Improving documentation of procedural sedation in an adult emergency department

Abstract

Introduction: This study evaluates the effects of an educational intervention and the use of a preprinted form on the adequacy of documentation of procedural sedation in an adult emergency department.

Methods: The study was conducted at a tertiary hospital's emergency department. Structured medical record review was performed before and after a multipronged educational intervention and again after the introduction of a preprinted form that included factors distilled from published procedural sedation guidelines. Good documentation was defined as having less than five of 22 documentation items missing, and greater than 10 items missing was defined as a poor documentation.

Results: The baseline group consisted of 93 patients with 102 included posteducation and 118 included after the introduction of the form. At baseline, 4.3% had good documentation, and 47.3% had poor documentation. Posteducation, these results were 16.7 and 30.4% for good and poor documentation, respectively. After the introduction of the form, 33.9% had good documentation and 38.1% had poor documentation. Only 39% of cases used the form, which resulted in 80.4% of medical records having good documentation and with none having poor documentation. Concurrently, if the form was not used to assist documentation, 1.4% had good documentation and 62.5% had poor documentation.

Conclusion: Baseline documentation was poor and improved slightly after both the educational interventions. Use of a preprinted form was associated with no medical records being classified as having poor documentation; however, uptake of the form use was low. Emergency departments should develop and consider mandatory use of such an aid together with training staff in the use of the aid and the important implications of adequate procedural documentation.