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RACS ASC 2024

Can standardised reporting improve documentation quality for regional endoscopy units?

Poster

Poster

Disciplines

Rural Surgery

Presentation Description

Institution: Department of General Surgery, Kalgoorlie Regional Hospital - Western Australia, Australia

Purpose: Endoscopy makes up 54% of the caseload of a provincial General Surgeon. However, there is no standardised colonoscopy reporting system for regional Western Australia. A previous audit of a single regional endoscopy unit found that documentation of indicators for the Colonoscopy Clinical Care Standards – bowel preparation(BP) and withdrawal time(WT), were inconsistent. We set out to determine if a standard proforma could improve current documentation practices. Methodology: This was a single centre, multi-endoscopist prospective study. From October 2023 to January 2024, a standardised proforma with fields for indication BP quality using the Boston Bowel Preparation Score(BBPS) and WT was implemented. For comparison, current electronic documentation of BP and WT for the previous three months was extracted. A Z-test examined for differences, with significance set at p<0.05. Results: A total of 127 colonoscopies were performed during the study period, with a 57.5% proforma completion rate. 131 colonoscopies were performed during the control period, with electronic documentation of BP and WT occurring in 86.3% and 79.4% of cases. In the study period, the proforma saw a significant increase in documentation of BP(100%, p<0.01) and WT(90%, p<0.01). Additionally, study period showed an increase in electronic documentation of BP(89.8%) and WT(89.8%, p<0.05). Conclusion: A standardised reporting proforma can significantly improve documentation of BP and WT. Additionally, the proforma inadvertently improved quality of existing electronic documentation. However, the proforma completion rate underlined the need for a centralised, standardised colonoscopy reporting system in regional centres, with stakeholder consultation.

Speakers

Authors

Authors

Dr Dhanushke Fernando - , Dr Iman Antoun -