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The effect of quality assurance on flight nurse documentation
ORIGINALCONTRIBUTION
The Effect of Quality Assurance on Flight Nurse Documentation • Valerie F. Kiefer, RN, CORN, CEN, EMT-P;Robert J. Schwartz, MD, MPH; Lenworth M. Jacobs, MD, MPH, FAGS
This study was developed to evaluate if a structured quality assurance program has an effect on nursing documentation. A randomized, retrospective audit of records was conducted from 1985 to 1989, and in November 1987, a structured QA program was initiated for flight nurses. Each chart was audited for completeness of 69 elements from seven categories: administrative information, patient history, physical exam, management plan, vital signs, medications and intravenous access. A comparison of audit results was conducted before and after the QA program was initiated. A total of 224 charts were audited, 123 before the QA program and 101 after. There was statistically significant improvement in 4 of 13 administrative, 5 of 7 history, 21 of 31 physical exam, 2 of 6 management, 2 of 2 vital signs, 0 of 4 medication, and 0 of 6 intravenous access elements. Twenty-five of 35 categories that did not show improvement had initial completion rates greater than 90 percent. The significant improvement in documentation by flight nurses after a formal QA program was initiated lead the authors to conclude that QA benefits air medical programs by providing a mechanism to improve documentation. Key Words: Q u a l i t y a s s u r a n c e , d o c u m e n t a t i o n , gency
flight nursing, helicopter emer-
Valerie F. Kiefer, RN, CCRN, CEN, EMT-P, is assistant chief flight nurse for the LIFE STAR Aeromedical Program, Hartford Hospital, Hartford, Conn. Robert J. Schwartz, MD, MPH, is director of research of, and Lenworth M. Jacobs, MD, MPH, FACS, is director of, the Department of Emergency Medicine/Trauma at Hartford Hospital.
Air Medical Journal ° January/February 1993
The LIFE STAR QA Process T h e r e s e a r c h f o r t h i s s t u d y was
medical service
The importance of the medical record is often defined by the statement, "If it's not written, it wasn't performed." Documentation, or the written medical record and anything written or printed that is relied on as a record of proof, is used as evidence of professional accountability and credibility. 1,2 It is a process that involves everyone in medicine, and if documentation is poorly p e r f o r m e d , it can be
patient, and the health care system in general for providing proof of the quality of care provided and of a mechanism by which that care is maintained. 4 In addition, air medical services have the responsibility to establish and maintain credibility and document the necessity and effectiveness of air transport in reducing morbidity and mortality. 5,6 Quality a s s u r a n c e provides that mechanism as a way flight nurses can provide sound evidence of effective quality care.
assumed that patient care has also been substandard. No doubt, docu m e n t a t i o n and the care of the patient are directly linked. 2 Medical documentation is also important because it is used by the legal system. One of four malpractice suits are decided based on information from the patient's chart. 2 Therefore, a quality assurance program that looks specifically at documentation and improves charting is beneficial to any care facility. A hospital's accreditation, medical liability and payment for services rendered are, in part, based on successful nursing documentation. 2 The concept of QA is to enable health professionals to assess their actions and improve patient care. 3 Health professionals still need to be a c c o u n t a b l e to the courts, the
carried out at the LIFE STAR Critical Care Helicopter Program at H a r t f o r d Hospital in Hartford, Conn.7, 8 The patient care team on LIFE STAR c o n s i s t s of a flight nurse/paramedic and a respiratory therapist/EMT-I. The LIFE STAR QA program, begun in November 1987, incorporates a multidiscipli-
Categories for Chart Review Category
Number of Elements
Administration . . . . . . . . . . . . . . . . 13 Patient History . . . . . . . . . . . . . . . . . 7 Physical Exam . . . . . . . . . . . . . . . . 31 Management Plan . . . . . . . . . . . . . 6 Vital Signs . . . . . . . . . . . . . . . . . . . . . .
