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REVIEW ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 124-135

Improving the quality and timeliness of neonatal intensive care unit discharge note: A quality improvement project


1 Department of Pediatrics, Neonatal Division, Sidra Medicine; Department of Pediatrics, Weill Cornell Medicine, Doha, Qatar
2 Department of Pediatrics, Neonatal Division, Sidra Medicine, Doha, Qatar

Date of Submission29-Nov-2021
Date of Decision11-Jan-2022
Date of Acceptance14-Feb-2022
Date of Web Publication20-Apr-2022

Correspondence Address:
Naveed Ur Rehman Durrani
Department of Pediatrics, Neonatal Division, Sidra Medicine, Zone 51, Street 2309, Bldg: 10, Al Gharrafa street, Al Rayyan, PO Box 26999, Doha
Qatar
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.jcn_138_21

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  Abstract 


Objective: Due to a delay in the discharge process because of an incomplete auto-population of discharge notes (DN), we undertake this quality improvement (QI) project to expedite the discharge process from our neonatal intensive care unit (NICU) and increase provider's satisfaction levels. Materials and Methods: Plan, Do, Study, Act cycles, surveys, and feedback approaches were adopted to see the reasons behind incomplete DN and appreciated ideas to improve them. The project was started in January 2021 and completed on October 31, 2021. Results: After introducing sections of DN in admission and daily progress notes in distinctive font colors, we improved the DN' readiness as the discharge date from NICU approached. Adopting this methodology resulted in improved provider satisfaction, patient care, and other educational sessions attendances. Conclusions: Delays in the discharge process not only affect admission and referrals but also cause dissatisfaction among various providers. A QI approach with measures implemented within the existing system significantly improves the discharge process and provider's satisfaction in the local NICU.

Keywords: Discharge note, electronic medical record, neonatal intensive care unit


How to cite this article:
Rehman Durrani NU, Cowsill C, Krishnappa SB. Improving the quality and timeliness of neonatal intensive care unit discharge note: A quality improvement project. J Clin Neonatol 2022;11:124-35

How to cite this URL:
Rehman Durrani NU, Cowsill C, Krishnappa SB. Improving the quality and timeliness of neonatal intensive care unit discharge note: A quality improvement project. J Clin Neonatol [serial online] 2022 [cited 2022 Dec 6];11:124-35. Available from: https://www.jcnonweb.com/text.asp?2022/11/2/124/343420




  Introduction Top


A discharge note (DN) is a document that summarizes the clinical course of any newborn admitted to the neonatal intensive care unit (NICU). The contents in DN are directly related to the complexity of underlying problems and duration of stay in the NICU.

A DN is an important document that links information or events during a NICU admission based on which future follow-up is based. Hence, primary care providers in busy outpatient settings need brief details of relevant information that are easily understandable quickly to allow the ongoing neonatal health needs in a community.

Besides providing the transition of ongoing neonatal care, a DN also provides follow-up of investigations awaiting results at the time of discharge,[1] data provision for future research studies, accurate coding of clinical events, and Diagnosis Related Group (DRG).[2]

Writing a DN should not pose a problem if someone is familiar with the course of events during the NICU admission. However, due to the scheduled responsibilities of physicians, advanced neonatal nurse practitioners (ANNP), residents, and fellows covering different areas of newborn care, it is challenging to keep essential details of a DN updated regularly. Moreover, there might be instances when a provider is required to complete a DN for a neonate they were not involved in their care. Therefore, a robust system where any provider could complete the DN after reviewing the patient's last daily progress note is vital in any busy tertiary level NICU. DNs are particularly challenging to write for ex-preterm neonates with a prolonged NICU admission or a neonate with complex problems requiring multidisciplinary follow-up with homecare and supplies. These neonates need to have pertinent sections of their DN updated regularly to ensure creating a concise DN on the day of discharge is feasible.

The present quality improvement (QI) project was designed to provide an easy and robust method of updating the resolved problems in the electronic medical record (EMR) to ease the writing of a DN by any provider, even if not involved in the recent clinical management of neonate.

Problem identification

Our hospital uses an EMR to document the clinical progress of neonates from admission to discharge. The EMR provides ease of assessment of clinical events, safety and improves legibility. Tools like copy and paste in EMR ease the auto-population of documents, improving clinical efficiency[3],[4]in a busy tertiary level NICU. One must be careful to modify and reshape the contents, as it may potentially cause harm by disseminating false information resulting in error, note bloating with outdated and redundant contents often leaving essential information buried or lost.[5],[6],[7] The EMR efficiently collects and integrates all clinical data, including medications and patient demographics, to facilitate medical decision-making as reflected in the documentation.[8] However, in our EMR, there is no inbuilt template for documenting daily progress notes or retrieving important past events to auto-populate a concise DN. Therefore, the provider must go through each document to familiarize themselves with past events and then summarize this in a succinct DN.

