Organization: MedStar Union Memorial Hospital Solution Title: Call 911: Our Documentation Died! Program/Project Description, including Goal: Our Emergency Department (ED) converted to an electronic medical record (EMR) in February 2013. It was a huge change going from a narrative paper flow sheet to a series of checkboxes and tabs on the computer. Despite in-service trainings, many nurses were uncomfortable with how and where to document their care. Charting the nursing process (assess, diagnose, plan, implement and evaluate) became a challenge in the new format and essentially our documentation died. Performance improvement reviews and requests for billing validation revealed deficient documentation. Patient safety and revenue were threatened. It was quickly noted that improving documentation directly impacts departmental goals of patient safety, continuity of care, reimbursement criteria, liability protection and staff efficiency. A quality improvement project was initiated to resuscitate nursing documentation to 80% compliance by Oct 2013 by developing documentation guidelines, educating staff, conducting monthly chart reviews and providing individual feedback. Process: Four bedside nurses and three leadership nurses formed a committee, Emergency Nurses Building Emergency Excellence (ENBEE) to create uniform documentation guidelines in April 2013. Nine areas directly affecting patient safety and continuity of care were targeted, including: vital signs, focused reassessments, intake and output, cardiac monitoring, pain assessments, purposeful rounding, discharge criteria, technician documentation and psychiatric care. ENBEE members conducted a literature search using Pub Med, Emergency Nurses Association (ENA), American Nurses Association (ANA), The Joint Commission (TJC) and hospital policies & procedures, but found little guidance on documentation in these nine areas. Solution: ENBEE created documentation guidelines (see attached tools) for the nine key areas based on the literature search, departmental policy and collective practice founded in the nursing process. The standardized guidelines outlined minimally expected documentation including what, where and how often to chart in the EMR. They included screen shots of the EMR highlighting exactly where to chart nursing care. A template was designed to assist ENBEE members in reviewing charts (see attached tools). All staff members were assigned to an ENBEE representative responsible for chart reviews and providing individual feedback. The reviewers check one chart per nurse per month for completeness in all of the nine areas plus fall risk and skin integrity assessments using the template. The documentation guidelines, chart review template and review process were disseminated to staff via emails, in-service trainings, staff meetings, orientation and job aids. Templates were collected and entered in Excel to track compliance. After implementation ENBEE created an additional set of critical care guidelines and matching chart check template to standardize other areas of ED documentation (see Tools below).
Measurable Outcomes: A total of 720 charts (including all ED nurses) were reviewed, highlighting 22 variables for completeness. A convenience sample of 143 charts were included in the data analysis. Of these charts, 54 were pre-enbee and 89 post-enbee guideline implementation. Comparisons were made between February/March 2013 (pre-enbee), October 2013 (post-enbee) and July/August 2014 (post-enbee). Although the small sample size resulted in no statistical significance, improvements were noted in 20 variables. Only two measures with very small sample sizes did not show improvement: pain education on discharge and suicide assessment every shift. Only eight of the 22 variables met the 80% compliance goal in Oct 2013, and only five of the 22 variables met the goal in July/Aug 2014. Pre-ENBEE (Feb & Post-ENBEE (Oct Mar 2013) 2013) Post-ENBEE (Jul & Aug 2014) Hourly Rounding 30% (15/50) 83% (20/24) 72% (42/58) Focused Re-assess 20% (9/46) 64% (14/22) 57% (28/49) Cardiac Monitoring 6% (1/18) 44% (4/9) 23% (8/35) Morse Falls 61% (33/54) 96% (23/24) 95% (56/59) VS every 2 Hours 41% (20/49) 65% (15/23) 60% (35/58) Pain Assess 78% (40/51) 100% (24/24) 83% (49/59) Skin 77% (41/53) 92% (22/24) 96% (55/57) Psych Nutrition Band 0% (0/3) 50% (1/2) 75% (3/4)
