Increasing Compliance: The Benefits of Using a Computerized Triage Documentation System

2.50
Hdl Handle:
http://hdl.handle.net/10755/162721
Type:
Presentation
Title:
Increasing Compliance: The Benefits of Using a Computerized Triage Documentation System
Abstract:
Increasing Compliance: The Benefits of Using a Computerized Triage Documentation System
Conference Sponsor:Emergency Nurses Association
Conference Year:2007
Author:Brecher, Deena, N, MSN, APRN, BC, CEN
P.I. Institution Name:A.I. duPont Hospital for Children
Title:Clinical Nurse Specialist û Emergency Department
Contact Address:1600 Rockland Road, Wilmington, DE, 19803, USA
Contact Telephone:(302) 651-6282
Co-Authors:Ken Molczan MSN, RN-CS, CRNP, CPN, CEN
Purpose: Triage documentation can be a challenging task, because data entry must comply with a number of organizational rules - from Federal regulations to JCAHO requirements to hospital policies. Electronic triage documentation can make compliance easier, but only if the electronic form is structured properly. The purpose of this project is to describe how we developed an emergency department (ED) information system (EDIS). We began with a review of our medical records. We found that not every field had to be mandatory and instead designed the form focusing on four key data areas in need of improvement: primary assessment, pain assessment, demographic information, and acuity assignment.

Design: This quality improvement project followed the framework of the hospital-developed SAFER model. "SAFER" refers to Select the project and data to be collected; Analyze the data; Find and prioritize opportunities for improvement; execute actions; and reevaluate the effectiveness of actions.

Setting: A suburban, pediatric teaching hospital in the Northeast, with 35,000 ED visits annually.

Participants: The clinical nurse specialist (CNS), ED manager, and a registered nurse (RN), who designed the initial triage form, as well as ED staff of various roles, backgrounds, and computer skills trained as "superusers" to implement the resultant electronic triage and tracking system.

Methods: This project focused on improving the rate of triage documentation for four key data areas: demographic information, primary assessment, pain assessment, and acuity assignment. Through trial and error, our EDIS team created an electronic system and triage form that automatically populates the form with as much demographic information as possible at Quick Registration. Fields also were created to prompt data entry in the areas of pain assessment and acuity assignment. In addition, a "primary assessment check-box" was developed to facilitate the assessment process. RN superusers tried out the new form, and based on their feedback, a "hard stop" was added to prevent signing off before documenting pain. An additional trial with triage nurses resulted in further revisions to the form. Data gathered from subsequent chart reviews were evaluated at departmental meetings, and the form again revised, based on input from the entire nursing staff. The CNS then reviewed the electronic medical records for compliance and the results were compared to those obtained before implementing the new system.

Results: The new EDIS system has greatly improved compliance. Demographic information is now documented at a rate of 100%, compared to a previous rate of 85%. Our pain score/scale is at 90%, compared to a previous low of 70%, and should reach 100% after making the field mandatory. Primary assessment is now documented 96% of the time, compared to a previous rate of 85%, and acuity designation is now documented 100% of the time, compared to a former rate of approximately 85%.

Recommendations: Computerized triage can be a powerful documentation tool, but an EDIS system is only as good as the thought that goes into creating it. Making every field mandatory is not the answer. Before attempting to design an EDIS, emergency departments must evaluate their own strengths and needs and opportunities for improving compliance. Only then can a template can be designed that will improve triage documentation.
Repository Posting Date:
27-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Emergency Nurses Association

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleIncreasing Compliance: The Benefits of Using a Computerized Triage Documentation Systemen_GB
dc.identifier.urihttp://hdl.handle.net/10755/162721-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Increasing Compliance: The Benefits of Using a Computerized Triage Documentation System</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Emergency Nurses Association</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2007</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Brecher, Deena, N, MSN, APRN, BC, CEN</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">A.I. duPont Hospital for Children</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Clinical Nurse Specialist &ucirc; Emergency Department</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">1600 Rockland Road, Wilmington, DE, 19803, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">(302) 651-6282</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">dbrecher@nemours.org</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Ken Molczan MSN, RN-CS, CRNP, CPN, CEN</td></tr><tr><td colspan="2" class="item-abstract">Purpose: Triage documentation can be a challenging task, because data entry must comply with a number of organizational rules - from Federal regulations to JCAHO requirements to hospital policies. Electronic triage documentation can make compliance easier, but only if the electronic form is structured properly. The purpose of this project is to describe how we developed an emergency department (ED) information system (EDIS). We began with a review of our medical records. We found that not every field had to be mandatory and instead designed the form focusing on four key data areas in need of improvement: primary assessment, pain assessment, demographic information, and acuity assignment. <br/><br/>Design: This quality improvement project followed the framework of the hospital-developed SAFER model. &quot;SAFER&quot; refers to Select the project and data to be collected; Analyze the data; Find and prioritize opportunities for improvement; execute actions; and reevaluate the effectiveness of actions. <br/><br/>Setting: A suburban, pediatric teaching hospital in the Northeast, with 35,000 ED visits annually.<br/><br/>Participants: The clinical nurse specialist (CNS), ED manager, and a registered nurse (RN), who designed the initial triage form, as well as ED staff of various roles, backgrounds, and computer skills trained as &quot;superusers&quot; to implement the resultant electronic triage and tracking system. <br/><br/>Methods: This project focused on improving the rate of triage documentation for four key data areas: demographic information, primary assessment, pain assessment, and acuity assignment. Through trial and error, our EDIS team created an electronic system and triage form that automatically populates the form with as much demographic information as possible at Quick Registration. Fields also were created to prompt data entry in the areas of pain assessment and acuity assignment. In addition, a &quot;primary assessment check-box&quot; was developed to facilitate the assessment process. RN superusers tried out the new form, and based on their feedback, a &quot;hard stop&quot; was added to prevent signing off before documenting pain. An additional trial with triage nurses resulted in further revisions to the form. Data gathered from subsequent chart reviews were evaluated at departmental meetings, and the form again revised, based on input from the entire nursing staff. The CNS then reviewed the electronic medical records for compliance and the results were compared to those obtained before implementing the new system.<br/><br/>Results: The new EDIS system has greatly improved compliance. Demographic information is now documented at a rate of 100%, compared to a previous rate of 85%. Our pain score/scale is at 90%, compared to a previous low of 70%, and should reach 100% after making the field mandatory. Primary assessment is now documented 96% of the time, compared to a previous rate of 85%, and acuity designation is now documented 100% of the time, compared to a former rate of approximately 85%. <br/><br/>Recommendations: Computerized triage can be a powerful documentation tool, but an EDIS system is only as good as the thought that goes into creating it. Making every field mandatory is not the answer. Before attempting to design an EDIS, emergency departments must evaluate their own strengths and needs and opportunities for improving compliance. Only then can a template can be designed that will improve triage documentation.</td></tr></table>en_GB
dc.date.available2011-10-27T10:33:02Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-27T10:33:02Z-
dc.description.sponsorshipEmergency Nurses Associationen_GB
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