Author: Thomas Rosenthal
Anesthesia residents rarely documented all 12 items identified as essential for urgent/emergent intubations (UEIs) outside the operating room, according to a new study.
The retrospective study of 136 standardized electronic medical records (EMRs) documenting non-OR UEIs at Tufts Medical Center in Boston, between Jan. 1, 2016, and Feb. 28, 2017, found that only four of the notes (2.9%) included all 12 essential items.
“Although we have no formal data on incomplete UEI documentation affecting outcomes, anecdotally incomplete UEI documentation has resulted in delays in extubation,” said Andrea Tsai, MD, a critical care anesthesiologist at Tufts Medical Center, who oversaw the research and delivered the presentation at the 2018 annual meeting of the Society of Critical Care Medicine (abstract 1267).
Incomplete documentation could result in a mismatch between the resources necessary at peri-extubation and those that were present, Dr. Tsai noted. For example, “precautions may be taken when extubating a patient who is a known difficult airway in order to facilitate reintubation, should extubation fail. However, if there is no documentation of airway difficulty and extubation fails, the patient could experience morbidity during efforts to re-secure their airway.”
Frequency of Documentation
The researchers found that the most frequently documented essential items were procedure type (99.2%), equipment used (97.06%) and attending anesthesiologist’s presence (97.1%). The least frequently documented items were details of mask ventilation (20.6%) and complications (presence or absence, 27.9%). There were 63 notes (46.3%) that included all essential items except mask ventilation details and complications, the study found.
The most senior residents, CA-3, had the most complete documentation, at 68.8%, whereas CA-1 residents showed a completion rate of 40.0%, followed by CA-2 with 30.4%, Dr. Tsai said. “Given that all 12 items on our checklist were deemed essential, I think the most serious items [that were] underidentified were the two least documented items: mask ventilation and complications,” she said.
“This is a very important issue from several perspectives—education, quality, patient safety and medicolegal,” said Joanna Kuppy, MD, FAAP, an assistant professor of pediatrics in the Section of Pediatric Critical Care Medicine and associate clerkship director for Pediatrics, Rush University Medical Center, in Chicago, who was not involved in the study and was asked to comment.
Dr. Kuppy said having thorough and routine documentation is helpful for subsequent providers to know what difficulties were present when taking care of the patient. “This information is not always consistently relayed.”
She also said, “As an end user of this documentation, I use it to inform my own practice when emergently intubating patients.” Dr. Kuppy said a further area of investigation would be to “identify what data the end users find most informative and how to make sure that is captured appropriately.”
Dr. Tsai said the researchers believed the reasons for incomplete documentation are a lack of generally agreed upon UEI documentation content, no formalized requirement or training to document, a lack of awareness that missing documentation is even a problem, and simple oversight.
“As a next step in this project, we created an electronic UEI note template with all the elements we considered essential for UEI note documentation,” Dr. Tsai said. The researchers will repeat the analysis of documentation completeness after introduction of the template.
“In the EMR era, a prescriptive UEI template prompting documentation of essential items may provide improvements and be a feasible alternative to free text notes.”
Dr. Kuppy said it would be interesting to determine if there are any trends. “Do CA-3s more reliably document elements that CA-1s leave off, and why?” That may identify “what clinical knowledge they acquired in the interim, during training, that has led to the realization that these items are important as well.”
Additionally, Dr. Kuppy said, knowing which items residents document as they become more experienced can also inform what needs to be taught.
“You could theoretically use that data to shape formal didactics on appropriate documentation for anesthesia residents.”
Dr. Kuppy said, “In undergraduate medical education, I spend a lot of time teaching students that their documentation is not just to check a box, but rather to serve as enduring communication to subsequent providers. As educators, we need to emphasize that communication is not just verbal—it is written as well, and holds significant weight for other providers when caring for patients. As such, it should be clear and informative.”