Inguinal hernia repair integrated care pathway (ICP)

Transcription

1 Name Ward Hosp no DOB Affix patient label Inguinal hernia repair integrated care pathway (ICP) Inclusion criteria Patients undergoing inguinal hernia repair aged under 3 months corrected gestational age Instructions for using this ICP The ICP incorporates the detail and information required for this patient journey/episode together with specific activities and variance tracking, which compares planned and actual care. When activities are completed the practitioner should initial in the box and enter the date and time in the adjacent boxes. In the event of variance from the plan or if an activity is not, the practitioner should initial the not box, enter the date and time and complete the variance tracking at the foot of the page. Important Each professional making an entry in this record must complete the signature sheet on page 2, after which they should use only initials when making an entry. In using this ICP the practitioner should refer to trust policies, clinical practice and procedure guidelines and protocols, which provide evidence and support the activities contained herein. This document complements rather than includes existing stand-alone documentation in use at GOSH. The integrated care pathway forms part of the legal record of care received so must be completed fully. Version: 1.0 Version date: Oct 11 Review date: Oct 13 Document development lead: Carole Irwin Document status: PILOT Great Ormond Street Hospital for Children NHS Trust, 2011 Page 1 of 16

2 Signature sheet Name Designation Signature Initials Date Abbreviation FBC U&E G&S CNS NBM EP CEWS Abbreviations and glossary of terms used in ICP Term in full Full blood count Urea and electrolytes Group and save Clinical nurse specialist Nil by mouth Electronic prescribing Children s early warning score Page 2 of 16

3 Specific needs of child Specific need Solution required Action taken, date and initials EXAMPLE Child is hearing impaired and wears hearing aids Remove hearing aids for procedure but ensure put back in recovery Recovery staff informed JB 31/3/2010 Discharge criteria For this procedure, the child will be able to be discharged or transferred when the following criteria have been : Child is tolerating full feed volume Wound is healing satisfactorily Documentation accompanying this integrated care pathway Family Form 2 Patient Assessment Form Consent form Page 3 of 16

4 Pre-admission assessment - Complete prior to or on day of admission ID Activity Met Not Met Not Enter initials/time Enter initials/time 0001 Confirm child and family understanding of reason for admission 0002 Complete assessment using Family Form 2, Patient Assessment Form, Birth History and Immunisation History forms 0003 Confirm any allergies and document 0004 Identify any specific needs of child (disability, cultural or language) and make arrangements for those to be during stay record on page Check that details on PiMS are correct including next of kin and parental responsibility 0006 Admit child onto EP 0007 Ensure that family have been given appropriate written information about the procedure if available 0008 Continue consent procedure with child and family 0009 Record weight and height/length and add to EP 0010 Record baseline temperature, pulse, respirations, blood pressure and oxygen saturation 0011 Complete pressure area care assessment 0012 Complete moving and handling assessment 0013 Complete baseline pain assessment 0014 Inform parents/carers about what to do with regular medications on day of surgery 0015 Confirm admission and fasting times with family 0016 Advise parents to ensure supply of pain relief at home Page 4 of 16

5 Outcomes for episode ID Activity Met Not Met Not Enter initials Enter initials X0001 All records for child available and up to date X0002 Child and family understand reason for procedure X0003 Parent understanding of fasting instructions confirmed Notes Page 5 of 16

6 Between pre-operative assessment and night before admission ID Activity Met Not Met Not Enter initials/time Enter initials/time 0017 Send other outstanding test results to consultant/team 0018 Arrange accommodation for one parent/carer 0019 Arrange transport if required 0020 Ensure notes are available and up to date ID X0004 ID Activity Outcomes for episode All test results required seen by consultant/team Activity Night before admission Met Not Enter initials Met Not Met Not Enter initials Met Not Enter initials/time Enter initials/time 0021 Contact family to confirm that child is well and bed is available 0022 Confirm medications to take on day of procedure with family 0023 Confirm and check family understanding of fasting instructions ID Activity Outcomes for episode X0005 X0006 Child confirmed to be fit and well Met Not Enter initials Met Not Enter initials Parent understanding of fasting instructions confirmed Page 6 of 16

