The Science Journal of the American Association for Respiratory Care

2004 OPEN FORUM Abstracts


Elsie Collado-Koman,BS,RRT,RCP, UCSD Medical Center, SD Ca

Assuring adequacy of documentation is essential in the continuity of patient care. It also facilitates the gathering of information for medical research, satisfies regulatory and community standards, and improves communication among care providers. While most documentation at our facility is performed using Clinivision, ventilator documentation is still provided manually through entry on a bedside flowsheet. Periodic observations indicated there were deficiencies in RCP documentation. We implemented a system to monitor the comprehensiveness and accuracy of RCP charting and processes that encourage RCPs to chart appropriate information on a regular basis.

A series of
steps were established to monitor and assess appropriateness of ventilator charting documentation in paper forms. A form was developed identifying the required content of RCP documentation. In addition to the ventilator and alarm settings, required documentation included: airway type, size, placement reference and cuff pressure, weaning assessment and status, and other narrative entries of the patients’ condition. An average of twenty patients were monitored per month. Patient’s ventilator charts were selected at random and at different times of the day. Observations were made once per patient. Once data corresponding to the first four months of observation was acquired the results were presented to the staff. Mechanisms were establish to increase staff awareness of the charting deficiencies, their importance related to the National Patient Safety Goals, training and education on policy, and the types of medical errors that result from charting problems. Charting compliance was then reassessed.

Observation following inservices and awareness activities were tabulated.

Ventilator Documentation

  Baseline 2003 Variance Apr-04 Variance May-04 Variance Jun-04
Ventilator # 50% 38% 80% -118% 37% 49% 72%
Airway Type 56% 38% 90% -35% 67% 20% 83%
Airway Size 56% 38% 90% -42% 63% 24% 83%
Alarms Checked 50% -25% 40% 37% 63% 5% 67%
Ambu Bag Doc. 25% 58% 60% 5% 63% -27% 50%
Compliance Doc 24hrs 69% 2% 70% 19% 87% -20% 72%
Cuff Press Doc. 12hrs 56% 20% 70% 9% 77% -6% 72%

  Baseline 2003 Variance Apr-04 Variance May-04 Variance Jun-04
Reason Not Done 88% 13% 100% -3% 97% 3% 100%
F/VT 94% -34% 70% 28% 97% 3% 100%
Time Started/ Ended 100% 0% 100% -3% 97% 3% 100%

Ventilator Weaning Documentation The results reflect an improvement in ventilator documentation after the education and training interventions.

Screening tools can be developed to effectively quantify documentation compliance and the impact of measures directed at improving documentation. This issue is important to respiratory care considering the high-risk nature of caring for ventilator patients. Providing accurate and current information to other members of the care team meets regulatory agency expectations such as the National Patient Safety Goals as they relate to improving communication.