Clinical Audit and Documentation of Vital Signs - Literature review Example

This paper is a description of a clinical audit including explaining the process of selection of the selection of an audit topic. A description of the development of an audit tool is described and the process of implementation is critiqued. The paper offers recommendations for the audit process after the conclusion of the initial audit. The clinical audit will be conducted in an inpatient hospital in Sydney with a capacity of 200 beds. The facility provides health services for a range of patients and offers a range of services such as surgery, maternity pediatrics and general health. Clinical audit makes the health unit more effective since it determines what is being done against what needs to be done (Braine 2006). It is through the definition of standards that an organization may be able to improve practice (Graingier 2010). Auditing in the health care setting is aimed at ensuring that the patients get care which is of utmost quality (Benjamin 2008). When interventions are made, safety, efficiency and reduction of costs are enhanced (Manucci 2011). According to Patel (2010) audit may be a tool that may enhance and maintain appropriate provision of service and professional standards in health provision. Benjamin (2008) established that while there are many benefits to be attained from clinical audit not all audits will be appropriate or useful. Scott (2009) established that difficulties in getting access to published work and clinical data, lack of literature on given topics, lack of clear staff procedures, motivation and time made some audits ineffective. (Grangier 2010) suggests that the taking charge and ownership of the process in the improvement of practice by nurses would be useful in enhancing the audit process. In order for audit to be effective it has to follow a cycle; The National Institute for Clinical Excellence sets out the steps of a n audit as; preparation, criteria selection, measurement of performance levels, making changes and sustaining improvements. Cooper and Benjamin (2003) also asserted that the audit process is an ongoing one aimed at continual improvement of clinical practice. Selection of a topic for the audit needs to take into account a number of factors which should be in line with corporation objectives if senior management is to offer support Hubbard 2000). Since there are many standards there should be agreement on what is good clinical practice (Cooper and Benjamin 2003), this will then be employed in standard setting in the search for audit topics (Graingier 2010). Audit goals ought to have a wide range of evidence in clinical practice if they are to be effective (Benjamin, 2008). It was decided to conduct an audit on Documentation of Vital Signs. Documentation of clinical data is a critical component of health care if critical errors are to be avoided (Beaumont, Luettel & Thompson 2008) as such the clinical nursing professional is charged with ensuring data for the patient is accurately documented(Attin et al 2002). The use of computerized documentation has been on the rise since its effectiveness was established in the early 2000s (Howell 2012). However the use of computerized records has some issues which may limit its effectiveness in documentation (Rajkumar, Karmarkar & Knott 2006). Computerized documentation has inherent limitations which need to be well understood by the professional for proper documentation of vital signs (Schulz 2007). Patients stand to receive better health care if health care professionals are knowledgeable on how to use computerized records (Howell 2002). In conducting this we sought authorization from the head of the clinical unit (Cooper and Benjamin 2004) Cooper and Benjamin (2004) assert that a questionnaire ought to be used in order to make the collection of data. The sample size and the length of the questionnaire ought to be limited in order to ensure only relevant data is collected and that participants don’t feel their time is being wasted. In order to maintain anonymity data that could identify a participant was not included (Cooper & Benjamin 2004). It is critical to be clear on the objectives and goals of the audit (Benjamin 2008). We identified three critical aspects to include in the questionnaire; how computerized documentation works, factors affecting input of data, and factors impacting the retrieval of the same data (Attin et al 2002, Casey 2011, Rajkumar, Karmarkar & Knott 2006, Schuls 2011). According to a study by Hubbard (2000) an auditor ought to be knowledgeable and familiar with the workplace in order to complete an audit successfully. Upon the completion of tool development the findings were submitted to the manager of the Nursing Unit and the d’charge of Clinical affairs in order to get approval and feedback (Cooper & Benjamin 2004). Staff must be made to acknowledge the importance of clinical audit processes in enhancing professional practice. In their responses the respondents showed that they acknowledged the role of audit. Nursing staff were more likely to complete questionnaires if the questions were put to them by fellow respondents or in real time. In the development we established that the respondents were enthusiastic and had a deep desire to participate in the process which was a good for the audit (Braine 2006). It has been established that strategies of quality improvement will be more successful if they are driven by the health care professional or the patient (Scott 2009). According to Grangier (2010) a questionnaire ought to be concise and unambiguous if it is to be an effective audit tool. Our audit tool consisted of 13 questions which we deemed would be appropriate in not taking away the clinicians from patient care. There was no set timeline for the clinicians to complete their questionnaire. The results of the audit were found to be relevant