Documentation of Communication with relatives in the ICU
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Transcript of Documentation of Communication with relatives in the ICU
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Documentation of Communication with relatives in the ICU
Dr Michael McGinlay
ST3 Anaesthetics
Craigavon Area Hospital ICU
Coppel Prize 2014
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Background• A patient can receive perfect medical care, whereas the documentation
may have flaws (1)
• Historically documentation of family discussions in medical notes is poor
• “time and again, poor communication with patients and their families is at the core of what goes wrong” (2)
• Relatives of the critically ill often become surrogate decision makers therefore thorough documentation of these meetings is essential
• Documentation is time consuming thus we must do so efficiently in order to carry out our primary duty, providing patient care (3)
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Aims• To determine how well communication with patient relatives is
documented by medical staff and whether this is consistent with nursing notes
• To assess the relationship between patient age, length of stay, illness severity and mortality on the frequency of documentation
• To determine whether or not the implementation of a dedicated communication insert improves frequency of documentation by junior medical staff through re-audit
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Method• Retrospective analysis of patient case notes who were admitted to
Craigavon Area Hospital ICU between July and August 2013
• Data obtained by screening both medical notes and a dedicated ‘relative communication sheet’ within the nursing notes
• Number of communication episodes documented and grade of documenter from both medical and nursing notes was collated and compared
• Other data including patient age, length of ICU stay, ICNARC score, degree of invasive organ support and clinical outcome was obtained
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Results (1)
• 42 case notes of patients admitted between July and August 2013
• A mixture of medical (n=23) and surgical (n=19) patients
• Age ranging between 22 and 89 years old (mean 62 years)
• ICU length of stay ranged from 1 to 26 days (mean 4.4 days)
• A total of 11 NFR orders were placed and 9 deaths occurred
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• 46 medical entries (over 22 case notes)• 1-5 entries per patient• Content variable• Significant variation in time to first entry• Consultant documentation in all 9 deaths / 2 NFR orders
Medical Documentation
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ICU LOS Age
Illness Severity Organ Support
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• 191 entries (145 ward / 45 phone)• Ranging 1 – 33 entries per patient• Content variable• Additional 32 additional discussions with medical staff documented
Nursing Documentation
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Conclusions• Overall documentation of communication with relatives by medical staff
was poor despite evidence from the nursing notes that communication was taking place
• Nursing documentation was significantly better, correlating well with medical notes although actual content was variable
• Trend to document discussions with relatives in those patients who have a greater severity of illness, longer duration of stay or predicted death
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A Potential Solution ?
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Results (2)
• 42 case notes of patients admitted between July and September 2014
• Medical (n=24) and surgical (n=18) patients
• Patients aged between 23 and 95 years old (mean 64)
• ICU length of stay ranging from 1-18 days (mean 4.4 days)
• A total of 12 NFR orders in place with 9 deaths
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• 56 entries (over 20 case notes)• 1-7 entries per patient• Dedicated communication sticker used in 10 case notes
19 used in total (consultants 9, trainees 11)• Consultant documentation in all 9 deaths / 3 NFR orders
Medical Documentation
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ICU LOS Age
Illness Severity Organ Support
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• 185 nursing entries made (144 Ward /41 Phone)• 1-20 entries per patient• Content variable • Additional 27 family discussions with medical staff were documented
Nursing Documentation
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Conclusions
• An increase in the frequency of documentation was observed although the overall number of patients with a single entry remains relatively unchanged
• Lack of significant improvement following introduction of this sticker
• Continues to demonstrate that communication with family members is occurring despite poor documentation
• Emphasises that nursing staff remain vastly superior in this regard but they should not be relied upon to document on behalf of medical staff
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Key Points• We as medical staff need to become more vigilant when it comes to
documenting family discussions
• Evidence to suggest we are communicating better than what we are documenting
• Use of a dedicated communication sticker within CAH ICU may allow us to reduce the time spent on documentation and promote a positive change in documenting culture, particularly amongst trainees
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References1. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW.
Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007; 297:831-41
2. Girbes Armand R.J, Zijlstra, Jan, G. Spend time on patients and families or on documentation.. Anaesthesia and Analgesia 2009 Vol 109, No 3
3. Health Service Ombudsman’s Review January 2013
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Thank You