Documentation Compliance Research Articles

Adherence to Evidence-Based Guidelines and ImplicationsWhen Designing Electronic Documentation for Urinary Catheters.

The aim of this study was to investigate the point prevalence and the rate of adherence to evidence-based guidelines for patients who had indwelling urinary catheters in three Australian acute care hospitals. A cross-sectional observational design was used. A multisite cross-sectional observational design was utilised in three acute hospitals across Australia. Data were collected from each site in a single day directly from observation of the patient, the bedside notes and medical records. The data collected included observations of clinical care and scrutiny of the documentation of the insertion details and catheter care using best practice guidelines. Of the 1730 patients audited, 47% were female. The mean point prevalence of catheters insitu across three sites was 12.9%. Correct documentation compliance was reported to be, on average, 40%. Documentation was significantly better when a template was available to guide information recorded: this was regardless of whether it was hard copy or electronic. Overall, clinical care compliance with best practices was 77%. Of note for improvement was the fixing of the urinary catheter to the thigh in highly dependent patients. It was identified that there is a need for improvement across all three sites: specifically regarding securement of the urinary catheter to the patient's thigh within the ICU. In addition, it was identified that there is a need for documentation of the urine bag change in ward areas. Documentation may be improved by incorporating templates into healthcare documentation systems in the future. Further work is needed to ensure nurses are aware of the adverse effects of urinary catheters and thus, the need to adhere to best practice guidelines. There has been no patient or public contribution. We have adhered to the STROBE guidelines for reporting.

Audit of Geriatric Emergency Medicine-Unit staff compliance in providing care in line with the Age Friendly Health Systems Conceptual Framework

Abstract Background The Geriatric Emergency Medicine Unit (GEMU) in University Hospital Limerick (UHL) is in the Emergency Department for the assessment of those over the age of 75. The unit is staffed by a multi-disciplinary team with specialist skills in older person’s care. The aim of this audit was to determine assessment and documentation compliance with the Age Friendly Health Systems conceptual framework for older persons who present to GEMU. Methods A retrospective documentation review took place from patients who attended GEMU between January-March 2023. Medical record numbers were selected at random from the Health and Social Care Professionals (HSCP) team data management system with individual patient records subsequently retrieved from the Therefore Emergency Medicine (EM) patient management system. Patient records were reviewed by SW, which included Nursing, EM Doctors documentation and HSCP documentation. Results 15 charts were reviewed. Compliance varied across all areas from 0-100%. Compliance was greatest in the domains of the EWS score, mobility assessments, falls history and 4AT. Hydration and the documentation of ‘What Matters’/patient care preference were both 0%. Otherwise, compliance broadly was >50%. The first re-audit of 15 charts took place from December 2023-January 2024. Improvements were noted across all assessments, with 100% compliance additionally achieved in CFS, cognitive status, co-morbidities and nutritional intake. A second re-audit of 15 charts took place from March-April 2024, with further improvements seen in terms of lying and standing blood pressures and polypharmacy assessments. Conclusion Results demonstrate the continued improvements made amongst the team in adhering to the Age Friendly Health Systems Framework. Efforts are ongoing to focus specifically on the care preference component, with structured QIPs in place and a view to re-auditing in Q4 2024.

Roadmap to success: Blueprint for enterprise-wide deployment of a point-of-care ultrasound platform, inclusive of governance, policy, education, credentialing, and quality assurance.

Point-of-care ultrasound (POCUS) has emerged as a cost-effective diagnostic tool that significantly augments physical examinations. Positioned as an extension of traditional examination methods, particularly appealing to the upcoming generation of clinicians, it holds promise in potentially replacing the stethoscope in various medical assessments and procedures. The University of Rochester is deploying 2500 POCUS machines, enhancing compliance for image storage and documentation. Halfway through our 4-year deployment plan, we will discuss our governance structure, educational initiatives, and credentialing strategies. While POCUS adoption has seen organic growth over the past decade, our aim is to implement a comprehensive strategy ensuring adherence to established protocols for image storage and documentation. At present, we have successfully deployed 789 probes, with integration across 64 departments or divisions into our IT platform. Notably, this implementation has resulted in a remarkable 116% increase in hospital charges, underscoring the tangible impact of POCUS integration. However, achieving compliance and education among established providers has proven to be challenging.