to professional practice and this was found true through 90% of the respondents asserting that they used computerized systems, and 10% asserting that they did not. Participants responses on question 5 and 9 showed such questions were not very clear and needed revision. Question 7 was the only question which all respondents answered correctly. However, they failed to give details regarding the methodology they used to input data into the system. The last question was not understood very clearly by respondents as they did not understand concepts of rechecking and counter checking. Many respondents could not distinguish between the two words. The responses were a reflection of this as 45% replied false and 55% replied true. Since the audit toll was brief it was possible to have different perspectives on clinical scenarios which are relevant to the audit processes of computerized documentation as found by Howell (2002). Given the brevity of the audit tool it would be easy to improve it especially on question clarity especially after feedback is obtained from the respondents (Cooper & Benjamin 2004). It would be important to modify the tool since clinical audit ought to be a continuous process that needs constant improvement and changes (Benjamin 2008). Cooper and Benjamin (2004) asserted that participation is enhanced by anonymity. On the other hand Attin et al (2000) asserts that educational interventions which could be made from the feedback in order to enhance effectiveness were hard to implement. This is because the final reading would find it hard to establish if the same persons who were involved in the first survey are the same ones on which follow up is being made. Questions 3-6 were dealing with the effectiveness of inputting data in the computerized system. Most of the respondents were knowledgeable regarding how to input data into computerized systems. On the other hand Casey (2011) asserts that it is critical to comprehend how computerized data input systems work in order to be able to tell whether the responses given were valid. Questions 7-9 dealt with aspects of incorrect input of data into the systems. Most participants were of the opinion that the system was responsible for the errors which occurred in data input resulting in adverse events. 85% believed that lack of proper training resulted in the erroneous documentation of data into the system (Rajkumar, Karmarkar, &Knott 2006). 90% were of the opinion that wrongful input of data would not result in severe adverse events. Question 10-13 sought to establish what factors made clinical practitioners uninterested in the process of computerized documentation. 60% of the respondents asserted that computerized documentation was the way to go in enhancing quality care (Casey, 2011). There needs to be more education and awareness o0n the benefits and use of computerized documentation in clinical nursing practice. It is plausible to find that some clinicians have completely no knowledge regarding the process of computerized documentation. Question 12 elicited some confusion since the question on whether documentation would be enhanced by education and training was not answered correctly. However the results of one study may not give the whole story regarding computerized documentation. As such it would be good to conduct follow up audits to determine validity of results (Howell 2002). It is important to accurately input data into the system in order to prevent the happening of adverse events. In a setting in which a wide variety of patients with different illnesses are cared for it is important that proper documentation be carried out. Documentation records for persons in the general wards and outpatients needs to be correctly input in order to avoid complications. Lack of proper documentation procedures is responsible for approximately 30% of adverse events in general health care settings. During the audit it was established that a significant number of clinical practitioners were deficient in knowledge regarding computerized documentation and as such it would be import to bring up training and education for these practitioners (Jones and Cawthorn 2003). In order to be effective practitioners need refresher course and proper training on how to use computerized systems (Casey 2011). Better training would enhance the effectiveness of personnel and enhance clinical outcomes. Patel (2010) asserted that clinical audits are only effective if they enhance patient outcomes. In order to make education effective it must be acknowledged as being practical and enhancing clinical outcomes and practice (Jones & Crawthorn 2003). In the filling of the questionnaire some of the respondents asserted that some of the questions were complicated. Results confirmed that a significant number of the respondents had a knowledge ddeficit regarding documentation. This points the management to be involved in arranging for enhancement of the knowledge base of the clinical staff (Mannucci 2011). Timely feedback from the audit will result in behavioral change and further education and continuous auditing will be valuable in ascertaining the levels of knowledge base Jones & Cawthorn 2003). References Attin A, Cardin S, Dee V, Doering L, Dunn D, Ellstrom K, Erikson V, Etchepare M, Gawlinski A, Haley T, Henneman E, Keckeisen M, Malmet M, Olsen L 2002, ‘An educational project to improve knowledge related to pulse oximetry’, American Journal of Critical Care, vol. 11, no. 6, pp. 5298- 534. Beaumont K, Luettel D, Thomson R 2008 ‘Deterioration in hospital patients: early signs and appropriate actions’, Nursing Standard, vol. 23, no.1, pp. 43-48. Benjamin A 2008, ‘Audit: how to do it in practice’, British Medical Journal, vol. 336, pp. 1241-1245. Braine M 2006, ‘Clinical governance: applying theory to fact’, Nursing Standard, vol. 20, no. 20, pp. 56-65. 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