2
Medications . . . . . . . . . . . . . . . . . . . . 4 Intravenous Access . . . . . . . . . . . . 6
11
TABLE 2
Comparison of Completion Rates Before and After QA Program Category and Element
Ratio Complete Before QA
Ratio Complete After QA
Category and Element
Ratio Complete Before QA
Ratio Complete After QA
Location
Medications 43/75
43/63** Route
123/123*
101/101
Initial
121/123"
100/101
Location
116/123
99/101
Rate
117/123
97/101
Position of trach for Rate
88/123
80/101
116/123
100/101
intravenous Access Breath sounds
ns of chest trauma
48/76
65/65** 92/101
*Initial completion rate >96 oY0, therefore mathematically impossible to improve. **Statistically significant improvement (Fisher exact test, p <.05).
nary approach b y i n c l u d i n g the medical director, flight nurses, respiratory therapists and ED attending physicians. These groups meet for a QA meeting on the second and fourth Monday of every month. At the end of every two w e e k 12
period prior to the QA meeting, the chief flight nurse and medical director review all LIFE STAR run forms generated during that period. All documentation discrepancies are noted and shared with the flight nurse who completed the run form.
Three to five cases are selected for presentation at QA rounds, and all deaths are reviewed. Flights involving unusual patient management or challenges and a variety of patient classifications are conside r e d for p r e s e n t a t i o n . Also disAir Medical Journal * January/February 1993
cussed are all flights in which difficulties arose that had the potential to affect patient care.
Adjusted Statistically Significant Improvement Rates
Methods Fourteen flight nurses were involved in this study, with eight original flight nurses and six flight nurses who started in September 1986. Four out of the original group and one out of the new group left before the study was completed in 1989. A chart audit, developed by the chief flight nurse at the beginning of the program in 1985, was performed on all run forms. The audit i n c o r p o r a t e s hospital charting standards in seven categories with 69 elements (see Tables 1 and 2). A checklist is completed by comparing the run form with the elements in the audit form. Using the audit form, a randomized r e t r o s p e c t i v e c h a r t audit review of flight records was performed starting in June 1989. Fifty charts w e r e randomly r e v i e w e d each year using a random numbers table, b u t only 24 c h a r t s w e r e reviewed for the first year, prorated for the length of time the program was in service. A single rev i e w e r (a n u r s e ) a u d i t e d each chart for completeness, and the reviewer's charts were also audited. The number of charts for any individual nurse ranged from two to 32, but the amount of charts reviewed per nurse was directly proportionate to their length of employment, to s u p p o r t t h e r a n d o m i z a t i o n process. A total of 224 c h a r t s w e r e audited, 123 prior to the initiation of QA and 101 after. A comparison was performed of audit results before and after the initiation of QA using the Fischer exact test and a p level of <.05 was used to determine statistical significance. Each c h a r t was a u d i t e d for completeness of 69 different elem e n t s using the c h a r t auditing system. Each element was checked as complete, incomplete or nonapplicable.
Air MedicalJournal°
Category
Number ElementsShowing Improvement/ Total Elements
Percent
4/7
I 57
5/5
~ 100
21/28
1
75
2/4
I 50
2/2
~ 100
014
1 0
34•50
I
68
*Improvement not statistically possible.
Results Table 2 provides the results from all 69 elements before and after the QA intervention. Those results show several areas were improved after the QA program was begun. For example, four elements out of 13 in the administrative area showed a statistically significant improvement, including attending physician and disposition of valu-
January/February 1993
ables. In the history category, five e l e m e n t s (time of injury, initial patient condition, previous days in hospital, past medical history and reason for transfer) were charted more frequently. In the physical exam category, the charting of six out of the seven elements improved (it was statistically impossible for the seventh to improve). In the m a n a g e m e n t category, cervical-
13
spine immobilization for trauma patients was charted more frequently than before QA policies were in place, and two other elements also showed statistical improvement in charting. Medications and intrav e n o u s fluids a l r e a d y had high completion rates prior to implem e n t a t i o n of the QA p r o g r a m , h e n c e t h e r e was little r o o m for improvement. All 69 e l e m e n t s had g r e a t e r completion rates after QA was initiated, and 34 out of 69 (49%) showed a statistically significant improvement. Recalculation of the improvement rate, adjusting for the 19 elements that could not statistically show improvement, demonstrates that 34 out of 50 (68%) of the elements showed statistically significant improvement in docum e n t a t i o n after the QA program (Table 3).
