Z K Thompson, S Lloyd, E Smit. Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK. Ticking all the.

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Z K Thompson, S Lloyd, E Smit. Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK. Ticking all the boxes to better documentation of infection screens in neonates. Conclusion: This quality improvement project has shown that by implementing a simple tick box form documentation can be greatly improved. This will positively impact on patient care by allowing for improved continuity of care between team-members and providing future care-givers with essential information regarding the course of IV antibiotics as well as keeping the parents informed. In future, we aim to encourage higher usage of the forms in order to further improve documentation. We will perform regular re-audit to ensure that standards are improved and maintained (aiming for target of 100%). Problem: A retrospective audit of neonatal notes from 01/08/15-07/08/15 showed poor documentation when neonates were screened for infection and commenced on antibiotics on the postnatal ward and NICU (4% had “complete documentation” – as defined below). This led to miscommunication between team-members with the potential of leading to prescribing and management errors. Discussion with parents was also very poorly documented (13%) and parental complaints had been received by the unit. The aim of this project was to improve documentation of infection episodes in patients’ notes to 100% over a 12 month period. Study Method: We implemented the forms on the neonatal unit and postnatal ward in March To evaluate whether the implementation of these forms improved documentation we conducted a prospective re-audit of notes over one week period 26/05/16-02/06/16 in postnatal ward and NICU. Results 1: The pink form was used in 60% of the notes audited. Below is a graph showing the percentage of notes that had the essential criteria documented in the first audit and in the re-audit. The third group shows the data from only the notes where the pink form was used in the re-audit. Results were better for all criteria when the pink form was used. Results 2: The average number of criteria documented improved in the re-audit from 1.2 to 2.4 (3.3 where pink form used). Below is a graph showing improvement in documentation following implementation of the forms. It also shows our target of 100% for documentation. Further audit results will also be plotted on this graph to track progress. Solution: Four essential criteria were defined that should always be documented when antibiotics are commenced: 1.Reason for commencing antibiotics 2.Culture types taken 3.Antibiotic choice 4.Discussion with parents. We created a simple tick box form (printed on coloured paper) to allow quick and easy documentation when infants are commenced on antibiotics. Results 1: The pink form was used in 60% of the notes audited. Below is a graph showing the percentage of notes that had the essential criteria documented in the first audit and in the re-audit. The third group shows the data from only the notes where the pink form was used in the re-audit. Results were better for all criteria when the pink form was used. Study Method: We implemented the forms on the neonatal unit and postnatal ward in March To evaluate whether the implementation of these forms improved documentation we conducted a prospective re-audit of notes over one week period 26/05/16-02/06/16 in postnatal ward and NICU.