Putting guidelines into practice: a tailored multi-modal approach to improve post-operative assessments.
BACKGROUND
The Scottish Intercollegiate Guideline Network (SIGN) published Postoperative Management in Adults in 2004, advocating post-operative assessments to optimize post-operative care. Our aim was to improve post-operative assessments in a surgical high-dependency unit (HDU).


METHODS
A prospective audit of post-operative admissions to surgical HDU over two 4-week periods was performed. Medical and nursing documentations were reviewed. A tailored multi-modal approach targeting specific barriers to change was used to implement changes; education of staff, introduction of designated HDU bleeps and a post-operative assessment pro forma. Re-audit was performed after 6 months.


RESULTS
The first cycle included 72 patients and the second included 62 patients. Time to assessment improved after changes. Forty-six (74%) patients compared with 27 (37%) patients before were assessed within 4 hours. The number of individual reviews increased and number of reviews due to nursing concerns decreased. Thirty-eight (61%) patients compared with 15 (21%) patients before were assessed through an individual review and one (2%) patient compared with 23 (32%) patients due to nursing concerns. Documentation improved. Documentation of relevant past medical history, medications, allergies, complications and post-operative instructions improved from 2 (3%), 1 (1%), 0, 8 (11%) and 26 (36%), to 18 (29%), 28 (45%), 20 (32%), 18 (29%) and 55 (89%), respectively. Difference between first and second cycles was highly significant throughout (P < 0.001).


CONCLUSIONS
Clinical practice was improved by a tailored multi-modal approach. Educating staff, improving communication and documentation, and re-audit has shown significant improvement. However, further improvements are required to reach best practice.
Department of General Surgery, Aberdeen Royal Infirmary, Aberdeen, UK. john.ford@abdn.ac.uk
John A
JA
Ford
Craig
C
Mackay
Chris
C
Peach
Paul
P
Davies
Malcolm
M
Loudon
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D057189:Checklist; D003142:Communication; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D007318:Inservice Training / Q000458:organization & administration; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care / Q000379:methods*; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D011787:Quality of Health Care / Q000458:organization & administration; D013997:Time Factors