Improving inpatient results endorsement in a tertiary cardiac, respiratory and cancer centre

Abstract

Introduction: The timely follow up of results of investigations that are requested during a clinical encounter is a fundamental patient safety issue. However, a significant portion of inpatient diagnostic tests results, 20%–62% according to a systematic review (1), are not reviewed or acted on. This lack of follow up on test results is considered a vital patient safety concern by the WHO (2) and can lead to patient harm. Electronic health records allow accurate audit and tracking (‘endorsement’) of test results. Materials and methods: ProblemAt a large tertiary Cardiac, Respiratory and Cancer Centre in the UK, multiple serious incidents were reported where patients presented with advanced disease that could have been diagnosed earlier with timely review and acting upon earlier investigations.StrategyIn response these serious incidents, a priority quality improvement project was initiated with the aim of electronically endorsing all test results in a timely manner. The first intervention was a multi-disciplinary team (MDT) educational approach, where hospital staff were reminded about the importance of result endorsement and instructed on how to do this on different hospital communications platforms including the trust intranet. This was followed by appointing a designated champion in each ward who would follow their area's progress and would further encourage results endorsement. Simultaneously, opinion surveys were conducted to evaluate barriers for results endorsement. Using QI methodology, multiple primary and secondary drivers were identified (Figure 1), including test results being mostly reviewed but not electronically endorsed, and lack of awareness of how to endorse and why results should be endorsed. A further package of interventions included intensive daily reminders during ward rounds, training sessions and providing posters and leaflets on how to endorse results. Education around results endorsement was also added to junior doctor inductions for new starters. Results: The baseline result endorsement was 39% when these issues were identified. Transient increase in results endorsements were noted around periods where staff received reminders to endorse test results, though there was considerable variation. However, sustained improvement, with an endorsement rate averaging >80% over 6 months, was achieved only after implementing the more substantial change ideas (appointing a champion for each ward, posters and formal training in induction) in response to the staff identified barriers. Transient drops in endorsement were seen around staff changeover dates. A time series is shown in Figure 2. Conclusion: Test results endorsement for all patients in a timely manner is crucial. E-mail reminders resulted in transient improvements in endorsement, but a more intensive change package of posters and in-person education led to more sustained change. However, owing to regular staff rotation, these interventions must be continuous to maintain consistently high results of endorsement rates.