GO Electronic: The Implementation of Perioperative Nursing Information System in Ruttonjee Hospital

Abstract Description

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Authors (including presenting author) :

Mo FP(1), Tam YY(1), Cheng KM(1), Kwong PS(1), Ng LK(2)

Affiliation :

(1)Operating Theatre, Ruttonjee Hospital (2)Anesthesia, Operating Theatre, O&T, Surgical, CSSD, CEU, Ruttonjee Hospital

Introduction :

Proper documentation provides an accurate and clear record of assessments, changes in conditions, care delivered and other relevant patient information to the multidisciplinary team to provide continuity and consistency of care. Paper documentation has been used by nurses in the operating theatre for decades. We sometimes came across documentation problems which resulted in communication chaos. Electronic approach provides a structured and standardized format for intraoperative nursing documentation. Perioperative Nursing Information System (PNIS) was adopted to digitalize the hand-writing sheet and whiteboard previously used for intraoperative nursing documentation.

Objectives :

1. To digitalize and standardize the documentation of the intraoperative nursing record and counting record 2. To improve the communication between different health care disciplines 3. To enhance the quality of patient care

Methodology :

PNIS was introduced to the nursing staff of the operating theatre in Ruttonjee Hospital since 2016. A workgroup responsible for designing the configuration of PNIS was set up. Template from other hospitals were used as reference. Trial run was done in early 2018. Finally, the tailor-made version of PNIS was born after fine tuning according to staff’s feedback and was officially launched in June 2018.

Result & Outcome :

WIFI connections and other hardware were available in all operating rooms. Each operating room has individual tablet, mobile 50” smart TV and WIFI account. The tablet replaced the sheet of intraoperative nursing record while the TV replaced the count sheet. PNIS has been used for intraoperative nursing documentation in more than 2700 operations since installation. Only 3 cases need to resume paper documentation due to WiFi connection problem. In the meantime, the workgroup will keep collecting feedback from nursing staff to improve the documentation system, monitoring the quality of documentation and anticipating any potential problems. Staff training which includes change of mindset and technical support, and adequate backup of hardware are crucial factors in ensuring the smooth and safe implementation of PNIS. Electronic documentation allows the retrieval of clear and accurate patient information anytime, anywhere and by anyone with access to the Clinical Management System. Therefore, the continuity and consistency of quality patient care can be safeguarded.