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This study was conducted in the Intensive Therapy Unit at St Vincent's Hospital, Sydney. The study investigated the current documentation system in the unit and challenged it by piloting a context-designed flow chart. The results demonstrated a need for improved documentation and the flow chart as a strong contender for the job.
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Lisa Crimmins. RN, Intensive Therapy Certificate. Lisa is currently working as a CNS in the MU at St. Vincent's Hospital, Sydney. Melanie Kriss, RN, Intensive Therapy Certificate. This study was undertaken as part of the Intensive Therapy Course, 1989 - 90 at St. Vincent's Hospital, Sydney. |
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Documentation in the Intensive Therapy Unit (ITU) is carried out for a number of reasons. It ensures continuity of care and provides up-to-date patient status. It fulfils hospital policies which furnish the legal aspects of 'duty of care'.
Bavin (1988: 387) and Fracassi (1987: 66) both argue that the intensive care nurse has to be highly skilled today due to technological advances and complex care of the critically ill patients. Also the documentation and care required are complex and time consuming.
This study focused on the documentation of patient data in relation to the nursing and medical observations and therapies in St Vincent's ITU. The study investigated the possible use of a 'Flow Chart' to improve the present documentation system. The ITU is a nine (9) bed unit generally providing acutely ill patients with continuous monitoring and in most cases respiratory support. Criteria for admission to the unit may include such conditions as multi-trauma. drug overdose, post-operative major vascular surgery, cardio-pulmonary arrest and sepsis.
The current process of documentation in the intensive care unit involves numerous and separate charts. The most common charts in use are as follows: -
Vital signs:These charts are all used for specific observations or treatments. They are arranged in bundles on a clipboard into four groups, observations; fluids; medications and management. It can be readily seen that this large number of charts, arranged on one clipboard at each bedside, is cumbersome. It appeared that a lot of time was spent flipping through the charts to actually record observations. and that often these smaller charts could be misplaced. Flow charts in critical care areas are used throughout the world in major teaching hospitals, and have been shown to decrease problems with documentation. Fracassi (1987) comments, flow sheets are useful because they increase efficiency, use of time and enhance legibility and accuracy. Kleiber and Chase (1989) stated that a flow chart system saved time, made it easier to find information and cut down on the number of forms nurses had to use.
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The main purpose of the study was to examine the need for improvement in the process of documentation for the ITU. The research question posed was in what ways can the use of a context designed flow chart improve documentation in the St Vincent's ITU? The concept of a flow chart was proposed given its apparent superiority (Fracassi, 1987; Kleiber & Chase 1989; and Bavin, 1988). The proposed flow chart should fulfil the following criteria:-
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The use of multiple charts is time consuming, repetitious, cumbersome in the retrieval of data, paper wasting, expensive and inefficient in terms of the use of nursing hours. This assumption is based on the literature (Fracassi, Bavin, Kleiber & Chase) and the observations of the researchers. The success of any new documentation methods would require staff support and administrative approval and participation.
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An examination of the literature about flow charts, charting methods, documentation in nursing, Intensive care charting methods and record keeping revealed that little research had been reported. This may be due to already wide acceptance and use of flow charts in many intensive care settings.
Three articles were chosen for their relevance to this study. All articles identified flow charting as a superior means of record keeping. There were many identified advances in record keeping as well as in nursing productivity at Valley Children's Hospital, Fresno, California following a trial and subsequent two months implementation phase. Bavin, in reference to this study, states that this new clinical tool simplifies documentation and allows nurses to have more time at the bedside. This satisfies one of the aims of an improved record keeping method proposed by this study.
Kleiber and Chase concluded that the system we implemented saved time, made it easier to find information, and cut down on the number of forms the nurses had to use. Staff comments supported the decision to improve documentation practices, for example, increases time available to spend with patients... enhances consistency in charting. The authors emphasised the need to familiarise staff with the new procedures prior to and during implementation in order to avoid difficulties in practice.
Fracassi's (1987) findings supported the savings in time spent charting, and therefore decreasing overtime needs. This study highlighted the need for thoughtful design to provide easy storage in normal medical records. Fracassi endorses the findings of Rich (1983), who argues a detailed flowsheet has two basic advantages. It eliminates the need to write voluminous notes and it eliminates duplication of information. Any way you look at it, it saves you time. However, Fracassi (1987) notes that there were design problems identified by users of flowcharts such as unused sections that can be misinterpreted in retrospective review and raise legal questions as well as inadequate space for complete record of unusual events.