FP6.9 - Improving Compliance & Implementation of the STAR Score at a tertiary level hospital in India: A continuous process

Abstract Aim To perform an audit to check the Quality and compliance of Surgical documentation using STAR Score at a tertiary hospital in India. Method A total of 90 case files were studied and assessed in detail from all surgical departments. The “STAR: Surgical tool for auditing records” tool was used to collect data accordingly. The results were compared with standard guidelines and further analyzed. A series of departmental training and implementation meetings were carried out. Three cycles were carried out and a re-audit was performed at the end of every cycle. Result The overall compliance score of the hospital was found to be 74%. While the departments of General surgery and orthopaedics showed a higher rate of compliance, each constituting 82%, Neurosurgery showed the least compliance at 62%. It was also seen that the maximum percentage of missing information constituted anaesthetic records and subsequent entries. At the end of 3 cycles, a considerable improvement was observed, with the compliance rate improving to 98% in all departments. Conclusion We believe that compliance and implementation of the STAR Score is mandatory, as it can significantly improve the quality of documentation and can be implemented universally.

Early Identification, Intervention, and Prevention of Hospital-Acquired Pressure Injuries Using a Nurse-Driven Pressure Injury Prevention Program.

The purpose of this quality improvement project was to reduce the hospital-acquired pressure injury (HAPI) rate to less than 1.177 per 1000 patient-days, increase staff competency and care in pressure injury prevention best practices through implementation of a nurse-driven pressure injury prevention program, to engage patients in pressure injury prevention through implementation of skin rounds, and improve staff adherence to documentation requirements for pressure injury interventions on an amputee/stroke unit. HAPIs can lead to negative patient outcomes including pain, infection, extended hospitalization, and morbidity. Using an evidence-based education strategy, the Agency for Healthcare Research and Quality pressure ulcer prevention clinical pathway and skin rounds were implemented. Focused education for nursing, staff competency, daily audits, HAPI rates, and documentation compliance were evaluated pre and post intervention. The HAPI rate reduced from 1.177 to 0.272 per 1000 patient-days. After completion, the unit maintained zero pressure injuries, daily patient care for pressure injuries improved, documentation compliance increased, and staffs' knowledge and skill set in early identification, intervention, and prevention of pressure injuries heightened. A nurse-driven pressure injury prevention program was successful in the reduction of the HAPI rate.

Preceptorship terhadap Kepatuhan Melaksanakan SPO Pemasangan Infus dan Pendokumentasian dalam Melakukan Tindakan Pemasangan Infus

This study aims to determine the effect of preceptorship on compliance in implementing SOP for infusion installation and documentation in carrying out infusion installation actions. The method used is a quasi-experiment with a one-group pretest–post-test design. The results showed compliance in infusion installation by the SOP before and after preceptorship increased from 67.6% to 88.2%. At the same time, compliance in documentation in carrying out actions before and after preceptorship rose from 52.9% to 85.3%. In conclusion, preceptorship affects compliance in implementing SOP for infusion installation and documentation in carrying out infusion installation actions in the Inpatient Room of Bertha Medika Hospital, Sukabumi Regency. Keywords: Compliance, Documentation, Infusion Installation, Preceptorship

A Pain in the Pilot.

