P17: IMPROVING PLASTIC SURGERY OPERATION NOTE ACCESSABILITY AT A MAJOR TRAUMA CENTRE: A PROSPECTIVE COMPLETED AUDIT CYCLE

Abstract Introduction Quality operation note documentation is essential for ensuring continuity of care amongst the multi-disciplinary team. The Royal College of Surgeons has published clear and succinct guidelines which outline the necessity for timely, accurate and accessible operation note documentation. Our department uses a bespoke electronic operation note template which is stored within a departmental database. The aim of this study was to evaluate the effect of online operation note guidance on the accessibility of operative documentation. Method A prospective audit of operation note documentation was conducted during two one-month periods in May and November 2018. All reconstructive surgical procedures, both trauma and elective, were included. A bespoke online reminder system was introduced to our electronic platform to encourage operation note upload onto electronic medical records. Result 224 cases (127 elective, 98 consultant-led) were included in the initial audit and 239 cases (173 elective, 131 consultant-led) in the post-intervention audit. 56% of operation notes were accessible to nursing staff pre-intervention. Post-intervention 83% of operation notes were accessible to nursing staff (p< 0.05). No significant correlation was found between operation note accessibility and the type of case (elective vs emergency, r= -0.179), grade of operating surgeon (consultant vs registrar, r=0.259) and the number of operating surgeons (r=0.208). Conclusion This study highlights the importance of operation note accessibility to every member of the multidisciplinary team. A pop-up based intervention significantly improved accessibility of operation notes within electronic medical records although performance remains significantly below the expected standard. Take-home message The use of bespoke, online platforms may limit access to operation notes. A simple, pop-up based intervention significantly improves upload rate to electronic medical records however accessibility remains significantly below the expected standard.

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Improving Communication Between Nursing Staff and Surgery Residents in the age of Electronic Medical Records

The American Surgeon ◽

10.1177/0003134820956290 ◽

2020 ◽

pp. 000313482095629

Author(s):

Jacob Veith ◽

Katherine Spitz ◽

Kevin Luftman ◽

Samuel Long ◽

Joselyn Martin ◽

...

Keyword(s):

Electronic Medical Records ◽

Nursing Staff ◽

Medical Records

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171 Early senior assessment and access to CT in an emergency department

Emergency Medicine Journal ◽

10.1136/emj-2020-rcemabstracts.10 ◽

2020 ◽

Vol 37 (12) ◽

pp. 831.1-831

Author(s):

Marta de Andres Crespo ◽

Cheryl Zogg ◽

Alex Novak ◽

David Metcalfe

Keyword(s):

Emergency Department ◽

Time Series ◽

Rat Model ◽

Trauma Centre ◽

Interrupted Time Series Analysis ◽

Post Intervention ◽

Electronic Health Record Data ◽

Early Evaluation ◽

Major Trauma Centre ◽

Ct Head

Aims/Objectives/BackgroundThe Rapid Assessment and Treatment (RAT) model provides early senior assessment of undifferentiated ‘majors’ patients and has been proposed as a strategy for improving Emergency Department (ED) efficiency. One goal of RAT is to organise essential imaging at an earlier stage within the patient’s ED journey. This study aimed to identify any potential early impact of a RAT initiative on time to imaging for patients requiring CT head.Methods/DesignElectronic health record data were extracted for all patients that underwent head CT while in the ED over a 54-month period (48 months pre-intervention and 6 post-intervention) at a single Major Trauma Centre in England. Interrupted time series analysis was used to estimate any effect of RAT on time from ED arrival to imaging.Results/ConclusionsThere was a pre-existing gradual trend over the entire time series towards patients waiting less time for CT. Although time to CT appeared to increase when the RAT model was implemented, this change was small and not statistically significant (9.8 [95% CI -1.6 to 21.3] minutes). Following RAT implementation, the pre-existing trend towards quicker access to CT resumed but without any change in the slope of the line.This early evaluation did not identify an association between RAT implementation and speed of access to CT head. The system may mature over time and further evaluations will be necessary to identify delayed effects on access to imaging as well as other process measures intended to improve ED safety and efficiency.

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Improving Communication between Nursing Staff and Surgery Residents in the Age of Electronic Medical Records

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2018.07.480 ◽

2018 ◽

Vol 227 (4) ◽

pp. S219

Author(s):

Jacob P. Veith ◽

John M. Uecker ◽

Kevin M. Luftman ◽

Sadia Ali ◽

Jared Bell ◽

...

Keyword(s):

Electronic Medical Records ◽

Nursing Staff ◽

Medical Records

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Perception of electronic medical records (EMRs) by nursing staff in a teaching hospital in India

International Journal of Advanced Medical and Health Research ◽

10.4103/2349-4220.148008 ◽

2014 ◽

Vol 1 (2) ◽

pp. 75 ◽

Cited By ~ 4

Author(s):

NaveenKumar Pera ◽

Amrit Kaur ◽

Raveendra Rao

Keyword(s):

Electronic Medical Records ◽

Teaching Hospital ◽

Nursing Staff ◽

Medical Records

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83 Closed Loop Audit Examining Documentation of Advanced Trauma and Life Support (ATLS) Secondary Survey in Polytrauma Cases at The Royal Infirmary of Edinburgh (RIE)

British Journal of Surgery ◽

10.1093/bjs/znab134.363 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

J Balfour ◽

M Powell-Bowns ◽

J Leow ◽

C Arthur

Keyword(s):

Life Support ◽

Trauma Centre ◽

Royal Infirmary ◽

Local Policy ◽

Post Intervention ◽

Exact Test ◽

Major Trauma Centre ◽

Secondary Survey ◽

Polytrauma Patients ◽

Mean Time

Abstract Introduction Secondary survey is a key aspect of the ATLS guidelines in avoiding missed injuries in polytrauma patients. Aim: Evaluate the documentation of secondary survey in polytrauma cases admitted to the RIE A+E department. Method Standard audit protocol, retrospective data collection. Polytrauma patients and patients requiring Trauma CT were identified from the local trauma database. Primary outcome was successful completion and documentation of secondary survey. Cycle 1: All patients from 01/01/2015-01/09/2015. Local policy change included an A+E trauma booklet and policy of secondary survey on admission to Intensive Care. Cycle 2 was completed post-intervention for patients presenting between 11/01/2019-29/05/2019. Results Cycle 1 (N = 20, N Secondary survey documented=10, mean=50%). Mean time to secondary survey was 8 hours (range 3-49). Cycle 2 (N = 28, N Secondary survey documented=24, mean=87.5%). Mean time to a secondary survey was 4 hours 30 minutes (range=1-21hrs). Significant improvement in documentation (Fisher’s Exact Test, P = 0.017). Conclusions Implementation of the secondary survey protocol and trauma booklet significantly improved documentation of secondary survey in the polytrauma patient. Evidence also suggests improved time to secondary survey. However, documentation of secondary survey is not universal indicating further improvement is required in trauma care, as the RIE moves towards becoming a National Major Trauma Centre.

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