Discussion B e c a u s e this was a t i m e - s e r i e s study design, some of the improvement could be from the increase of experience of the flight nurses over the duration of the study. However, flight nurses who started after the QA program was in place had better initial documentation rates than the original flight nurses at the beginning of the program. For the six new flight nurses, their initial documentation rates were 25% to 30% better than the other flight nurses. Quality assurance programs are vital not only to air medical programs but for all aspects of the medical facility. The Joint Commission on the Accreditation of Health Care Organizations now mandates that QA be p e r f o r m e d for individual practitioners and that this QA be used in the reappointment process. This level of critique has not been
used in all aspects of medicine, but as a systematic, dynamic, ongoing effort to improve all aspects of care, it is beneficial for both patients and medicine. The rigor that is used to maintain high standards of documentation and clinical care can have a significant impact t h r o u g h o u t the institution. For example, improvement in documentation has implications in patient care risk management and in preparation for litigation. 9 The study demonstrates that flight nurse documentation can improve with the initiation of a QA program. The chart-audit form in conjunction with QA is an important adjunct in delivering high-quality care to patients and has become part of the LIFE STAR program. Quality assurance can enhance any helicopter emergency medical services' evaluation of patient care through improvement in documentation. • References 1. Edelstein J: A study of nursing documentation. Nsg Mgmt 1990; 21(11):40. 2. Peters: Quality documentation quality care. Caring 1988; October:30. 3. Klein KA: Principles of QA for transport systems. Where do we begin? Emerg Care Q 1991; 6(4):27-32. 4. Eastes LE: QA for aeromedical transport. JEN 1987; 23 (4):223. 5. Nadzam, Atkins: The pyramid for QA. J Nsg QA 1987; 2:15. 6. Schwartz RI, Jacobs LM, Yaezel D: Impact of pre-trauma center care on length of stay and hospital charges. J Trauma 1989; 29(12) :1661-1615. 7. Jacobs LM, Schwartz RJ, Gonsalves D, et al: A three-year report of the medical helicopter transportation system of Connecticut. Conn Mad 1989; 53 (12) :703-710. 8. Jacobs L, Bennett B, Schwartz R: A medical helicopter transportation system for Connecticut. Corm Mad 1985; 49(8) :489-495. 9. Ulrich B, Freding N, Cavauras CA: Assuring quality through a professional practice approach. Nsg Economics 1986; 4 (6) :787.
14
Air Medical Journal ° January/February 1993
The Effect of Quality Assurance on Flight Nurse Documentation • Valerie F. Kiefer, RN, CORN, CEN, EMT-P;Robert J. Schwartz, MD, MPH; Lenworth M. Jacobs, MD, MPH, FAGS
This study was developed to evaluate if a structured quality assurance program has an effect on nursing documentation. A randomized, retrospective audit of records was conducted from 1985 to 1989, and in November 1987, a structured QA program was initiated for flight nurses. Each chart was audited for completeness of 69 elements from seven categories: administrative information, patient history, physical exam, management plan, vital signs, medications and intravenous access. A comparison of audit results was conducted before and after the QA program was initiated. A total of 224 charts were audited, 123 before the QA program and 101 after. There was statistically significant improvement in 4 of 13 administrative, 5 of 7 history, 21 of 31 physical exam, 2 of 6 management, 2 of 2 vital signs, 0 of 4 medication, and 0 of 6 intravenous access elements. Twenty-five of 35 categories that did not show improvement had initial completion rates greater than 90 percent. The significant improvement in documentation by flight nurses after a formal QA program was initiated lead the authors to conclude that QA benefits air medical programs by providing a mechanism to improve documentation. Key Words: Q u a l i t y a s s u r a n c e , d o c u m e n t a t i o n , gency
flight nursing, helicopter emer-
Valerie F. Kiefer, RN, CCRN, CEN, EMT-P, is assistant chief flight nurse for the LIFE STAR Aeromedical Program, Hartford Hospital, Hartford, Conn. Robert J. Schwartz, MD, MPH, is director of research of, and Lenworth M. Jacobs, MD, MPH, FACS, is director of, the Department of Emergency Medicine/Trauma at Hartford Hospital.
