Objectives & Background Anaesthetic charts are an invaluable source of concurrent and retrospective information. They provide relevant history and events during surgical and/or anaesthetic procedures. Admission notes to the intensive care unit showed poor record keeping of events outside the theatre environment. In accordance with standards set by the Royal College of Anaesthetists (RCoA) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI), we developed an 'Emergency Anaesthetic Chart', to be used in the Emergency Department by both emergency physicians and anaesthetists. The aim was to improve the quality and quantity of information recorded during an emergency requiring critical care input, in a recognisable and easy to use format.
Methods A retrospective notes based review of admissions to the intensive care unit from the Emergency Department provided comparison against standards set by RCoA and AAGBI. The results were presented at a departmental meeting and the development of an ‘Emergency Anaesthetic Chart’ was undertaken to drive improvement. This was based on the current trust ‘Day/23 hour Anaesthetic Record’ used in the theatre environment. A further review looked at admission data since the implementation of the new chart, with the final data collection ongoing.
Results In the initial audit 9 sets of notes were examined over 6 week period, in the re-audit 11 sets of notes over a 6 week period were examined, 7 using the new chart. All were patients admitted from the emergency department.
Re-audit data (before, after) showed that demographic data remained well recorded at 100%. Improvement was seen in recording of medical history (56%, 100%) initial observations, (56%, 86%) and airway assessment (11%, 29%). Most importantly recording of procedural events (44%, 71%), repeat observations (33%, 100%) and subsequent drug administrations (22%, 86%) all showed significant improvement.
Conclusion We revealed poor record keeping during critical care involvement in the emergency department and identified the need for a more reproducible and standardised method of data recording. An adapted version of a current anaesthetic chart has been found to be effective in increasing the quality and quantity of information recorded for emergency admissions. This improves adherence to the required standards, and is also recognisable and user friendly for staff conditioned to use the Trust's anaesthetic charts.
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