Despite difficulties experienced in designing and developing staff competence in the use of flowcharts. the advantages of flowcharts as a method of record keeping in intensive care settings was well supported.
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A pilot study was undertaken in St Vincent's ITU to trial a twenty-four hour flow chart in two bed areas for a period of seven days. Registered nurses and Clinical Nurse Specialists who work in the unit trialled the flow chart. The variables considered were past experience of staff with flow charts, and whether or not the experience was a positive one. Also some staff had worked on the unit for a very long time and had become proficient with the multichart system. The Medical Director of the unit was happy with the system in use because continuous charting was used throughout the patients' length of stay in hospital. Many people appeared reluctant to try the chart as they felt that they would never have such a chart in the unit in the long term.
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The instruments used consisted of a flow chart, instruction booklet, a comment sheet, a questionnaire and informal observations and communication between the researchers and the intensive care staff during implementation.
A flow chart was actually designed for the study, as existing flow charts did not satisfy the needs of the St. Vincent's ITU. A variety of flow charts were available. however they could not be easily integrated into the medical records. nor did they satisfy staff in their format.
The needs identified in developing better documentation for the ITU were:-
In attempting to fulfil these criteria, the pilot flow chart was designed with reference to other flow charts from nine hospitals.
The pilot chart was also designed with reference to the context of the charts used in the St. Vincent's ITU (multi-charts.) Some input into the designs also came from medical and nursing staff who work in the ITU. Significance of previous studies was also taken into account.
A final design was drafted after multiple alterations and refinement. The final draft which consisted of one large chart (60cms x 59cm) and an overlay chart ( 60cm x 29.5cm) was drawn to scale on graph paper. The chart was drafted using computer software.
The final draft was compiled by cutting and pasting 12 pieces of paper with some further alterations. The next step entailed finding a facility to photocopy (printing was too costly for the trial) the sheet as one unit, to avoid a messy appearance of a 'cut and paste' alternative using A3 paper. It was commercially copied at a cost of $116. As funding was limited. the chart was produced as a black and white copy, and printed on only one side. The chart was cut to size and a display/work board for the trial, was made by the researchers and a carpenter from the hospital.
The finished chart was divided into three main sections each the size of three A4 sized papers (Figures 1-3). The sections were:-Each section followed a twenty-four (24) hour design with all observations and recordings for each hour being in vertical alignment. for ease of use. The main chart (Figure 1 & Figure 2 combined) lay on the display board with the fluid chart (Figure 3) placed over the top. The fluid chart could be moved up and down to expose which ever part of the large chart the user desired. The medication chart, nursing management plan and problem sheet were kept separately to the left on the main display board. A hand book was written and attached to the display board to help the nursing staff use the chart as much as possible.
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Figure 1. Section 1 of the Flow Chart. (Not an exact reproduction)
The cardiovascular section (Figure 1) comprised a graphed area allowing enough room to make four observations per hour. It had been observed and noted by the researchers prior to the designing, that if the patient was unstable there was usually little time to do more than four observations in one hour. The blood pressure, heart rate and temperature were to be recorded by the use of lines and dots.
Below the cardiovascular section, there was room to record respiratory observations for spontaneously breathing patients, and central venous pressure recordings. There was also enough room to record inotropic infusion rates, mean arterial blood pressures and general nursing care such as eye, mouth and perineal toilets.
Figure 2. Section 2 of the Flow Chart. (Not an exact reproduction)
The second part of the chart was fairly straightforward with all the observations that had to be recorded clearly marked (Figure 2). The handbook demonstrated to staff how this section could be used for different respiratory treatment regimes eg. ventilation, Continuous (or intermittent) Positive Airway Pressure (CPAP), or oxygenation using a puritan mask. Also included in this part of the flow chart was space for biochemistry results e.g. blood gases and electrolytes, so that there was no need for staff to transcribe time of sampling or oxygen rate. Directly below the respiratory observations was space for the recording of neurological observations, based on the Glasgow Coma Scale.
Figure 3. Section 3 of the Flow Chart. (Not an exact reproduction)
The third section was devoted to fluids, input/output (Figure 3). In the input section staff simply had to record the site the fluid would be entering the body, eg. peripheral line, central venous catheter, nasogastric or oral. Next the starting volume of the fluid was recorded, then when the current infusion was discontinued or completed, the amount that the patient had actually received would be recorded in the 'amount infused' space for the appropriate hour. At the end of the twenty-four hour period the total could be calculated by summing across the row.
