Do weekend plan standard forms improve communication and influence quality of patient care?
- Correspondence to: Dr C Grainge Derriford Hospital, Derriford Road, Plymouth PL6 8DH, UK;
- Received 25 October 2004
- Accepted 22 December 2004
Weekends are critical times in an inpatient stay, when daily review of patients is not routine and the usual team of doctors responsible for a patient’s care is often not available. Communication between the patient’s own doctors and the on call team is vital for continuity of care and to maintain patient safety. The provision and completeness of weekend plans was assessed before and after the introduction of a standard form. The introduction of the form led to a significant improvement in the proportion of notes containing a weekend plan and the proportion of notes containing a resuscitation decision (p<0.05), which will have a significant impact on patient care.
Quality of patient care is reliant on the quality of information communicated between health care professionals. With new patterns of working (partial and full shift patterns) and ward based management systems, a patient’s admission to hospital may involve several doctors and geographical moves. Each phase shift may distort or lose information that is crucial for patient care and so the clinical risk escalates, in a proportion dependent on the number of changes. The management of this risk, and consequently the quality and safety of patient care depends on clear documentation.
Previously published in this journal, at this institution we have shown that post-take ward round standard forms improve communication and influence quality of patient care.1 This system improved communication after admission to hospital but there was concern that communication between on call teams, especially over the weekend period could be improved.
Locally produced guidelines based on national standards2–5 state that each patient should have a weekend plan, resuscitation decision, deep vein thrombosis (DVT) prophylaxis decision, and expected date of discharge recorded in the notes to aid on call teams to manage the patients effectively. Weekends are times when it is unlikely that patients are cared for by their usual team. Previous studies have shown that the rate of avoidable cardiac arrest and mortality in some subgroups increases at the weekend.6,7 At such times good communication is especially important. The weekend is also a good opportunity to summarise the findings of the preceding week and to reiterate the resuscitation decision.
This study assessed the adequacy of documentation throughout an inpatient stay after the post-take ward round and the impact of introducing a short weekend plan form (fig 1) on documentation.
Initially 33 patient records were randomly selected from the medical inpatients and examined after a weekend to establish presence or absence of a weekend plan, resuscitation decision, weekend review, DVT prophylaxis, and expected date of discharge. Although a “results to be checked” box was included on the subsequently introduced form, this was not audited on this occasion as it had not been included in data collected before the introduction of the form.
After this initial study a weekend plan form was designed and introduced. It was not piloted before its introduction, although the format was widely consulted upon among junior and consultant physicians. It was designed to be used in all patients’ notes in patients admitted under physicians including all inpatient specialties. Junior doctors were educated about the introduction of the form at working party meetings and via hospital emails. They were encouraged to incorporate the weekend form into patients’ notes on a Friday, although this was not automatic. The responsibility for insertion of the form was the junior doctor caring for the patient on the particular Friday. The form was not routinely examined by the supervising consultant.
After the form had been in use for three months, the audit was repeated, again examining records after a single weekend, all patients on medical wards were surveyed on the second occasion, no patients were excluded. Results were compared by χ2 analysis, with a Yates’s correction on a Microsoft Excel program. Comparisons with p⩽0.05 were considered significant.
Thirty three records were examined initially, 273 after introduction of the form. Table 1 shows the results. Weekend review was a clinical assessment of the patient’s condition as would normally occur on a ward round.
A significant improvement in documentation was seen. Specific improvements included the presence of a weekend plan (p<0.01) and presence of a resuscitation decision (p<0.01). Interestingly the number of records detailing the decision regarding DVT prophylaxis fell significantly (p<0.01). This may have been as the form did not contain a specific space for this, and introduction of a form may stimulate answers only for those items mentioned on it. Future print runs of forms will have DVT prophylaxis specifically mentioned as a result. There was also no significant change in the number of patients who were reviewed at the weekend. This is not surprising as the planned review of unwell patients is communicated verbally to oncoming teams.
Most doctors, when questioned about the form, found it straightforward and user friendly. It was regarded as a useful adjunct to clinical practice. Other health professionals, especially nurses, found it a useful reference document when asking an on call doctor to review an unfamiliar patient. The improvements in documentation of the resuscitation decision especially have an impact beyond the provision of weekend care. The weekly review of the resuscitation decision provoked by the form ensures the “regular” review suggested by the British Medical Association, the Resuscitation Council (UK), and the Royal College of Nursing.2
To improve documentation, structured documents or forms have successfully been introduced after the post-take ward round1 in acute asthma management in accident and emergency8 and pathology reporting.9
This pilot study confirms the benefits of a weekend plan form for medical patients’ notes and shows the improvement in documentation after its introduction. After the introduction of the form for medical patients in our hospital, it has also been introduced for surgical inpatients. This study requires follow up work to establish whether decision making over the weekend period has been improved since the introduction of the form.