Multi-agency guidelines recommend use of a functional pain assessment tool as an objective assessment of pain, rather than relying on a subjective verbal rating scale. This project was created to address issues managing Patients' pain in inpatient settings. The project aimed to answer: 'How can we adopt the use of a Functional Pain Assessment into our clinical practice, optimising its effectiveness for ALL patient groups in our inpatient ward areas?' Output from multi-disciplinary working group: two electronic documents were created - Pain Assessment Tool and Pain Observations Chart: for staff to document routine pain observations. Five wards participated in the pilot study, with training/support provided. Result: Staff and patients preferred the new approach, compared to previous pain documentation method. However, documentation compliance was not as good as expected. Pilot proved the concept, documents are effective in pain management, but more education and support is needed to embed cultural shift.

Enhancing Procedure Documentation in Neonatal Intensive Care Unit (NICU): A Quality Improvement Initiative at a Tertiary Neonatal Hospital.

Background Accurate and comprehensive procedure documentation in Electronic Medical Records (EMR) is crucial for high-quality patient care, especially in high-acuity settings like Neonatal Intensive Care Units (NICU). Gaps in documentation at Corniche Hospital's NICU that were affecting patient safety and continuity of care were identified and addressed by following a pre and post-intervention design in the research. The process involved the initial audit, educational sessions with healthcare providers, and follow-up audits to measure improvements.Results post-intervention showed a significant increase in compliance with documentation standards, pointing out the effectiveness of educational interventions in improving EMR documentation practices. The local problem is demonstrated through the observation ofincomplete and inconsistent procedure documentation in the NICU,hindering effective patient management and multi-disciplinary team communication. Methods A Quality Improvement Project (QIP) was implemented, including a baseline audit, educational interventions targeting healthcare providers, and subsequent re-audits to assess improvement. The project involved tailored educational sessions focused on correct EMR usage, adherence to documentation standards, and practical aspects of documenting procedures. Results Post-intervention, there was a significant increase in documentation compliance. The percentage of compliance in procedure encounter placement in EMR increased from 81% to 100%, and nursing documentation compliance improved from 11 (52.4%) to 18 (85.7%). However, a slight decrease in the completeness of physician documentation was noted. Conclusions The QIP effectively improved procedure documentation in the NICU. Continuous education and periodic review are essential for maintaining and further enhancing documentation standards. This initiative underscores the importance of targeted training and consistent audits in improving clinical documentation in healthcare settings.

Intensi Berbasis PMT terhadap Kepatuhan Pengisian Dokumentasi Asuhan Keperawatan

This study aims to determine the influence of protection motivation theory (PMT)-based intentions on nursing care documentation compliance behavior. In this research, motivation that influences behavior is described by intention, which is an indication of how strongly someone wants to carry out a behavior. The method used in literature searches uses four databases, namely Google Scholar, PubMed, ProQuest, and ScienceDirect. Search for articles or journals using keywords and Boolean operators. The research results show that the most applicable benchmark for individual behavioral motivation in protection motivation theory is intention. The research conclusions illustrate that there is an intention showing a person's willingness to try to carry out behavior in accordance with applicable orders or policies. If the individual understands the risk of non-compliance in filling out nursing care documentation, then the individual will have the motivation to protect themselves (protection motivation) in the form of a desire to carry out documentation in accordance with the policy procedures that apply at the hospital. Keywords: intention, protection motivation theory, documentation of nursing care

Centralized Multipatient Dashboards' Impact on Intensive Care Unit Clinician Performance and Satisfaction: A Systematic Review.