Air Medical Journal ° January/February 1993
The LIFE STAR QA Process T h e r e s e a r c h f o r t h i s s t u d y was
medical service
The importance of the medical record is often defined by the statement, "If it's not written, it wasn't performed." Documentation, or the written medical record and anything written or printed that is relied on as a record of proof, is used as evidence of professional accountability and credibility. 1,2 It is a process that involves everyone in medicine, and if documentation is poorly p e r f o r m e d , it can be
patient, and the health care system in general for providing proof of the quality of care provided and of a mechanism by which that care is maintained. 4 In addition, air medical services have the responsibility to establish and maintain credibility and document the necessity and effectiveness of air transport in reducing morbidity and mortality. 5,6 Quality a s s u r a n c e provides that mechanism as a way flight nurses can provide sound evidence of effective quality care.
assumed that patient care has also been substandard. No doubt, docu m e n t a t i o n and the care of the patient are directly linked. 2 Medical documentation is also important because it is used by the legal system. One of four malpractice suits are decided based on information from the patient's chart. 2 Therefore, a quality assurance program that looks specifically at documentation and improves charting is beneficial to any care facility. A hospital's accreditation, medical liability and payment for services rendered are, in part, based on successful nursing documentation. 2 The concept of QA is to enable health professionals to assess their actions and improve patient care. 3 Health professionals still need to be a c c o u n t a b l e to the courts, the
carried out at the LIFE STAR Critical Care Helicopter Program at H a r t f o r d Hospital in Hartford, Conn.7, 8 The patient care team on LIFE STAR c o n s i s t s of a flight nurse/paramedic and a respiratory therapist/EMT-I. The LIFE STAR QA program, begun in November 1987, incorporates a multidiscipli-
Categories for Chart Review Category
Number of Elements
Administration . . . . . . . . . . . . . . . . 13 Patient History . . . . . . . . . . . . . . . . . 7 Physical Exam . . . . . . . . . . . . . . . . 31 Management Plan . . . . . . . . . . . . . 6 Vital Signs . . . . . . . . . . . . . . . . . . . . . .
2
Medications . . . . . . . . . . . . . . . . . . . . 4 Intravenous Access . . . . . . . . . . . . 6
11
TABLE 2
Comparison of Completion Rates Before and After QA Program Category and Element
Ratio Complete Before QA
Ratio Complete After QA
Category and Element
Ratio Complete Before QA
Ratio Complete After QA
Location
Medications 43/75
43/63** Route
123/123*
101/101
Initial
121/123"
100/101
Location
116/123
99/101
Rate
117/123
97/101
Position of trach for Rate
88/123
80/101
116/123
100/101
intravenous Access Breath sounds
ns of chest trauma
48/76
65/65** 92/101
*Initial completion rate >96 oY0, therefore mathematically impossible to improve. **Statistically significant improvement (Fisher exact test, p <.05).
nary approach b y i n c l u d i n g the medical director, flight nurses, respiratory therapists and ED attending physicians. These groups meet for a QA meeting on the second and fourth Monday of every month. At the end of every two w e e k 12
period prior to the QA meeting, the chief flight nurse and medical director review all LIFE STAR run forms generated during that period. All documentation discrepancies are noted and shared with the flight nurse who completed the run form.
Three to five cases are selected for presentation at QA rounds, and all deaths are reviewed. Flights involving unusual patient management or challenges and a variety of patient classifications are conside r e d for p r e s e n t a t i o n . Also disAir Medical Journal * January/February 1993
cussed are all flights in which difficulties arose that had the potential to affect patient care.
Adjusted Statistically Significant Improvement Rates
Methods Fourteen flight nurses were involved in this study, with eight original flight nurses and six flight nurses who started in September 1986. Four out of the original group and one out of the new group left before the study was completed in 1989. A chart audit, developed by the chief flight nurse at the beginning of the program in 1985, was performed on all run forms. The audit i n c o r p o r a t e s hospital charting standards in seven categories with 69 elements (see Tables 1 and 2). A checklist is completed by comparing the run form with the elements in the audit form. Using the audit form, a randomized r e t r o s p e c t i v e c h a r t audit review of flight records was performed starting in June 1989. Fifty charts w e r e randomly r e v i e w e d each year using a random numbers table, b u t only 24 c h a r t s w e r e reviewed for the first year, prorated for the length of time the program was in service. A single rev i e w e r (a n u r s e ) a u d i t e d each chart for completeness, and the reviewer's charts were also audited. The number of charts for any individual nurse ranged from two to 32, but the amount of charts reviewed per nurse was directly proportionate to their length of employment, to s u p p o r t t h e r a n d o m i z a t i o n process. A total of 224 c h a r t s w e r e audited, 123 prior to the initiation of QA and 101 after. A comparison was performed of audit results before and after the initiation of QA using the Fischer exact test and a p level of <.05 was used to determine statistical significance. Each c h a r t was a u d i t e d for completeness of 69 different elem e n t s using the c h a r t auditing system. Each element was checked as complete, incomplete or nonapplicable.
