Buried in paper charts? Computers can dig you out
Neonatal unit rids itself of paper charts
The neonatal intensive care operation at Duke University Medical Center in Durham, NC, has moved its charting and care paths documentation from pen and paper to computers, and they’d like to report that life is better on the cyber side.
Those 30-page pen and paper charts that staff either lugged around or had to search for are gone. Instead, the information is available literally at their fingertips in bedside personal computers. The various errors that haunt paper charts also disappeared, care became more consistent, and length of stay for many patients has dropped by up to two weeks as a result.
The transition began about two years ago as part of an institutionwide move toward computerization, says Michael Alton, RN, MS, CCRN, interim nurse manager in the Intensive Care Nursery/Transitional Care Nursery (ICN/TCN). First, new computers were installed in the unit for documentation purposes, primarily for assessments and flow sheets.
The next step was to computerize the care maps that delineate the day-to-day care plans for the infants in a variety of gestational ages. The first unit to participate in the change was already using care maps the old fashioned way, with paper and pencil. "That was OK, but it was cumbersome because you had to initial this, write over that, or move this to another page," Alton says.
"On paper, everything had to be included on 81¼2 by 11-inch pieces of paper, which can be difficult if you’re trying to document clinical needs," he adds. "So if a patient doesn’t meet an outcome say the patient doesn’t maintain oxygen saturation within an appropriate level we need to document that."
This could produce thick, clumsy charts. Important pieces of paper could be lost or placed in the wrong chart. Sometimes, an entire chart could simply be misplaced or carried away. "You could go 48 hours before you found it again. But where do you document in the meantime?" he says.
"We already had this brand new bedside computerized documentation system with all the bells and whistles, and all we were doing with it was physician assessment and flow sheets. We asked what else could be done. The group working on care maps and the group working on computerized documentation got together and said let’s combine them.’"
Sorting out the care maps
First, they looked at the paper-and-pencil care maps to see "what made sense and should be kept, and what needed to be trashed," he adds. The rest was a matter of converting the care maps into a computer program, which was done by medical center technical staff.
Because the bedside computer system had previously been installed, staff were already somewhat PC-friendly, says Cathy Simmons, RN, CCRN, clinical specialist in the ICN/TCN. There was still something of a learning curve as nurses adjusted to computerized care maps, and during the past 18 months, several two- to three-hour inservice training sessions have been held to acquaint staff with adjustments.
The change has been dramatic. "We can document to a clinical pathway in about a minute and a half now. Prior to that, if you could even find a pen and pencil chart, it took five to 10 minutes, depending on what was going on with the infant."
Before the change, a nurse would have to go to another form to chart a care map variance and write the note by hand to explain why the variance occurred. "With the computer program, you can just click on a number for which variance it was and make a quick comment on the same screen," she says. "Then we hit store’ and it goes to the physician’s notes. Then everyone can read what’s going on, and data can be pulled from that."
Babies discharged on time
An example of the improved efficiency Simmons cites is head ultrasound. "These had to be done on a Thursday for the baby to go home on a Saturday. But Saturday might come around and uh-oh nobody noticed it. That’s not a routine thing that can be done on a Saturday, so the baby has two more days of critical care placed on the bill, and they were using up a bed space. But when you have that information popping up on a computer screen, the physicians can communicate it. If they miss it, the nurses can communicate it, and infants can get out faster because they’re not caught up in the mumbo jumbo of paperwork.
"It’s totally taken paper out of our unit," she adds."You don’t have to hunt for it anymore. Just click, click, and it’s there."
Besides the improved clinical efficiency, Alton praises the system built around Hewlett Packard’s Careview technology for administrative efficiency. "We used it in contract negotiations for setting up third-party payers or partnerships. It enables us to say This is our standard of care, and this is what your patients can expect, and this is what we can say we expect is reasonable in terms of lab tests, medication utilization, LOS, etc.’"
The entire changeover went so smoothly that Simmons says she can’t think of anything they should have done differently. "The advice I’d give is when you put that [care map] into a computer program, you need to work out as many of the kinks as you can. Care of neonates is changing very rapidly and new recommendations are coming out that affect what we do, and it has to be changed on the clinical pathway."
Adds Alton, "You need to make the system as flexible as possible. Things change fast, and you’re constantly being held to a new standard or a program. And you have to be able to handle those changes."
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