Intensive care unit (ICU) clinicians encounter frequent challenges with managing vast amounts of fragmented data while caring for multiple critically ill patients simultaneously. This may lead to increased provider cognitive load that may jeopardize patient safety. This systematic review assesses the impact of centralized multipatient dashboards on ICU clinician performance, perceptions regarding the use of these tools, and patient outcomes. A literature search was conducted on February 9, 2023, using the EBSCO CINAHL, Cochrane Central Register of Controlled Trials, Embase, IEEE Xplore, MEDLINE, Scopus, and Web of Science Core Collection databases. Eligible studies that included ICU clinicians as participants and tested the effect of dashboards designed for use by multiple users to manage multiple patients on user performance and/or satisfaction compared with the standard practice. We narratively synthesized eligible studies following the SWiM (Synthesis Without Meta-analysis) guidelines. Studies were grouped based on dashboard type and outcomes assessed. The search yielded a total of 2,407 studies. Five studies met inclusion criteria and were included. Among these, three studies evaluated interactive displays in the ICU, one study assessed two dashboards in the pediatric ICU (PICU), and one study examined centralized monitor in the PICU. Most studies reported several positive outcomes, including reductions in data gathering time before rounds, a decrease in misrepresentations during multidisciplinary rounds, improved daily documentation compliance, faster decision-making, and user satisfaction. One study did not report any significant association. The multipatient dashboards were associated with improved ICU clinician performance and were positively perceived in most of the included studies. The risk of bias was high, and the certainty of evidence was very low, due to inconsistencies, imprecision, indirectness in the outcome measure, and methodological limitations. Designing and evaluating multipatient tools using robust research methodologies is an important focus for future research.

Adequacy and Acceptability of the Self-Collected Anal Pap Smear in People Living With Human Immunodeficiency Virus in the Infectious Diseases Clinic.

Background Anal Pap smears are imperative to screening for human papillomavirus (HPV)-associated anal squamous cell cancers, particularly in patients living withhuman immunodeficiency virus (HIV) given a higher incidence of disease. Self-collection of specimens may be favored by patients and more feasible to collect, increasing screening. Methods This was a single-center observational cohort study at a single academic medical center Infectious Diseases clinic from October to December 2021. We aimed to improve compliance of anal Pap collection documentation of "self-collected" versus "physician-collected" as well as verify if self-collected specimens (SCS) were adequate for interpretation equivalent to physician-collected specimens (PCS). Additionally, we aimed to evaluate patient and provider satisfaction with self-collected anal Paps. Results Sixty anal Pap smears were available for evaluation. The rate of documentation of the collection method (self-collected vs. physician-collected) was 88% during the intervention. A total of 75% of patients opted for self-collection, and 35/45 (78%) of these samples were adequate for interpretation. There was no difference in the adequacy of specimen (the ability of a cytopathologist to interpret the specimen) between the SCS and PCS. Conclusion Limited prior data suggest self-collected anal Pap specimens are adequate for interpretation only slightly less often than PCS. In our small cohort, there was no statistically significant difference between collection methods. Satisfaction with self-collection of specimens was high for both patients and providers. Additional validation in more diverse/larger clinical settings may be helpful to support this practice.

Documentation for Orthopaedic Surgery: An Audit to Ensure Compliance with the Most Recent Guidelines

Background: Consistent and thorough documentation in orthopaedic surgery is critical for ensuring quality patient care and protecting the legal interests of surgeons. Adherence to the Royal College of Surgeons (RCS) guidelines is fundamental to achieving this. However, studies have identified a persistent deficiency in compliance with these guidelines across various surgical specialities. Objective: The audit aimed to evaluate the existing compliance of orthopaedic surgical documentation with RCS guidelines at Dr. Ziauddin Hospital and to implement a tool to improve documentation practices. Methods: A closed-loop, two-cycle audit was conducted. The first cycle retrospectively analysed 200 surgical notes from January to July 2023, using a standardized operation sheet to assess compliance with RCS guidelines. Identified deficiencies were addressed by introducing an aide-memoir in all orthopaedic operating rooms. The second cycle prospectively analysed 100 surgical notes from August to October 2023 to evaluate the impact of the intervention. Results: The initial audit revealed a 0% compliance rate in documenting the date, time, and type of surgery (elective or emergency). Following interventions, the second cycle showed significant improvements, with compliance rates rising to 100% for date and time, and to 87% for identifying the surgery type. Additional documentation parameters such as the recording of the assistant's name and incision details also improved, though exact numerical increases were not specified. Conclusion: Introducing an aide-memoir significantly enhanced compliance with RCS surgical documentation guidelines. This simple, effective tool facilitated a remarkable improvement in the quality of operative notes, underscoring the need for regular audits and potential integration of electronic documentation systems.

