General Surgery Resuscitation Preference Documentation: A Quality Improvement Initiative.

Publisher: National Association For Healthcare Quality Country of Publication: United States NLM ID: 9202994 Publication Model: Print Cited Medium: Internet ISSN: 1945-1474 (Electronic) Linking ISSN: 10622551 NLM ISO Abbreviation: J Healthc Qual Subsets: MEDLINE

Original Publication: Skokie Il : National Association For Healthcare Quality

Quality Improvement* ; Documentation*/standards ; Documentation*/statistics & numerical data; Humans ; Checklist ; Resuscitation Orders ; General Surgery/standards ; Resuscitation/standards

Background/purpose: Documentation of resuscitation preferences is crucial for patients undergoing surgery. Unfortunately, this remains an area for improvement at many institutions. We conducted a quality improvement initiative to enhance documentation percentages by integrating perioperative resuscitation checks into the surgical workflow. Specifically, we aimed to increase the percentage of general surgery patients with documented resuscitation statuses from 82% to 90% within a 1-year period.
Methods: Three key change ideas were developed. First, surgical consent forms were modified to include the patient's resuscitation status. Second, the resuscitation status was added to the routinely used perioperative surgical checklist. Finally, patient resources on resuscitation processes and options were updated with support from patient partners. An audit survey was distributed mid-way through the interventions to evaluate process measures.
Results: The initiatives were successful in reaching our study aim of 90% documentation rate for all general surgery patients. The audit revealed a high uptake of the new consent forms, moderate use of the surgical checklist, and only a few patients for whom additional resuscitation details were added to their clinical note.
Conclusions: We successfully increased the documentation percentage of resuscitation statuses within our large tertiary care center by incorporating checks into routine forms to prompt the conversation with patients early.
Competing Interests: The authors declare no conflicts of interest.
(Copyright © 2024 National Association for Healthcare Quality.)

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Date Created: 20240502 Date Completed: 20240502 Latest Revision: 20240620

20240620

10.1097/JHQ.0000000000000439

38697096