888 Improving the Documentation of Skin Closure and the Plan for Its Removal for Trauma & Orthopaedic Patients

Abstract

Abstract Aim Surgical patients require closure of wounds with skin clips or sutures. Removal at an appropriate time can prevent complications, namely infection. Our goal is to ensure clear documentation of closure type and plan for removal. The Royal College of Surgeons states that “details of closure technique” and “detailed post-operative care instructions” are required. Method Retrospective data collections were undertaken in January and September 2022 for trauma patients in Altnagelvin Hospital. Data was gathered from Operation Notes. The first collection included 30 patients, the second included 24 patients. Two main interventions were implemented. The first of these was presentation of the initial findings at a departmental audit meeting for the purpose of education. The second was to amend operative proformas to include different types of skin closure and its removal at a prescribed time in the post-op plan as “delete as appropriate” options. Results Following our interventions, the correct skin closure was documented in 100% of patients. Plan for removal of closure was documented in 84.6% overall between both written and typed notes. Typed operative notes had 100% plan for removal documentation compared with only 66.67% of written notes. In the first collection, only 55% of patients had adequate removal plans documented on typed notes so the amended operative notes being introduced have resulted in a clear improvement. Conclusions Accurate documentation is essential for patient safety and simple interventions can result in a drastic improvement in quality. Pre-typed operative notes were superior to written operative notes and should be used where available and appropriate.