Compliance Corner: Documentation Authentication

This article addresses the following topics related to medical billing and documentation compliance: Denial due to untimely authentication Know regulations and payer policies Preemptive compliance actions (avoiding surprises) Defending your practice against unfavorable audit findings

Increasing venous thromboembolism risk assessment through a whole hospital-based intervention: a pre-post service evaluation to demonstrate quality improvement.

Venous thromboembolism (VTE) is a primary cause of morbidity and mortality in hospitalized patients. VTE risk assessment is a crucial part of the VTE prevention guideline. However, VTE risk assessment was not consistently undertaken for admitted patients. The aim of this study was to identify whether a quality improvement project implemented to change documentation of VTE risk assessment for hospitalized patients impacted patient safety by decreasing the rate of VTE incidences. The study was set in a 600+ bed acute hospital that provides medical and surgical services for adult patients during the period October 2018-September 2020. The hospital adopted the American College of Chest Physicians (ACCP) 9th edition VTE prevention guidelines and followed the Modified Caprini risk assessment tool. Following the FOCUS-Plan-Do-Check-Act (FOCUS PDCA) improvement methodology, the improvement team implemented multicomponent interventions over a 3-month period, including conducting educational sessions, sharing VTE documentation compliance results, giving reminders during rounds, assigning a VTE liaison physician within each clinical specialty, and updating and communicating the hospital adopted VTE guidelines. A total of 17 612 patients were included, respectively, 8971 in pre-intervention and 8641 post-intervention period. Documentation of VTE risk assessment upon admission increased significantly in the post quality improvement intervention period (60% vs. 42%, relative increase of 30%, χ2 = 1.43, P < 0.001). The run chart trend analysis demonstrated significant improvement shift and improvement trend after quality improvement project implementation, and it was sustained for 15 months. There was no impact on patient safety with a slight not statistically significant decrease in the VTE incidences rate post intervention period (0.4% vs. 0.5%, relative decrease of 1%, χ2 = 0.82, P < 0.397). The quality improvement project intervention significantly increased the percentage of patients assessed for VTE risk in a hospital setting.

Surgical safety checklist compliance process as a moral hazard: An institutional ethnography.

Charting is an essential component of professional nursing practice and is arguably a key element of patient safety in surgery: without proper, objective, and timely documentation, both benign and tragical errors can occur. From surgery on wrong patients to wrong limbs, to the omission of antibiotics administration, many harms can happen in the operating room. Documentation has thus served as a safeguard for patient safety, professional responsibility, and professional accountability. In this context, we were puzzled by the practices we observed with respect to charting compliance with the surgical safety checklist (SSC) during a study of surgical teams in a large, urban teaching hospital in Canada (pseudonym 'C&C'). This article leverages institutional ethnography and a subset of data from a larger study to describe and explain the social organisation of the system that monitored surgical safety compliance at C&C from the standpoint of operating room nurses. This data included fieldnotes from observations of 51 surgical cases, on-the-spot interviews with nurses, formal interviews with individuals who were involved in the design and implementation of the SSC, and open-ended questions from two rounds of survey of OR teams. We found that the compliance form and not the SSC itself formed the basis for reporting. To meet hospital accuracy in charting goals and legislated compliance documentation reporting requirements nurses 'pre-charted' compliance with the surgical checklist. The adoption of this workaround technically violated nursing charting principles and put them in ethically untenable positions. Documenting compliance of the SSC constituted a moral hazard, constrained nurses' autonomy and moral agency, and obscured poor checklist adherence. The findings highlight how local and extra local texts, technologies and relations create ethical issues, raise questions about the effectiveness of resulting data for decision-making and contribute to ongoing conversations about nursing workarounds.

