Abstract

When patients become acutely unwell on the ward, it is often a Foundation (FY1/2) doctor who assesses initially. Doctors are encouraged to use the ‘Airway, Breathing, Circulation, Disability, Exposure’ (A-E) approach to assess. The pressured nature of reviewing patients may lead to incomplete assessment.

We aimed to introduce a proforma to improve assessment of unwell patients on orthopaedic wards, based around GMC guidelines for assessment.

Plan-Do-Study-Act (PDSA) cycle 1: Surveyed junior doctors.

50% didn’t use an A-E approach when documenting reviews. 63% would use a proforma for documentation. 75% thought it would be useful and increase their confidence communicating with seniors. All believed it would improve documentation.

Cycle 2: Pre-proforma assessment/documentation.

85% were reviewed by FY1/FY2 doctors, with 15% subsequently reviewed by a senior. There was inadequate patient identification in 30%. No contact details were documented in 90%. Reason for review was always documented; A-E approach was used in 55%. Essential aspects were missed (Airway patency – 55%; Heart rate – 50%; chest exam – 30%). Impression was noted in 45%. Reviews were highlighted on ward rounds in 10% of cases and it was never documented that information was given to the patient.

Cycle 3: Post-proforma assessment/documentation.

60% were reviewed by a FY1/FY2, with 80% subsequently reviewed by a senior. Patient identification increased to 100% and documentation of reviewers’ contact details to 80%. Use of A-E approach and documentation of impression increased to 100%. Acknowledgment of previous review on ward rounds was 85% and information was provided to the patient in 80%.

Cycle 4: Surveyed doctors.

67% felt the proforma improved assessment, communication with seniors, and identification of patients reviewed during subsequent ward rounds. All felt it improved documentation.

An A-E proforma can improve care and documentation.

We will continue to analyse proforma use at 4 weekly intervals through PDSA cycles.