Context A tertiary neonatal intensive care unit (NICU). Involved were the unit doctors, and advanced nurse practitioners (ANPs).
Problem Cranial ultrasound scanning (CrUSS) is a useful diagnostic tool used for assessment of brain structure, identification of pathology, and for monitoring. The doctors and ANPs scan inpatients on the NICU. There was no formal guidance as to when these ought to be done, on whom, and how to documented findings. I identified a need for clarity and formalisation of the scanning process and documentation.
Assessment of problem and analysis of its causes I undertook an audit of inpatient notes looking at when scans were done, why they were done, and what had been documented. I asked the consultants to formalise when they would expect a baby to be scanned, what documentation they expected, and what scanning schedule they anticipated would be required. The standard for the audit was that uniformly agreed by the consultants. We found that all who should be scanned were (preterm, had required ventilation, had suffered Hypoxic Ischaemic Encephalopathy, or had another reason e.g risk factor for brain injury/anatomical variation detected antenatally), however there were varying time frames in-between scans, with little guidance for the junior scanning team as to when the next scan should be scheduled. Essential documentation including the date/ time of the scan, gestation of the baby, and a legible name of the scanning doctor was poor.
Intervention I created a unit guideline formalising scanning procedure, schedules, expected views and a template for documentation. The template provides a section separate from other radiological reports for ease of clarity reviewing when scans have been done, what the findings were, and when the next scan is due (Figure 1).
Strategy for change The findings of the initial audit were presented to the NICU in February 2014. I created the guideline and documentation template in agreement with the consultant body over the next nine months. A poster summarising the guideline and demonstrating the new documentation template was placed in the doctors office and on our "one minute wonder education board" for all staff to read. The documentation template was emailed to the medical team by the consultant in charge of clinical governance, and printed copies placed ready for use in our documentation trolley. The guideline is available in our unit guidelines folder.
Measurement of improvement The guideline, documentation template and poster have been implemented from November 28th 2014. After 8 weeks I will reaudit inpatient notes on the NICU, and have the findings ready to present at our unit Audit Presentation meeting on February 4th 2015, and at the RCPCH annual conference 2015.
Effects of changes We anticipate this project will help us optimise patient care by providing accessible reports, guiding the team as to when the next scan is due so that we provide a scanning schedule appropriate to each baby. Medicolegally the template provides clear evidence as to who undertook the scan, when it was done, what was found, and if a consultant reviewed it.
Lessons learnt Creating a unit guideline and template for documentation required agreement from all the Consultants. This takes time to arrange. The motivating factor is the knowledge that you are improving the quality of care you give to patients.
Message for others It is important that there is a structured approach in a unit where junior team members change every 6 months, rotating gives us the opportunity to provide insight into areas that could be improved and to implement change.
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