7 Notes Page 7 of 16

8 Day of admission Pre-procedural care ID Activity Met Not Met Not Enter initials/time Enter initials/time 0024 Check child and family understanding of reason for admission 0025 Explain outline plan for stay to child and family 0026 Ensure assessment using Family Form 2, Patient Assessment Form, Birth History and Immunisation History forms has been completed previously and record any additional information and/or changes since completion at assessment 0027 Confirm that fasting has been completed as per protocol 0028 Complete consent process and ensure that person with parental responsibility has signed consent form 0029 Complete surgical site marking documentation 0030 Attach patient identification wristband to child and explain its importance to child and family 0031 Carry out baseline observations (temperature, pulse, respirations, blood pressure and oxygen saturation) and record 0032 Repeat nose and throat swabs if child has attended another healthcare facility since last assessment 0033 Admit child onto EP 0034 Measure height and weight and add to EP 0035 Check blood test results and transcribe to pre-operative checklist 0036 Complete pre-operative checklist 0037 Review by anaesthetist 0038 Pre-medication prescribed and given if appropriate 0039 Accompany child to theatre 0040 Accompany parent/carer to post-operative ward 0041 Commence discharge planning using checklist on page Enter discharge date on PiMS Page 8 of 16

9 Outcomes for episode ID Activity Met Not Met Not Enter initials Enter initials X0007 All records for child available and up to date X0008 Child confirmed prepared for anaesthetic and procedure X0009 Child and family understand reason for procedure X0010 Family have given informed consent Notes Page 9 of 16

10 Operation report Nature of operation Date and time carried out / / at : Surgeon Sign Print Assistant Anaesthetist Report Prophylactic antibiotics prescribed: None 1 dose co-amoxiclav 3 doses co-amoxiclav Page 10 of 16

11 Day of admission - post-procedural care ID Activity Met Not Met Not Enter initials/time Enter initials/time 0043 Handover received from recovery nurse 0044 Bedside oxygen and suction checked and functioning 0045 Explain plan of care to family and negotiate care requirements 0046 Meet child and family and update on procedure 0047 Review by surgical team including medications and pain relief 0048 Commence oral feeds 0049 Record temperature, pulse, respirations and oxygen saturations half-hourly for 2 hours then hourly (blood pressure if required) 0050 Record pain scores as per protocol 0051 Check wound site hourly for 2 hours and then 4 hourly 0052 Check intravenous sites hourly 0053 Record strict fluid intake/output on fluid balance chart 0054 Assist with basic hygiene needs 0055 Medical handover sheet updated as necessary 0056 Nursing handover sheet updated as necessary 0057 Support patient and family 0058 Continue discharge planning using checklist on page 14 Page 11 of 16

12 Outcomes for episode ID Activity Met Not Met Not Enter initials Enter initials X0011 Observations within CEWS acceptable ranges X0012 Pain adequately controlled X0013 No sign of immediate wound complications X0014 Child and family updated on procedure X0015 Feed is available on the ward Notes Page 12 of 16

13 Post-procedure day 1 ID Activity Met Not Met Not Enter initials/time Enter initials/time 0059 Child assessed at beginning of shift with bedside handover 0060 Bedside oxygen and suction checked and functioning 0061 Explain plan of care to family and negotiate care requirements 0062 Review by team including medications and pain relief 0063 Record temperature, pulse, respirations and oxygen saturations 4 hourly (blood pressure if required) 0064 Record pain scores as per protocol 0065 Check wound site 4 hourly 0066 Record strict fluid intake/output on fluid balance chart 0067 Support patient and family 0068 Complete discharge planning using checklist on page Ensure cannulas removed 0070 Complete discharge notification and send to all relevant parties ID X0016 X0017 Activity Child discharged safely Discharge notification completed Outcomes for episode Notes Met Not Enter initials Met Not Enter initials Page 13 of 16

14 Discharge checklist Predicted date of discharge Discharged to Transport Yes No Details Initials Medication Prescribed Collected Explained Equipment Ordered Delivered Explained Teaching Follow up arrangements Discharge contact made Other GOSH clinicians Family doctor (GP) Local paediatrician Community team Social worker Other Page 14 of 16

15 Variance tracking record Instructions for use Each time a task is not, the variance should be recorded in the table below. This page should be photocopied and used for variance analysis professional judgement of individual clinicians. Staff should use their knowledge, experience and assessment of Name Hosp no DOB Affix patient label Date Time ID What occurred? Why? What did you do about it? Outcome Initials Example 31/11/08 10am 0013 Parents not given written information Computer network down File copy requested Parents given written information JB Page 15 of 16

16 professional judgement of individual clinicians. Staff should use their knowledge, experience and assessment of Name Hosp no DOB Affix patient label Date Time ID What occurred? Why? What did you do about it? Outcome Initials Example 31/11/08 10am 0013 Parents not given written information Computer network down File copy requested Parents given written information JB Page 16 of 16