Context Lumbar puncture (LP) is one of the most common invasive procedures performed in paediatrics. It generally causes a lot of anxiety to the child and parents. There are known post LP complications, such as headaches, discomfort, infection, and risk of not obtaining cerebrospinal fluid (CSF). Parents should be appropriately informed on the procedure: the way it is done, potential complications, and more importantly the reason for the procedure, and when results should be expected. Verbal information given under stressful situations is forgotten and not comprehended, hence the importance of a parent information leaflet. If complications arise, there can be medico legal implications; therefore correct documentation is essential for patient safety and good clinical practice. Different shift patterns may lead to miscommunication of investigations requested and results.

Problem Poor documentation of procedure and management of patient (pre-LP blood sugar, or macroscopic feature of CSF), will result in trying to piece together various sources for information and impacts on patient safety. Furthermore good documentation including consent and peri-procedure care, is important for patient safety.

Assessment of problem and analysis of its causes A retrospective observational study was conducted between September and November 2015 to identify 20 lumbar punctures carried out in the children’s emergency department and the paediatric ward, to assess baseline standards of documentation. A total of 17 notes were obtained, and analysis of the documentation showed only 65% of consent documented. Pre-LP BM’s were only done in 18% of cases. Regarding the results, macroscopic features were documented in 71% of cases. However there was no documentation regarding whether the fluid was sent for viral PCR’s.

Intervention In order to try and improve documentation, we created an A4 proforma, which is self-explanatory and easy to complete, with all the essential information required from this procedure. To improve documentation on consent, we created a parent information leaflet explaining the implications of a lumbar puncture.

Study design Prior to the intervention, documentation was poor, as shown by the above numbers. We aim to implement the intervention, and to look at the change after two months.

Strategy for change and Measurement of improvement We are planning to collect a further 20 patients two months after having implemented the change.

Effects of changes We suspect this will significantly improve documentation, as it is a time saving and easy to use tool. One will not only be guided on what to document, but also on how to carry out the procedure (aseptic technique, importance of doing a blood sugar)

Lessons learnt Use of a proforma improves documentation. Parents prefer written documentation to support oral information given.

We are aware that the limitation of this study is that a lot of systems are now computerised, Investigations sent will be recorded via computer system, and documentation can be done electronically. This is a tool that could potentially be integrated to a computer program.

Message for others Appropriate documentation of LP procedures is important both for patient safety and medicolegal purposes. Quality improvement measures such as proformas and patient leaflets are an effective tool in ensuring documentation is standardised and optomised.