Abstract WP99: A Multidisciplinary Approach to Modified Rankin Scale Assessment and Documentation

Objective: The aim of the QI project is to improve the documentation compliance of the Modified Rankin Scale (mRS) through utilizing a multidisciplinary approach. This includes training occupational and physical therapy specialists to assess the mRS scores in the stroke patient population at community hospital primary stroke center. Background: As the most widely used outcome measure for assessment of post-stroke recovery, research confirms that anyone with the appropriate training with regards to performing the mRS can utilize the tool. Initial documentation by nursing began August 2021, and initial documentation compliance of pre-stroke and discharge mRS had not risen above 82%. Methods: A multidisciplinary group consisting of frontline staff members, educators and stroke program administrator was created to implement the proposed practice change. They identified 6 steps to complete this process. ( Table 1 ) The goal for documentation compliance was set at 90% by the end of the first quarter of 2023. The change was implemented on September 15, 2022. Results: Supplementing nursing assessment and documentation of the mRS with the addition of physical and occupational therapy was a successful process change. Documentation compliance improved and reached the predetermined goal set by the multidisciplinary group by the end of January 2023. Documentation compliance reached 100% by March of 2023. Conclusion: Physical therapist and occupational therapist can increase documentation compliance for mRS scores. Increased documentation compliance improve evaluation of inpatient care and post-discharge follow-up to more comprehensively evaluate outcomes of stroke care.

Abstract WP55: Enhancing the Stroke Patient Education Experience: A Focus on Stroke Procedure Education

Background and Issue: Providing stroke patient education is a fundamental core measure for all levels of stroke centers with a generalized focus of topics including activation of emergency medical services, need for follow up after discharge, medications prescribed at discharge, risk factors for stroke, warning signs and stroke symptoms. A gap exists in patient education focusing on advanced stroke treatment procedures such as thrombolytic administration and mechanical thrombectomy. Available educational topics in the electronic medical record are often too generic and do not address the post procedural stroke patient population. Purpose: The purpose of this project was to develop a standardized set of post stroke procedural education topics and design a method of documentation to enhance and augment the stroke patients’ educational experience. Methods: Using Lean Six-Sigma methods, a multidisciplinary workgroup reviewed current literature on education topics, examined the existing EMR post procedure topics available, and queried other stroke centers for best practices in stroke post procedural patient education. Based on the results of findings, we created new procedural education topics focusing on thrombolytic administration, mechanical thrombectomy, aneurysm repair procedures, diagnostic angiogram, and carotid procedures. We developed an automated process to pre-populate the topics, specific to the procedural order set into the EMR. Results: In 2021, procedural stroke patient education documentation compliance was 63% (n=191); through improvement efforts compliance increased to 77% (n=210), year to date 2023. Conclusion: Creating a standardized set of education topics focusing on stroke treatment procedures and embedding education into procedural order sets helps to minimize education omission, increase education documentation compliance, and enhance the stroke patient’s educational experience overall.

2049 Evaluating the rate, timeliness and accuracy of centralised Clinical Frailty Score documentation at a major NHS A&amp;E department

Abstract Introduction Between 5-10% of patients attending the emergency department (ED) are elderly patients living with frailty. NHS England now recommends that all patents aged &amp;gt;65 presenting to acute care should have a Clinical Frailty Score documented within 30 minutes of arrival. We audited the CFS documentation from the Electronic Patient Record (EPR) for patients aged &amp;gt;65 presenting to our local E.D. Methods Our baseline audit looked at patients aged &amp;gt;65 presenting to our ED from 01/09/23-07/09/2023 (n=430). We extracted data for rate and timeliness of documentation from EPR. To calculate accuracy, we compared the documented scores from ED triage staff, with that of our therapist led Frailty Intervention Team (FIT). We excluded patients not assessed by the FIT. We then re-audited the data for 3 separate weeks after delivering a tailored teaching session for band 6 and 7 nurses, and introduction of an educational poster. Results We found exceptional baseline compliance and timeliness of CFS scoring with a 97% documentation rate with a median time of 31 mins from presentation. When assessing accuracy of triage nurse CFS documentation, we found that 42% of patients fell into a lower category of frailty when compared to scores allocated by the FIT. Following teaching sessions and poster education, we observed no improvement in this. Conclusion Our audit identified an overall excellent baseline compliance and timeliness in EPR documentation of CFS scores despite the department’s heavy workload. We noted a significant under-recognition of frailty at ED triage compared to specialist therapist scoring. Despite delivering education sessions and introduction of an educational poster there is still significant room for improvement in accurate identification of frailty with the CFS.

