477 Documentation of Resuscitation Decisions in Surgical Patients in a District General Hospital

Abstract

Abstract Introduction Every patient admitted into hospital has to have a clear documentation of their resuscitation decisions in their current health charts.1 This enables surgeons to provide the best and sometimes major surgical treatment without delay in the first instance. The aim of this study was to assess the completeness of the resuscitation decisions for surgical patients admitted into our department. Method All patients on our surgical handover list between 22nd August and 31st August 2022 who were admitted were included in this study. Patient charts were reviewed, and data collected in relation to the completeness of the resuscitation decisions and treatment escalation plan (TEP). Results A total of 50 patients were included. 35 patients (70%) had their resuscitation decisions documented whereas 33 patients (66%) had documented TEP. This is in contrast to guidelines as not all of admitted surgical patients had their resuscitation decisions or TEP documented. Our planned interventions were highlighting its importance in a virtual departmental meeting, educating new incoming junior doctors, sending departmental reminder emails and making the section of the proforma a mandatory field to complete. Conclusions Documentation of resuscitation decisions is important in providing quality of care for patients. Our result showed intervention is needed to ensure best practice is adhered to. We plan to achieve a better data completeness in our next audit cycle after intervention.