The output section was similar to what the staff were already using, the urine could be emptied hourly and a progressive total could be written below when the collection bag was emptied. This section was designed to have room for drain observations as well as the drainage from them. On the bottom of the fluid chart was room for 12 fluid orders, the daily urinalysis and, at the top the total daily balance.
The telephone questionnaire was used as a follow up to gain confidential staff opinion. As the unit is very busy, staff often did not have time to write down comments at the bedside. Twenty of the thirty Registered Nurses and Clinical Nurse Specialists working in the ITU who participated in the study were interviewed, as these staff document patient care more than any other group in the unit. It was anticipated that physiotherapists and doctors working within the unit would participate in the study if they had contact with the flow chart.
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An inservice was conducted to introduce to the staff the flow chart that they would be using. The immediate feedback from the staff was very enthusiastic as they seemed excited to try something new.
When the use of the chart was commenced for two chosen 'bed areas' one of the researchers was there to work with the staff. The transition from the multi-chart system to the flow chart went very smoothly and the nursing staff on that shift appeared to adapt readily to the new chart.
The following day a few problems arose as information about the chart was not communicated to other shifts. The main problem was with the output section of the chart as staff recorded the output for a patient between 1000hrs and 1100hrs in the 1100hrs space instead of the 1000hrs space. It was decided to re-label the output area of the chart to avoid further confusion. It would have been preferable of course for one of the researchers to be there most of the time, this was logistically impossible.
The trial went relatively smoothly despite some resistance from the medical staff. However the staff often didn't have time to write comments and had to be followed up. The trial brought forward comments positive negative and constructive so it appeared it was worthwhile.
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All comments written at the bedside and communicated to the researchers were condensed and put into point form. The responses from the telephone questionnaire were analysed using percentages.
Comments included:
| POSITIVE | NEGATIVE |
| See everything at a glance in front of you. |
It would be better in more than one colour (print). |
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A better overall picture, as you can see down the page observations correlating with fluids. |
It would be even more of an improvement if it incorporated even more charts eg. pain chart. |
| Great not to have so many pieces of paper. | Not enough space for intercostal catheters, have to draw up lines. |
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Dispenses with large pieces of paper for small amounts of information. |
Find it difficult to add fluids across instead of vertically. |
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Different colours for observations a great idea, cardiovascular chart is very clear. |
Would like larger area to write fluids. |
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Definite advantage over ward charts, gives holistic picture of the patient. |
Some areas of the chart would be wasted if the patient was only high dependency. |
| Very refreshing to try something new, | Prefer graphs for ventilation and neurological. |
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A great starting point for further improvements. |
One sheet would be better. |
The following results from the Telephone Questionnaire demonstrate the support within the unit for a change in documentation. They also demonstrate that a significant amount of staff prefer flow charts in that they are more effective, and easier to use and read. These results are interesting as the flow chart used for the pilot was not a 100% success.
72% of those surveyed had previously used flow charts. Over 60% viewed the flow chart favourably in that it required less time for charting, was easier to use, that patient data could be retrieved more quickly, and was more economical in the use of paper.
Significantly 80% of the surveyed staff felt that it was easier to identify trends in patients conditions using the flow chart, and similarly 80% preferred its use to the multi- charting they were accustomed to using.
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The use of flow charts in the St Vincent's ITU emerged as a controversial issue, between nurses and doctors alike. Despite the negative feedback from a lot of the stall earlier in the trial it became apparent from the telephone survey that there was a lot of support for changing the current documentation practices. Returning to the literature and the research problem, it seems reasonable to say that the point has been made that there is definitely room for improvement in the Intensive Care Unit's documentation practices and that the desire for change is there.
However the point must be made this would have to be a collaborative effort between medical and nursing staff, not just as two professional groups but also within these groups as well.
The reviewed literature emphasised that to fully implement a flow chart from first draft to a permanent fixture took four months to a year, co-ordinated by a task force convened for this purpose. Continuous education sessions were required for staff who found it difficult to change to a new system (and this happens for a variety of reasons).
Specifically if the staff participate in the development of the chart, they feel ownership and are more determined to see it work. This seems like a more realistic way of dealing with a quite difficult issue, as staff satisfaction and involvement would be necessary for true success. A remark on the comment sheet during the trial demonstrates this feeling well, "keep up the push!"
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