Moreover, the provider also assesses documentation from nurses, social workers, case managers, pharmacists, dieticians, and data from a plethora of laboratory and imaging results. The information thus obtained is then integrated into a patient care plan. Hence, the effectiveness of provider documentation is essential when dealing with neonates in intensive care settings with multi-system disease involving months of stay. The goal of such documentation should ultimately be to decrease the time burden in creating quality DN.[9]

Our earlier EMR documentation from 2018 to mid-2019 involving admission, daily progress, and DN was not structured or consistent, with high variations among various providers and had no linkage to track past events, especially in chronic patients with complex needs.

Therefore, after discussing these concerns within a working group in NICU, a standardized template for admission, daily progress notes, and DNs were created in a word document and saved outside the EMR. The admission note template was completed, copied, and pasted into the EMR at admission, and daily progress notes were similarly completed on subsequent days. Relevant details were then written in the progress note depending on the underlying condition and the complexity of care. This note then carried forward each day into the EMR of the respective neonate and updated daily using a clinical system-based format.

However, DNs were written with a standardized template [Appendix 1] but as a word document and saved outside EMR. These would be edited and customized for every admitted neonate by each provider managing their care. These documentations aimed to gradually build the DN as the infant approached their discharge date. These notes were saved under a shared drive under the NICU summary folder so that providers could easily modify, update, and access during the patient's stay in the hospital. These updates ultimately populated the DN and reduced the time required to finalize the DN. The final Microsoft word document was then pasted into the neonate's EMR to form the clinical outline and follow-up DN sections on the day of discharge.

Despite using the standardized format for discharge and progress notes in the EMR from mid-2019–2020, many concerns were expressed about investing extensive time in data entry, retrieving past pieces of information, and updating daily notes. These concerns created dissatisfaction among providers and decreased efficiency due to incomplete and not up-to-date DNs in a shared drive.

These ongoing issues of incomplete DN significantly impacted meeting the hospital key performance indicator (KPI) of discharges before 10 am. To meet KPI, one must ensure that DNs must be completed and updated in the EMR at least 48 h before discharge. By guaranteeing early discharge, these indicators facilitate.

  1. Adequate time availability to answer any parental questions and update about discharge instructions during morning rounds
  2. Provide necessary arrangements of beds to be ready by late afternoon to accommodate referrals or inpatient admissions.


We, therefore, recognized the need for a high-QI project with integrated, personalized feedback. A Plan, Do, Study, Act (PDSA) approach was decided upon to ensure greater provider satisfaction.


  Materials And Methods Top


Aim

To increase provider satisfaction with DN creation using satisfaction as a marker for improvement from 4% to 90%, by exploring ways to have an up-to-date DN in the EMR at least 48 h before the discharge date from NICU.

Settings

This QI project was done in NICU at Sidra Medicine, a 54 bedded quaternary level center in Qatar, using prospective PDSA, personalized feedback, and survey methods from January 1, 2021 to October 31, 2021.

Indicators

The outcome indicator was team satisfaction. The process measure was to adopt newly designed daily progress notes while the balancing measure identified potential barriers to using the template.

Description

A focused group comprising hospitalists and an ANNP was created to find the reasons behind suboptimal DN and failure to update discharge documentation regularly. We also brainstormed ideas and interventions to improve the timely updating of DN to improve team satisfaction.

Based on findings and various group meetings, we identified the following reasons that required attention to improve a timely DN process [Figure 1] and [Figure 2].
Figure 1: Key factors identified for delay in discharge Notes

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Figure 2: SMART Aims and interventions to address them

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  1. Patient discharge data
  2. Time utilization
  3. The acuity of the unit and multitasking
  4. Vulnerable patients
  5. Team members turnover/rotations
  6. Miscellaneous.


Patient discharge data

After reviewing a few DNs, we noticed an inconsistent provider approach in documenting and updating DN word documents on the shared drive. These notes contained unrelated patient details over-complicated with tedious and lengthy imaging reports, which were copied and pasted directly from the EMR unedited into the word document. The biggest concern and causing the most time utilization were the notes not being updated regularly, saved in different formats or by mistake while saving, saved under another patient's name, or with inaccurate information. In such circumstances, a whole new document was required to be created from the start.

Time distribution in preparing discharge notes

Due to the abundance of redundant content in some documents, it often took a lot of time to clean and summarize the information for the DN. Sometimes, it took a whole note to be rebuilt from the beginning, making providers frustrated, one of the most familiar reasons for not completing the documents on time.

