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G502(P) Improving documentation in the intensive care environment
  1. LC Winckworth,
  2. S Hines
  1. Neonatal Department, University College Hospital, London, UK

Abstract

Aims Intubations are commonly performed in neonatal units but record keeping is often poor. This study determined the adequacy of documentation surrounding neonatal intubations and the subsequent impact of introducing a new intubation-specific procedure sheet.

Methods Data was collected on all babies (n = 138) admitted to NICU over a two month period. The medical notes of each were reviewed and relevant information regarding each intubation extracted. An intubation-specific procedure sheet containing 15 items was then introduced as part of standard care. After six months a second cohort of neonates were studied over a two month period (n = 168) and the same data collected for comparison.

Results 102 babies were intubated over the 4 month period, with notes available for 89 (87%). Record keeping was universally poor prior to procedure sheet introduction with only 4 categories completed in at least 75% of notes (Table 1). Several categories were extremely poorly documented (present in less than 30% of notes): grade view, length endotracheal tube was cut, position on chest radiograph and final length after adjustment. The most reliably completed category was the signature of the documenter, seen in 84% of cases. There was a significant improvements in all other 14 areas of documentation following procedure sheet introduction (P values <0.001–0.04). Eight categories were completed in over 90% of notes, 11 in 75% and only 1 category was documented less than 50% of the time. However sheets were only completed in 57% of intubations, with the poorest uptake being after delivery room intubations (used in 35%).

Conclusions Documentation was severely substandard prior to the procedure sheet introduction. Using the sheet resulted in immediate and significant improvements but uptake needs to be increased. There remains further room for improvement, particularly around recording radiograph findings and final endotracheal tube adjustments. Clear and accurate record keeping in medical notes is of great importance – not only as a legal record but also to aid subsequent professionals, particularly if a difficult task. Procedure sheets such as this provide a rapid way to significantly improve documentation.

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