Documentation of Communication with relatives in the ICU

Dr Michael McGinlay

ST3 Anaesthetics

Craigavon Area Hospital ICU

Coppel Prize 2014

Background• A patient can receive perfect medical care, whereas the documentation

may have flaws (1)

• Historically documentation of family discussions in medical notes is poor

• “time and again, poor communication with patients and their families is at the core of what goes wrong” (2)

• Relatives of the critically ill often become surrogate decision makers therefore thorough documentation of these meetings is essential

• Documentation is time consuming thus we must do so efficiently in order to carry out our primary duty, providing patient care (3)

Aims• To determine how well communication with patient relatives is

documented by medical staff and whether this is consistent with nursing notes

• To assess the relationship between patient age, length of stay, illness severity and mortality on the frequency of documentation

• To determine whether or not the implementation of a dedicated communication insert improves frequency of documentation by junior medical staff through re-audit

Method• Retrospective analysis of patient case notes who were admitted to

Craigavon Area Hospital ICU between July and August 2013

• Data obtained by screening both medical notes and a dedicated ‘relative communication sheet’ within the nursing notes

• Number of communication episodes documented and grade of documenter from both medical and nursing notes was collated and compared

• Other data including patient age, length of ICU stay, ICNARC score, degree of invasive organ support and clinical outcome was obtained

Results (1)

• 42 case notes of patients admitted between July and August 2013

• A mixture of medical (n=23) and surgical (n=19) patients

• Age ranging between 22 and 89 years old (mean 62 years)

• ICU length of stay ranged from 1 to 26 days (mean 4.4 days)

• A total of 11 NFR orders were placed and 9 deaths occurred

• 46 medical entries (over 22 case notes)• 1-5 entries per patient• Content variable• Significant variation in time to first entry• Consultant documentation in all 9 deaths / 2 NFR orders

Medical Documentation

ICU LOS Age

Illness Severity Organ Support

• 191 entries (145 ward / 45 phone)• Ranging 1 – 33 entries per patient• Content variable• Additional 32 additional discussions with medical staff documented

Nursing Documentation

Conclusions• Overall documentation of communication with relatives by medical staff

was poor despite evidence from the nursing notes that communication was taking place

• Nursing documentation was significantly better, correlating well with medical notes although actual content was variable

• Trend to document discussions with relatives in those patients who have a greater severity of illness, longer duration of stay or predicted death

A Potential Solution ?

Results (2)

• 42 case notes of patients admitted between July and September 2014

• Medical (n=24) and surgical (n=18) patients

• Patients aged between 23 and 95 years old (mean 64)

• ICU length of stay ranging from 1-18 days (mean 4.4 days)

• A total of 12 NFR orders in place with 9 deaths

• 56 entries (over 20 case notes)• 1-7 entries per patient• Dedicated communication sticker used in 10 case notes

19 used in total (consultants 9, trainees 11)• Consultant documentation in all 9 deaths / 3 NFR orders

Medical Documentation

ICU LOS Age

Illness Severity Organ Support

• 185 nursing entries made (144 Ward /41 Phone)• 1-20 entries per patient• Content variable • Additional 27 family discussions with medical staff were documented

Nursing Documentation

Conclusions

• An increase in the frequency of documentation was observed although the overall number of patients with a single entry remains relatively unchanged

• Lack of significant improvement following introduction of this sticker

• Continues to demonstrate that communication with family members is occurring despite poor documentation

• Emphasises that nursing staff remain vastly superior in this regard but they should not be relied upon to document on behalf of medical staff

Key Points• We as medical staff need to become more vigilant when it comes to

documenting family discussions

• Evidence to suggest we are communicating better than what we are documenting

• Use of a dedicated communication sticker within CAH ICU may allow us to reduce the time spent on documentation and promote a positive change in documenting culture, particularly amongst trainees

References1. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW.

Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007; 297:831-41

2. Girbes Armand R.J, Zijlstra, Jan, G. Spend time on patients and families or on documentation.. Anaesthesia and Analgesia 2009 Vol 109, No 3

3. Health Service Ombudsman’s Review January 2013

Thank You