1. Death Documentation and Communication: Improvement through electronic innovation James McCallum Associate Medical Director 15th March 2017

2. Introduction
Despite training in verification and certification of death, documentation of inpatient deaths in case notes is often poor
The implications are:
Medico-legal
Poor communication to General Practitioners
Information not easily accessible to doctors
A project was set up to investigate the documentation of death and produce a new electronic template to improve this process 2

3. Method
The documentation of several factors associated with inpatient deaths were retrospectively reviewed (1st audit)
Implementation of a new tool (Intervention)
Documentation was re audited to monitor impact of the intervention (2nd audit)
Documentation was then introduced to an additional site (SJH) 3

4. The First Audit
All inpatient deaths between December 2014 and February 2015 on the respiratory ward at the Western General Hospital (WGH) were reviewed (n = 19)
Length of time taken to produce formal discharge letters (FDL) was also assessed
Only electronic notes were used 4

5. The Intervention
A new TRAK “canned text” was developed and implemented
It provided a template for recording deaths electronically
This was then promoted via presentations to the medical staff of several departments at WGH
The lead author introduced the template to senior medical staff at St John’s Hospital (SJH) and it was escalated to the Associate Medical Directors (AMDs)
Its use was encouraged by the medical department and AMDs via formal presentations, verbal and reminders 5

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7. Re-Audit and SJH The Re-Audit - Completed Cycle
The documentation of inpatient deaths over 3 month periods at the two departments in WGH were reviewed post introduction of the template.
Introduction at other Sites –The Third Audit
The template was further publicised to senior medical staff at St John’s Hospital (SJH). It was accepted and promoted throughout the SJH General Medicine department. The 3rd audit assessed the use of the template by the department between Jan –March 2016. 7

8. Results
The first audit showed poor levels of documentation (Fig.2). Cause of death was recorded in only 42% of cases
Only 58% had completed Formal Discharge letters, taking on average 43 days after the patient’s death to be sent to the GP
In the second audit at WGH the template was used in 89% of cases. Significant improvements in nearly all aspects of documentation were seen (Fig.3)
Cause of death was recorded in 83% and confirmed communication with GPs had been completed in 43% of cases
The audit at SJH showed great electronic documentation of inpatient death with use of the template in 86% of cases 8

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10. Discussion
The introduction and promotion of a new TRAK electronic template caused a dramatic improvement in the documentation of inpatient deaths
The electronic letter produced provides readily accessible information for the medical and multi-disciplinary team
When prompted an of the electronic letter will be sent to the patient’s GP practice
It is has now been promoted to the Clinical Directors across all sites in Lothian and has been incorporated as a permanent feature into departmental inductions. 10

11. Challenges ahead
Maintaining the use of the template at SJH (institutional memory)
Wider implementation throughout NHS Lothian across multiple sites and departments
Ensure the practice of template completion and automatic electronic GP notification becomes common practice (enhanced performance) 11

12. Next Steps
Involve both senior and junior members of all medical and surgical teams to ensure that this becomes an expectation of their unit
Rotating Foundation Year doctors to be targeted through their departmental and hospital teaching programmes and unit induction
Poster reminders are to be instated in doctor rooms in all departments. 12

13. Thank you Special thanks to: P. McAleer, Foundation Year 2
H. Gillet, Gastroenterology Consultant, Clinical Director MEDAS, St John’s Hospital
P. Reid, Respiratory Consultant, Western General Hospital 13