Perianesthesia Orientation Redesign Phase I: Standardizing Minimal Documentation Across the PACUs

Abstract

<h3>Background Information</h3> Standardizing orientation has been shown to reduce confusion and decrease patient care errors. Documentation remains the single largest area where differences exist and errors occur. <h3>Objectives of Project</h3> Standardizing postanesthesia minimal documentation's aim was to develop through nurses' consensus a consistent standardized method of charting essential PACU data elements that reflected American Society of Perianesthesia Nursing (ASPAN) and the Joint commission required documentation while at the same time increasing nurses' satisfaction and efficiency of care. Training and keeping existing staff to the same standards is key in reducing issues with orientees' learning documentation requirements. <h3>Process of Implementation</h3> Eight of the 11 PACUs worked together designing documentation guidelines based on goals to track compliance. Minimal documentation standards were designed and approved. Units identified one champion to manage unit superusers who trained end-user groups. Nurses received classes on the standards then practiced in Epic play environment. We piloted the standards on new hire nurses. Preceptors held their orientees to the standards. The audit process was designed to track compliance of minimal documentation standards. Initially the unit champions and superusers performed the audits. Audit data was collected and disseminated bimonthly to superusers to give real time feedback to their end-user members. By July, end-users started auditing monthly to reinforce minimal documentation training. <h3>Statement of Successful Practice</h3> Data showed an approximate increase from 87% to 98% compliance with ASPAN standards. Areas being missed differed from unit to unit. Data demonstrated need for re-education in those areas to harmonize over all PACUs. Areas for improvement were outpatient documentation, specialty assessments, and hospital required documentation (ex: belonging documentation). Orientees reported the review and bedside reminder pages were helpful in making documentation easier. Preceptors reported their orientees learned documentation quicker. Removing the duplication and standardizing the frequency was identified by staff as giving them more time for patient care. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> In standardizing documentation, we systematically reduced issues with orientation and lowered stress on nurses keeping up with their workload and throughput. In maintaining a standardized documentation practice we reduced confusion regarding what we should be documenting and when. This standardized program may be disseminated to other JHH health system PACUs.