A Multi-Institutional Natural Language Processing Pipeline to Extract Performance Status From Electronic Health Records.

Performance status (PS), an essential indicator of patients' functional abilities, is often documented in clinical notes of patients with cancer. The use of natural language processing (NLP) in extracting PS from electronic medical records (EMRs) has shown promise in enhancing clinical decision-making, patient monitoring, and research studies. We designed and validated a multi-institute NLP pipeline to automatically extract performance status from free-text patient notes. We collected data from 19,481 patients in Harris Health System (HHS) and 333,862 patients from veteran affair's corporate data warehouse (VA-CDW) and randomly selected 400 patients from each data source to train and validate (50%) and test (50%) the proposed pipeline. We designed an NLP pipeline using an expert-derived rule-based approach in conjunction with extensive post-processing to solidify its proficiency. To demonstrate the pipeline's application, we tested the compliance of PS documentation suggested by the American Society of Clinical Oncology (ASCO) Quality Metric and investigated the potential disparity in PS reporting for stage IV non-small cell lung cancer (NSCLC). We used a logistic regression test, considering patients in terms of race/ethnicity, conversing language, marital status, and gender. The test results on the HHS cohort showed 92% accuracy, and on VA data demonstrated 98.5% accuracy. For stage IV NSCLC patients, the proposed pipeline achieved an accuracy of 98.5%. Furthermore, our analysis revealed a documentation rate of over 85% for PS among NSCLC patients, surpassing the ASCO Quality Metrics. No disparities were observed in the documentation of PS. Our proposed NLP pipeline shows promising results in extracting PS from free-text notes from various health institutions. It may be used in longitudinal cancer data registries.

Impact of a Clinical Decision Support Alert on Informed Consent Documentation in the Neonatal Intensive Care Unit.

Informed consent is necessary to preserve patient autonomy and shared decision-making, yet compliant consent documentation is suboptimal in the intensive care unit (ICU). We aimed to increase compliance with bundled consent documentation, which provides consent for a predefined set of common procedures in the neonatal ICU from 0% to 50% over 1 year. We used the Plan-Do-Study-Act model for quality improvement. Interventions included education and performance awareness, delineation of the preferred consenting process, consent form revision, overlay tool creation, and clinical decision support (CDS) alert use within the electronic health record. Monthly audits categorized consent forms as missing, present but noncompliant, or compliant. We analyzed consent compliance on a run chart using standard run chart interpretation rules and obtained feedback on the CDS as a countermeasure. We conducted 564 audits over 37 months. Overall, median consent compliance increased from 0% to 86.6%. Upon initiating the CDS alert, we observed the highest monthly compliance of 93.3%, followed by a decrease to 33.3% with an inadvertent discontinuation of the CDS. Compliance subsequently increased to 73.3% after the restoration of the alert. We created a consultant opt-out selection to address negative feedback associated with CDS. There were no missing consent forms within the last 7 months of monitoring. A multi-faceted approach led to sustained improvement in bundled consent documentation compliance in our neonatal intensive care unit, with the direct contribution of the CDS observed. A CDS intervention directed at the informed consenting process may similarly benefit other ICUs.