discharge summaries are a simple way of providing GPs with the information they require to coordinate ongoing care, but little evidence is available to guide best practice.

AIM

This study aimed at better understanding the information needs of GP staff (GPs and practice nurses) supporting former patients of ICUs and their families following discharge from hospital, and identifying the barriers/facilitators associated with ICU-primary care information transfer.

DESIGN AND SETTING

This was a qualitative exploratory study of practices and participants throughout the UK.

METHOD

Audiotaped focus group discussions, complemented by small-group/individual interviews, were conducted with 15 former patients of ICUs, four relatives, and 20 GP staff between June and September 2015. Demographic data were captured by questionnaire and qualitative data were thematically analysed.

RESULTS

Findings suggest variability in discharge information experiences and blurred lines of responsibility between hospital and GP staff, and patients/relatives. Continuity of care was affected by delayed or poor communication from the hospital; GPs' limited contact with patients from critical care; and a lack of knowledge of the effects of critical illness or resources available to ameliorate these difficulties. Time pressures and information technology were, respectively, the most commonly mentioned barrier and facilitator.

CONCLUSION

Effective rehabilitation after a critical illness requires a coordinated and comprehensive approach, incorporating the provision of well-completed, timely, and relevant ICU-primary care discharge information. Health professionals need an improved understanding of critical illness, and patients and families must be included in all aspects of the information-sharing process.

Improvement Science: conceptual and theoretical foundations for its application to healthcare quality improvement

The development and study of healthcare quality improvement interventions have been reshaped, moving from more intuitive approaches, dominated by biomedical vision and premised on easy transferability, to gradually acknowledge the need for more planning and systematization, with greater incorporation of the social sciences and enhancement of the role of context. Improvement Science has been established, with a conceptual and methodological framework for such studies. Considering the incipient of the debate and scientific production on Improvement Science in Brazil, this article aims to expound its principal conceptual and theoretical fundamentals, focusing on three central themes: the linkage of different disciplines; recognition of the role of context; and the theoretical basis for the design, implementation, and evaluation of interventions. Resumo: O desenvolvimento e estudo de intervenções para a melhoria do cuidado de saúde tem ganhado novo contorno, movendo-se das abordagens mais intuitivas, com domínio da visão biomédica e assentadas no pressuposto de fácil transferibilidade, para gradativamente reconhecer a necessidade de mais planejamento e sistematização, com maior incorporação das ciências sociais e valorização do papel do contexto. A Ciência da Melhoria do Cuidado de Saúde vem se estabelecendo, propiciando referencial conceitual e metodológico para tais estudos. Considerando a incipiência do debate e produção sobre Ciência da Melhoria do Cuidado de Saúde no Brasil, este artigo objetiva discorrer sobre as principais bases conceituais e teóricas que a sustentam, com foco em três temas centrais: a articulação de diferentes disciplinas; o reconhecimento do papel do contexto; e o embasamento teórico para o desenho, implementação e avaliação das intervenções.

Improving the efficacy of elderly patients' hospital discharge through multi-professional safety briefings and behavioural change

At Leeds Teaching Hospitals NHS Trust doctors type an electronic discharge advice note (eDAN) which includes a prescription for discharge medication, before a patient can be discharged from hospital. In 2014 staff on the Medical Admissions Unit for Older People identified significant delays in the completion of this document, with an average completion time of 138 minutes. This caused patient harm and exacerbated bed management problems as patients remained in hospital longer than necessary to obtain their discharge medication. Ward staff wanted to improve the efficacy of older peoples’ discharge by speeding up this process in as safe a manner as possible. A number of interventions were tested, led by junior doctors in a ‘bottom-up’ leadership strategy. Interventions included a daily discharge briefing to recap discharges and help junior doctors prioritise workload. After several months of sustained effort, the average time to complete eDANs fell by over an hour resulting in discharge medication dispensed earlier in the day and improved patient safety.