Discharge documentation for febrile children in the emergency department: how can it be improved?
Background
Documentation of patient encounters in the paediatric emergency department (PED) is often neglected in the interests of time. The casualty admission sheet is the only record of patient encounters in the PED; full documentation of the discharge plan is very important, both in terms of patient care and communication and in terms of possible future medicolegal litigation. An earlier audit at our local hospital had shown deficiencies in several areas of discharge planning for febrile children. We planned appropriate interventions based on these findings and our goal was to assess the effectiveness of these interventions on documentation of discharge planning. The outcome was to improve both discharge documentation and discharge planning for febrile children in the PED.
Methodology
Our initial audit was performed over a six week period starting in December 2015 at Mater Dei Hospital, a regional centre providing secondary and tertiary paediatric services. Data were collected retrospectively with the aim of evaluating discharge documentation for children up to sixteen years of age who attended the PED with fever and were subsequently discharged home. The projected sample size of 380 patients was calculated to be representative of the annual number of visits to the PED. Documentation was assessed for the following criteria: diagnosis, treatment and doses prescribed, advice given, legibility and follow-up plan. A number of deficiencies in documentation of discharge planning were highlighted in this initial audit. Subsequently, the following interventions were implemented: presentation of initial audit findings to all doctors working in the PED emphasising the areas needing improvement, set-up of a follow-up clinic for children with pyrexia (to provide a pathway for early follow-up where needed) and the design of a handout for carers which contained information about caring for the febrile child, including when to seek urgent medical advice. The second audit was repeated one year following the initial one in order to assess for changes in the number of casualty sheets showing adequate documentation. Chi squared test was used to test for significance.
Results
386 children fit the inclusion criteria in the first audit cycle and there were 380 children in the second audit cycle. The majority of patients had a viral infection (77.9%). The proportion of casualty sheets having adequate documentation for discharge planning in the first and second audit cycles respectively were: diagnosis (83.9% vs 79.2%; p 0.09); treatment prescribed (73.8% vs 79.4%; p 0.07), doses prescribed (40% vs 49.3%; p <0.0001), advice given (11.4% vs 48.7%; p <0.0001), follow-up (31.9% vs 40.2%; p 0.01), legibility (83.9% vs 70%; p <0.0001).
Conclusion
Complete documentation of discharge planning is important, but may be deficient. Formal teaching does not necessarily lead to improvement. This study looked at the effectiveness of three alternative interventions on the level of documentation for discharge planning of febrile children from the PED, with significant improvement being achieved in some areas. Ongoing measures are necessary to maintain and improve the level of documentation for discharge plans from the PED for febrile children.
