MARTIN CHAINEY
Anne Plaskitt (right) carries out a patient assessment with senior sister Jo Flint at United Hospital Bath NHS Trust
Paper-free future A clinically driven, phased approach to the introduction of electronic nursing records is proving successful, as Daloni Carlisle reports Covering an office floor with piles of paper and setting to it with scissors and glue does not sound a promising start to a major IT project. But one London trust has taken this ‘paper first’ approach as it moves towards electronic nursing records. The two nurses leading the project at St George’s Healthcare NHS Trust – Jenny Muir, nursing lead for clinical documentation,
and Amy Gass, IT change management lead – felt strongly that this was a clinical project to be supported by IT, not an IT project being imposed on clinicians. And since nurses work on paper, that was the logical place to start. ‘We had also had a serious incident that prompted the review of all our documentation,’ explains Ms Muir. ‘We set up a working group, invited interested people
to join and gathered one copy of all the paperwork used by nurses.’ A total of 634 documents were collected, which the working group spread out on the floor. ‘It was a powerful way to see all the duplication, confusion and different ways of doing things,’ says Ms Muir. For example, rather than one standard fluid chart, the group found six were in use in the trust. The review’s most pressing need was to standardise nursing risk assessments, which not only affect quality of care and patient safety, but can also help trusts attract income from commissioners under Commissioning for Quality and Innovation (CQUIN).
24Nursing november 13 :: vol 28 no 11 :: 2013 NURSING STANDARD Standard. Downloaded from rcnpublishing.com by Iain Wood on Nov 15, 2013. For personal use only. No other uses without permission. Copyright © 2013 RCN Publishing Ltd. All rights reserved.
SUMMARY
Trusts earn CQUIN payments by showing they have complied with standards, for example, by assessing patients at risk of developing venous thromboembolism, pressure ulcers or falls. Nursing assessments are also a hot topic for the Nursing and Midwifery Council and the Care Quality Commission. ‘We are told as nurses, if it is not documented, you did not do it. It is that black and white,’ says Ms Muir. The next job was to work out how well assessments were currently completed. ‘We found it was pretty poor,’ says Ms Muir. The review working group, which included nurses from band 5 upwards, set about gathering together all the nursing assessments, and then, using scissors and glue, assembled a single document. The new assessment document was tested with clinicians, reworked, piloted on wards, and is now in the form of a ring-bound admissions booklet that is currently being introduced across the trust. ‘Everything is linked back to standards and policies,’ says Ms Muir. ‘Staff told us that the new nursing assessment took them longer and I do not think of that as a negative – it is because they are taking time to complete it.’ The company that provides St George’s electronic patient administration system, Cerner, has hosted three workshops for the trust’s clinicians at its headquarters, a first for the company. The clinicians were able to ‘play’ with different electronic records, seeing how they can build in expert knowledge systems or support managers in extracting data. However, the project will move to an electronic version only once ward
How to make a smooth transition to electronic nursing records Ensure it is a clinical project supported by IT, not an IT project imposed on clinicians. Involve clinical staff in the development of the new system. Look at how information is currently collected, and consider how much of it is necessary. The aim should be to ‘capture once and use often’. Test the system before implementing it. Do not rush. Moving to an entirely electronic system takes time, resources and staff training.
Nurses are increasingly recording patient information electronically. But getting this right requires the right IT support. Staff at one trust describe how they are moving towards electronic nursing risk assessments, while a nurse at another discusses the advantages of doing so. Author Daloni Carlisle is a freelance journalist
NURSING STANDARD
nurses have become accustomed to the new way of working. One trust already seeing the benefits of making the move is the Royal United Hospital Bath, which introduced electronic nursing risk assessments two years ago. Currently, nurses are completing assessments and reassessments for more than 95 per cent of cases, compared to 45 per cent when they used paper records. Anne Plaskitt, senior nurse quality improvement and one of the trust’s chief clinical information officers, says this is because electronic nursing assessments are significantly different from the paper-based version.
Automatic prompt
For a start, they can automatically schedule when reassessments should happen – flagging this up to nurses as they work – and automate tasks. ‘Take, for example, the patient who develops a pressure ulcer in hospital,’ says Ms Plaskitt. ‘This is recorded as a harm event, the nurse is then prompted by the system to reassess. The system also automatically sends an electronic referral to the tissue viability nurse. ‘The referral and care record can be viewed remotely by the tissue viability nurse who can then prioritise clinically. It is very useful.’ Electronic nursing assessments are also a powerful management tool, enabling rapid audit and validation of data. Any ward manager can now review all patients at a glance to check
whether assessments have been carried out – and what they show. ‘I can look at compliance across the whole trust – all 600-plus patients – in under 30 minutes,’ says Ms Plaskitt. Previously, both tasks would have required a physical inspection of every single paper record. Ms Plaskitt says that completing risk assessments – and having the ability electronically to trigger a reassessment – is fundamental to the trust’s ability to improve patient care and meet patient safety targets, achieve CQUIN payments, and demonstrate to regulators the quality of care the trust provides. ‘At first, using an electronic system was an alien concept to the nurses,’ she says. ‘But now we have reached a tipping point, where the automation and the systems we have built over the past two years have proved themselves.’ The ultimate aim is for all nursing and eventually all clinical records to be electronic. The big question though is whether patient care has improved. ‘I would love to say we have had “x” reduction in falls but it is not that simple,’ says Ms Plaskitt. ‘We have seen more reporting of incidents and that is a good thing. We are getting accurate information such as how many pressure ulcers really developed in hospital as opposed to how many were present on admission.’ Moving to an entirely electronic system will take time, resources and training, and at Bath they are going one step at a time. Next on the agenda is adding the social history assessment. Information collected in the social history will populate other sections of the record such as health rehabilitation and transfer of care records, helping to meet the overarching aim of ‘capture once and use often’. ‘For us, we felt the risk of taking all the paper records away in one go was too great,’ says Ms Plaskitt. ‘I think we have got the balance right in our phased approach, driven now completely by the nursing workforce’ NS
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Nursing Standard. Downloaded from rcnpublishing.com by Iain Wood on Nov 15, 2013. For personal use only. No other uses without permission. Copyright © 2013 RCN Publishing Ltd. All rights reserved.