A 3-Phase Interdisciplinary Quality Improvement Project Optimizing Neurogenic Bladder Care Documentation in an SCI Unit at a Veterans Administration Medical Center
1Tamayo N, 2Kiefer P, 2Willoughby G, 2Henzel M
1Case Western University MetroHealth Hospital, Cleveland, OH, USA; 2Louis Stokes Veterans Administration Medical Center, Cleveland, OH, USA
Of the more than 250,000 people living with spinal cord injury in the United States, approximately 80% of patients experience some degree of bladder dysfunction. Surveillance of catheter management has important clinical ramifications from tracking urological complications to planning for discharge. At the Louis Stokes Veterans Administration Medical Center (LSVAMC), urinary catheter documentation on the spinal cord injury (SCI) unit is accomplished through both paper and electronic medical records (EMR). However, we have identified gaps in the system that warrant improvement. Our main goals are to collect catheter data not currently being recorded, improve tracking of catheter information for better continuity of care from the inpatient to outpatient settings, and make access more efficient for providers. At present, our records do not reflect SCI specific catheter management in a centralized, user-friendly treatment note. In this article, we describe a 3-phase interdisciplinary quality improvement project to optimize neurogenic bladder care documentation in the SCI unit. We focus on the first phase of the project addressing paper documentation of our intermittent catheter (IC) program as we currently lack a template that captures the appropriate data. Our revisions add time of procedure, type and size of IC system used, urine characteristics, pre-void and post-void bladder scan volumes, and volumes for volitional voids to our records. This first phase will lay the groundwork for phase 2 and 3 which involve developing the template for EMR documentation and streamlining the process to decrease the burden of double documentation.
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