Percentage of Compliant Chart Reviews Pre-ENBEE (Feb/Mar 2013) Post-ENBEE (Oct 2013) Post-ENBEE (July/Aug 2014) Skin Assessment Morse falls Assessment Rounding-"not in room" documented, as applicable Hourly Rounding (+15 min & includes elimination, position & comfort) Initial Rounding (within 1 hr of assessment) Cardiac Monitoring (every 2 hr) Intake & Output Vein & artery specimen collection IV insertion & removal Pain education (dc pt) Pain score every 2 hours (+30 min) Pain reassessment within 1 hr of med Initial Pain assessment Psych-suicide asessment every shift & within 1 hr of handoff Psych-affect & LOC every 2 hrs Psych-nutrition band Psych-VS every 2hr if awake, 4hrs if asleep Focused re-assessment on ESI 4-5 (LOS > 5 hr) Focused re-assessment within 1 hour of handoff Focused Re-assessment (after intervention) VS 30 min prior to dc VS every 2 hr (+30 min) 0 10 20 30 40 50 60 70 80 90 100 Percentage of Compliance
Sustainability: Monthly chart reviews and feedback continue to occur. Direct staff evaluations have slowly increased charting awareness and compliance towards department goals. Most staff welcomed the documentation guidelines and monthly feedback, leading to the addition of critical care guidelines. Recognizing limitations such as poor overall compliance, reviewer variability, diverse styles of feedback, chart review time, resistance from some staff members, and high staff attrition has caused the committee to identify opportunities for change. ENBEE has expanded to recruit additional bedside nurses to assist with chart reviews; peer feedback and gaining more buy-in to the project. A share drive has been set up allowing for data entry and faster compilation. Based on user feedback ENBEE has managed to push through actual design changes in the EMR system. Poster and podium presentations of the guidelines have been shared with other MedStar facilities as well as at a national level through the Emergency Nurses Association (ENA). There are future plans to post monthly compliance reports for staff to view as well as survey staff for barriers to consistent compliance and brainstorm solutions. The members of ENBEE are committed to resuscitating our documentation and will adapt with the ever-changing EMR to improve patient safety, continuity of care, reimbursement criteria, liability protection and staff efficiency. Role of Collaboration and Leadership: Teamwork and collaboration played a significant role in the solution. The quality improvement initiative to resuscitate documentation in the ED was monumental and required teamwork beginning with the literature search to development of various guidelines to monthly chart reviews and individual feedback to ongoing education of staff and fellow colleagues. The ENBEE committee has expanded to include four additional bedside nurses. The ED is comprised of 70 nurses, 87% female and 13% male; half of the nurses have less than two years of nursing experience. Leadership sparked and sculpted the vision for success through active participation in ENBEE, supporting staff outside of clinical hours to work on the project and perform chart reviews. Hospital administration supported dissemination of this project by sending the entire committee to the national ENA convention in Indianapolis to present our poster. Innovation: This solution is innovative in many ways. At conception it uniquely combined forces of frontline staff nurses with leadership, quality and education nurses. The varied backgrounds and perspectives of this eclectic group allows for many angles of the project to be considered for optimal success. The group has learned to adapt and evolve with the ever-changing EMR system and staff responses. It is very sensitive to feedback. Although the original goal of 80% documentation compliance was not met on all 22 variables, the dedicated group continues to brainstorm new solutions. This committee has learned to think outside the box by collaborating with the informatics team to suggest design changes to the EMR; increasing membership to assist with time-consuming chart reviews and peer feedback; expanding guidelines to standardize other parts of the patient chart; creating nurse team leaders to coordinate patient care with coworkers and physicians each shift; and sharing project with fellow colleagues locally and nationally. Clear expectations and direct staff feedback encourage quality emergency nursing documentation that directly improves patient safety as well as other ED goals. Related Tools and Resources:
See attached documents: 1. Original Chart Review Template 2. Original Standardized Documentation Guidelines 3. Revised Chart Review Template 4. Critical Care Documentation Guidelines 5. Critical Care Chart Review Template 6. ENA Poster Presentation 1.Stokowski, Laura (2013, September 12). Electronic Nursing Documentation: Charting New Territory. Retrieved October 9, 2013 http://www.medscape.com/viewarticle/810573_5 2. Glynn, J. & McFarland, T. (2011, December 4). Emergency Department Charting Guidelines. Document posted http://www.ena.org/membership/document_share/doc/documents/charting GUIDELINES (2).doc Contact Person: Nancy Cimino, RN, BSN, CEN Title: Nurse Manager Emergency Department Email: nancy.cimino@medstar.net Phone: 410-554-2449