Acuity of the unit and multi-tasks

The middle-grade medical staff have various areas within and outside NICU to care for neonates, participate in daily morning rounds, complete procedures both on and off the unit, write daily progress notes, update handover documents, participate in clinical governance meetings and educational sessions. Due to such multitasking, it is difficult to get time to update a DN document, especially outside the EMR. Therefore, such notes were often left for many days with no significant events or updates added.

Vulnerable patients

Neonates with complex underlying disease and prolonged NICU stay are the most vulnerable patients and inevitably whose DNs are left blank or not updated for many weeks. Moreover, DN for such patients needs particular attention and should be:

  1. Succinate, highlighting the essential events in NICU
  2. Precise in details from multidisciplinary teams
  3. Easily understandable by receiving primary care physicians to guide future treatment plans and follow-ups
  4. Specific with dates and times of various follow-up details from multidisciplinary teams.


Team members turn over

The different monthly schedules of the middle-grade medical team, comprising physicians and ANNP in all areas of neonatology also put the DN details at risk of deficiencies. Moreover, fellows and residents during their rotation in NICU sometimes find it challenging to get Information Technology (IT) permission to access the shared drive folders due to security reasons. They are unable to access and modify the word documents on time. Some also have limited experience writing such documentation and are unfamiliar with the details required.

Miscellaneous

Good quality DNs reflect the quality of care provided in NICU and ensure safety in the transitioning of care from intensivist to primary care physician. Moreover, it ensures ease of follow-up and early discharge from the NICU, one of the KPIs for providing high-quality care.

Interventions

A series of potential interventions to aid the daily updating of DN without undue pressure on providers were designed, presented, and discussed in various audit meetings among different groups, comprising a series of PDSA cycles as shown in [Figure 3] and [Figure 4] and explained in detail below. The project included a total of 4 PDSA cycles from January 1, 2021, to October 31, 2021.
Figure 3: PDSA cycles

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Figure 4: Timeline/flow chart for PDSA cycles

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Plan, Do, Study, Act 1: (Jan/Feb/Mar)

After identifying the problem and need for improvement, ideas were brainstormed in various team meetings to implement change or device methodology to update the DN daily without compromising the quality. Following debates, we concluded that updating DN outside EMR is not feasible for many reasons, as shown in [Figure 1] and detailed in the section above. User time restraints were found to play a significant role in determining DN remaining up to date, and the EMR was not facilitating such updates due to the multitasking of providers. We also recognized that having the documents in two different locations (EMR and in a Microsoft word document in the shared drive) made updating clumsy, more time-consuming, and easy to forget about.

Plan, Do, Study, Act 2: (March/April/May)

After presenting the above findings in the focused working group, it was proposed to modify the admission templates and daily progress notes, incorporating clinical details that would summarize the neonate's admission. The resolved details would remain in the daily progress notes under each system and the current clinical status but in a different font color to highlight the past clinical history. It was agreed such sections should be kept succinct and updated with each change in clinical status [Appendix 2]. To make the DN process feasible, the admission note was also modified to incorporate details, such as patient's demographics, maternal pregnancy details, and delivery details to facilitate copying and pasting these sections in the DN without further modifications. The idea of such documentation in the daily progress notes was that on the day of discharge, these discharge contents would be copied and pasted into the DN word document outside the EMR with minimal modification. This process was expected to gradually build a concise and fluent DN that can be easily pasted directly into EMR at discharge.

The pros and cons of each document change were discussed among all providers. Finally, it was agreed to adopt the changes uniformly and start a pilot trial to evaluate if the perceived improvements of increased time efficacy and improved DN quality were accurate.

Plan, Do, Study, Act 3: (June/July/August)

The pilot project was launched with weekly scrutiny of 1–2 DNs for quality and ease of documentation. A few weeks into the pilot trial, the inability to complete and organize all DN contents on the day of discharge was still encountered. It remained challenging to perform such a task within a time frame considering other ongoing provider's assignments in a busy tertiary level NICU.

After discussing this concern in the working group, we agreed a preliminary DN should be created in the baby's EMR at least 48 h before the expected discharge date. Only minor modifications should be required on discharge, such as the final discharge date, discharge weight, medication changes, and finalized follow-up appointment times. Therefore, the DN could be created quickly on the day of discharge, expediating the discharge process, meeting the hospital's KPI of discharges by 10 am while multitasking all the other responsibilities in the morning on a busy NICU. Upon implementation, providers, including physicians and nurse practitioners, were communicated through various tools, as shown in [Figure 5], to begin completing a preliminary DN in the EMR at least 48 h before discharge.
Figure 5: Methods used for team communications

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Feedback was very positive, and no further modification of the template was required.

