How does Smart Auto-charting in Post-operative documentation improve the Quality of service in the Operation Room and Day Surgery Centre of United Christian Hospital

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Abstract Description
Abstract ID :
HAC653
Submission Type
Proposed Topic (Most preferred): :
Clinical Safety and Quality Service III (Projects aiming at quality service to patients and their carers)
Proposed Topic (Second preferred): :
Research and Innovations (new projects / technology / innovations / service models)
Authors (including presenting author) :
Lee MYD(1), Wong YH(1), Leung KW, Man LY(1), Ma YY (1)
Affiliation :
(1) Operating Theatre/ Day Surgery Centre, United Christian Hospital
Introduction :
Advancements in technology have significantly enhanced healthcare operations, leading to improved patient care and more efficient practice management. The shift towards paperless charting has transformed healthcare documentation, making it more accessible and manageable. In the United Christian Hospital Day Surgery Centre (DSC), implementing smart auto-charting for post-operative documentation is crucial in maintaining continuity of care by integrating observations from intra-operative and post-operative phases. The system marked the first paperless documentation in all Hospital Authority DSC.
Objectives :
This project aims to: 1. Integrate intra-operative and post-operative care documentation using the Anaesthesia Clinical Information System (ACIS). 2. Create a comprehensive electronic record to improve patient service.
Methodology :
Anesthesia Clinical Information System (ACIS) was applied to collect, store and accumulate post-anaesthesia data electronically in the Post-Anaesthesia Care Unit. During operations, ACIS was employed in the operating theatre to monitor and record intra-operative data. Post-operatively, patients were transferred to the DSC for further observation, where ACIS continued to be used during Phase 1 and Phase 2 recovery periods. For Phase 2 observation, a smart portable monitoring device facilitated auto-charting, automatically recording patients' vital signs and other relevant parameters. Auto charting was on trial run in 3-4Q 2020 and pilot conducted in 1-2Q 2021. Implementation of auto-charting was endorsed by the (COC) Anaesthesiology in August 2021. The system went live at the DSC in 1Q 2022.Despite initial challenges related to staff computer proficiency, these were resolved through six face to sessions training in small group and returned demonstration and system modifications.
Result & Outcome :
Results and Outcomes The survey resulted in a 90% staff satisfaction rate. The transition to computerized records (auto-charting) from manual records took place between 2020-2021. The paperless operational system since September 2022, has saved time by automatically capturing vital signs and other nursing documentation, allowing nurses to devote more attention to post-operative care. The initiative is on track to achieve full integration with the Clinical Management System (CMS) for paperless retrieval by early 2024.
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