Air MedicalJournal°
Category
Number ElementsShowing Improvement/ Total Elements
Percent
4/7
I 57
5/5
~ 100
21/28
1
75
2/4
I 50
2/2
~ 100
014
1 0
34•50
I
68
*Improvement not statistically possible.
Results Table 2 provides the results from all 69 elements before and after the QA intervention. Those results show several areas were improved after the QA program was begun. For example, four elements out of 13 in the administrative area showed a statistically significant improvement, including attending physician and disposition of valu-
January/February 1993
ables. In the history category, five e l e m e n t s (time of injury, initial patient condition, previous days in hospital, past medical history and reason for transfer) were charted more frequently. In the physical exam category, the charting of six out of the seven elements improved (it was statistically impossible for the seventh to improve). In the m a n a g e m e n t category, cervical-
13
spine immobilization for trauma patients was charted more frequently than before QA policies were in place, and two other elements also showed statistical improvement in charting. Medications and intrav e n o u s fluids a l r e a d y had high completion rates prior to implem e n t a t i o n of the QA p r o g r a m , h e n c e t h e r e was little r o o m for improvement. All 69 e l e m e n t s had g r e a t e r completion rates after QA was initiated, and 34 out of 69 (49%) showed a statistically significant improvement. Recalculation of the improvement rate, adjusting for the 19 elements that could not statistically show improvement, demonstrates that 34 out of 50 (68%) of the elements showed statistically significant improvement in docum e n t a t i o n after the QA program (Table 3).
Discussion B e c a u s e this was a t i m e - s e r i e s study design, some of the improvement could be from the increase of experience of the flight nurses over the duration of the study. However, flight nurses who started after the QA program was in place had better initial documentation rates than the original flight nurses at the beginning of the program. For the six new flight nurses, their initial documentation rates were 25% to 30% better than the other flight nurses. Quality assurance programs are vital not only to air medical programs but for all aspects of the medical facility. The Joint Commission on the Accreditation of Health Care Organizations now mandates that QA be p e r f o r m e d for individual practitioners and that this QA be used in the reappointment process. This level of critique has not been
used in all aspects of medicine, but as a systematic, dynamic, ongoing effort to improve all aspects of care, it is beneficial for both patients and medicine. The rigor that is used to maintain high standards of documentation and clinical care can have a significant impact t h r o u g h o u t the institution. For example, improvement in documentation has implications in patient care risk management and in preparation for litigation. 9 The study demonstrates that flight nurse documentation can improve with the initiation of a QA program. The chart-audit form in conjunction with QA is an important adjunct in delivering high-quality care to patients and has become part of the LIFE STAR program. Quality assurance can enhance any helicopter emergency medical services' evaluation of patient care through improvement in documentation. • References 1. Edelstein J: A study of nursing documentation. Nsg Mgmt 1990; 21(11):40. 2. Peters: Quality documentation quality care. Caring 1988; October:30. 3. Klein KA: Principles of QA for transport systems. Where do we begin? Emerg Care Q 1991; 6(4):27-32. 4. Eastes LE: QA for aeromedical transport. JEN 1987; 23 (4):223. 5. Nadzam, Atkins: The pyramid for QA. J Nsg QA 1987; 2:15. 6. Schwartz RI, Jacobs LM, Yaezel D: Impact of pre-trauma center care on length of stay and hospital charges. J Trauma 1989; 29(12) :1661-1615. 7. Jacobs LM, Schwartz RJ, Gonsalves D, et al: A three-year report of the medical helicopter transportation system of Connecticut. Conn Mad 1989; 53 (12) :703-710. 8. Jacobs L, Bennett B, Schwartz R: A medical helicopter transportation system for Connecticut. Corm Mad 1985; 49(8) :489-495. 9. Ulrich B, Freding N, Cavauras CA: Assuring quality through a professional practice approach. Nsg Economics 1986; 4 (6) :787.
14
Air Medical Journal ° January/February 1993