Various elements from different documents that need copying to populate DNs are shown in [Figure 6].
Figure 6: Elements that requires copying from different sections of relevant notes to populate discharge note

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Plan, Do, Study, Act 4: (September/October)

Two months after launching the final template and the requirement of a preliminary DN 48 h before discharge, a re-audit was conducted, revealing the quality of the DN had significantly improved along with the provider's satisfaction. Team members expressed better time distribution leading to better patient care and more time contributing to the unit educational meetings. We expect that by ensuring early completion of discharge document and making it visible in EMR, earlier discharges from NICU will meet the KPI, which is our next target to accomplish.

Key points in making a quality DN are summarized in [Figure 7].
Figure 7: Key points to make discharge note

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Provider satisfaction survey

Postintervention, an anonymous web-based survey, was conducted for each medical provider in NICU responsible for writing DN to determine their satisfaction with the changes. The survey comprised eight questions addressing subjective assessment of the modified daily progress and DN processes. The survey also included provider satisfaction and overall project evaluation using a Likert scale from 1 (Strongly agree) to 5 (Strongly disagree).

Descriptive statistics were used to evaluate the trends for all measures and presented in stack bars with colors to show different percentages of the Likert scales.


  Results Top


The overall response rate was 76%. There was agreement from about 96% of providers to change the DN process at the start of the project, while 92% were satisfied on the Likert scale as strongly agree or agree at the end. More than 85% of providers agreed that the new progress note template and the DN writing process had ensured better patient care and time distribution for unit meetings, educational sessions, and research commitments. All providers agreed that producing the final DN from the new progress note template was easier. However, 4% of respondents indicated either dissatisfaction or were not in favor of the changes.

There was a limited response rate from neonatal fellows because some had commenced their NICU rotation part way through the implementation process. However, those who had completed their rotation after implementing this project expressed satisfaction with the current daily progress notes documentation format.

Our survey did not demonstrate any increase in the time required for documenting or updating any section of the DNs. The overall documentation process was generally a favorable response by all providers.

The complete survey results are shown in [Figure 8]].
Figure 8: Survey result for discharge notes

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  Discussion Top


By adopting various means of team communication [Figure 5] and a standardized template for our daily progress notes to include acute and resolved problems in one document highlighted by a different font color [Appendix 2], our project significantly improved the DN quality, ensuring relevant details and earlier completion.

Time spent in documenting patient notes significantly affects physician workflow and patient care.[10] Various studies address this issue based on an objective assessment of residents' time on clinical documentation.[11],[12] One such study revealed that internal medicine house staff spend more than 50% of their average shift time on documentation,[13] which has been linked to residents' dissatisfaction and increased burnout.[14],[15],[16] This was similarly reflected in our presurvey results before implementing the project. With the help of ongoing PDSA cycles and communications, our postintervention survey results convinced provider satisfaction and devotion of more time in direct patient care and clinical governance.

We did not identify any barriers in using the new template design of progress notes for making DN. Mainly, we focused that time in writing DN is appropriately balanced with other day-to-day activities in any tertiary care NICU. A succinate summary does not miss important, relevant information that needs to be followed by a primary care pediatrician in the community. Compliance with process measures by team members is excellent, as shown by postintervention survey results with continued supervision of fellows and residents by middle-grade team members to ensure quality documentation.

The limitation of our project is its structural design to assess the time spent in updating DNs objectively; however, we believe that each DN is unique to the patient, reflecting their underlying complexity of the disease and on provider clinical and IT experience to retrieve information. We also think that although daily progress notes might look lengthy with potential note bloat, we believe that improvements in precise documentation will improve further with time and familiarity with the new process. To ensure sustainability, we aim to keep ongoing reminders and alerts on the daily sign-off sheets with documentation tips about keeping the clinical history sections concise and timely. Using the most pertinent radiology reports and sub-specialist recommendations will eventually improve note bloat and decrease time spent preparing the DNs.

Our project reflects an excellent collaborative effort among various providers to build a robust and effective documentation system utilization in auto-populating discharge notes. There is an overall improvement in efficiency and experience based on providers survey, which will ensure patient safety and documentation quality.


  Conclusions Top


The result of our QI project suggests that the creation of modified daily progress notes incorporating resolved problems with the current clinical status resulted in improved satisfaction among all providers. With the successful application of standardized QI methods and systems, outcome indicators such as team satisfaction and expectant improvement in early discharge from NICU can be achieved.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.







 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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