Care Planning Paper to Electronic

Mary Clarke – RGN Inpatient Nurse Manager Kate Sant – RGN Project Clinical Secondee

How it all began

• 2009 agreement to be care planning early adopter • March 2010 invited to CAG • September 2010 Clinical Secondee appointed • Go Live date set for January 2011

What we had

PATIENT CARE PLAN

Patient Problem ……………………………………… has been admitted for surgery and is unprepared for the procedure Aim To prepare safely for surgery as per Hospital Policy To ensure awareness of Manual Handling Policy Nursing Management and Action Orientate and welcome to ward Explain all procedures and allow time for questions Monitor and record baseline observations, and waterlow score Measure and provide anti – embolic stockings if required (NB Do not use stockings if the correct size is not available, of if there are ulcerated areas on her legs or feet) Ensure consent forms are signed Give prescribe bowel preparation or if patient is constipated offer suppositories Patients for operation should have top shave performed as close to theatre as possible Patient should have nothing to eat or drink as per consultant request Pre Anaesthetic checklist completed Date Commenced…………………..………… Nurse Signature ……………………………… Date Resolved ……………………………… Nurse Signature ……………………………..

PATIENT CARE PLAN

Patient Problem ……………………………………… has reduced mobility, and is therefore at risk of chest infection, DVT, PE, constipation, pressure sores etc Aim For the patient to be free of complications Detect complications early if they do arise Treat Effectively Resume as much mobility as possible Nursing Management and Action Advise patient to change her position every 2 hours (note manual handling policy). Observe pressure areas regularly (initially every 2 hours, and once mobile each shift) Monitor and record Waterlow score and use appropriate mattress Encourage deep breathing and leg exercises Refer to physiotherapist as appropriate Measure and fit anti embolic stockings Give prescribed anti coagulant Advise to follow a high fibre diet, and encourage a good fluid intake Encourage early mobility as able Observe any sputum, and observe for chest pain, or breathlesness. Note any calf pain, redness, tenderness, or swelling Report any complications to medical staff promptly Nurse Signature ……………………………… Date Resolved ……………………………… Nurse Signature ……………………………..

New paper

Test Patient

Test Patient

Test Patient

Test Patient

Test Patient

Test Patient

Test Patient

Test Patient

Test Patient

What went well

• More comprehensive and up to date care plans using standardised content from NHS Connecting for Health Library • Staff more involved in the development of the care plans therefore more consistency in patient care • Piloting of paper version invaluable • Excellent training and support from team • Better accessibility to computers

What could have been better

• Timing from pre-op go live to wards.

• Training took place too early and refresher training not mandatory • Did not recognise staff needed basic IT skills • More support post go live

Lessons learnt

• Early Involvement of Clinical staff • Importance of Paper pilot • Consideration of Business process/patient pathway • Clinical staff involved with testing • More Senior Management level involvement • Dedicated IT support • Ongoing floor walking support • Equipment: Computers Infection control Storage Security

Ongoing benefits

• Auditing • Record keeping • Comprehensive records • Version control • Less paper

Next steps

• Discharge letters.

• Referral letters.

• Coding.

Further Information

• Birmingham Women’s Hospital Electronic Care Planning Project contact: Mary Clarke, Inpatient Nurse Manager, Gynaecology, Birmingham Women's NHS Foundation Trust Email: [email protected] • NHS Library Care Plan Content NHS Care Plan Content project contact: Su Wilkinson, Strategic Alignment Lead, NHS Connecting for Health Email: [email protected] Access NHS Library of Care Plan Content (technical view) registration is free for NHS or SNOMED CT licence holders - download the Care Planning pack - Via: http://www.uktcregistration.nss.cfh.nhs.uk/trud3/user/guest/group/0 /home

Questions