IR operations are rapidly becoming an essential part of clinical management strategies for a variety of conditions; ranging from embolization approaches in the management of lower gastrointestinal bleeds (Oakland et al. 2019) or post-partum haemorrhage (Lindquist and Vogelzang 2018) to endovascular approaches for abdominal aortic aneurysm repairs (Chaikof et al. 2009). With the emergence and widespread endorsement of these techniques, there comes the relevant clinical responsibility. The extent to which this responsibility falls onto radiologists remains largely ambiguous and is often discordant between departments, hospitals and geographical areas. Nevertheless, the abundance of radiologically-guided procedures occurring daily in hospitals mandates a comprehensive approach to patient care, from the moment of vetting a referral to the point of discharging the patient from the IR department. Clinical documentation is a vital part, capturing the patient’s journey. In addition, it provides a measure of the performance of IR as a specialty and is an important part of maintaining a consistently high standard of care.
The aim of this pilot study was to establish the baseline performance of the current department with regards to clinical documentation and highlight, where appropriate, potential areas for improvement to maximise patient safety and continuity of care. In doing so, this provided a platform upon which an electronic proforma was created containing appropriate prompts to facilitate consistent, concise and accurate documentation for the completing clinician. The effects of which are implicit in the marked improvement of perioperative documentation completeness over the period of 18 months. Whilst there was a noticeable drop in performance following transition to electronic records, with several parameters suffering significantly, we attribute this to transitional adjustments where operators were only beginning to appreciate the way electronic records were being utilised as part of their new operative routine. This speculation is in fact reinforced by the results of the third audit, 18 months later, where improvements were observed across almost all parameters, suggesting that electronic records are indeed helpful and even more so in the presence of a proforma. On extrapolation to auditing processes in general, it is advisable to allow for a longer transition period for operators to familiarise themselves with the new record keeping system before re-assessment.
The stratification of study criteria into pre-, intra- and post-procedural information provided insight into whether there are specific timepoints in the patient journey where information collection and reporting may be lacking and thus requiring greater need for intervention. With the exception of post-operative documentation of the second audit, the other two audit cycles (paper-based and proforma) did not yield similar results. Although electronic transition, through the use of proforma, led to improvement in many of the documentation parameters, this does not entirely supersede the need for concurrent paper records for some of the parameters. For example, even though puncture site documentation was consistently excellent for both the paper-based and electronic records, the diagram on the front of the operative booklet for drawing the puncture site appeared to work well for most clinicians and aided immediate post-operative care. Furthermore, the consistently lower documentation rate for ‘Medications’ across all audit cycles, reflects more the fact that information remains dispersed rather than absent. A medication chart was present and completed in all patients’ operative booklets – however, identifying this was often problematic and time-consuming. The medication chart section in the proforma aims to encourage clear and more consistent medication documentation, with the downside, however, of often requiring duplicating clinical data. Complication recording was relatively low for both the paper-based and electronic records – a figure which improved dramatically with the proforma. In cases in which it was not appropriately documented, it was assumed that this was largely due to mere absence of complications.
Proformas have traditionally played an important role in streamlining clinical documentation and smoothing out inconsistencies across departments. For example, as Barritt et al. recently showed, the use of procedure-specific computerised proformas for hemi-arthroplasty operations significantly improved the quality of reports to meet The Royal College of Surgeons of England guidelines (Barritt et al. 2010). Similarly, Laflamme et al. concluded that electronic note templates are superior to dictation services in improving both the efficiency and the comprehensiveness of perioperative documentation (Laflamme et al. 2005). A further benefit of proforma use includes the reduction in reporting variability such that greater transparency is achieved when it comes to reimbursement of procedures (Taslakian and Sridhar 2017).
Whilst this pilot has yielded encouraging results, it must be remembered that the scope of this audit was limited to radiologically-guided angiographic procedures. This limits the generalisability of the specific template to other IR procedures. Moreover, given that this is only a draft template, it will likely undergo further long-term evaluation before its official implementation. The study would benefit from longer-term data including bigger samples and use across different hospital sites. It would be interesting to observe performance across district general hospitals where IR departments are smaller, with a varied daily workload and with potentially fewer angiographic procedures per day.
