“A century that began with children having virtually no rights ended with children having the most powerful legal instrument recognising and protecting their Human Rights”. (Bellamy 1999).
Changes in the UK’s healthcare setting including the introduction of The Children’s Act 1989, updated in 2004, with which the Government aims to provide support for children in a number of ways including provision of healthcare in hospital settings.
Paediatric care has changed considerably since the introduction of statutory regulation, the Convention on the Rights of the Child and recommendations implemented to ensure the provision of patient centred high quality child care. This has evolved following the realisation and increased awareness of children’s vulnerability and the effect experiences can have on their sociological and psychological development and wellbeing.
Children are individuals and may present difficulties for healthcare professionals in decision making regarding care and consent. Children should be involved in the care process and informed of the decisions made about them and be given the opportunity of making decisions should they be competent to do so as detailed under “Fraser Competence”. This was derived from a legal ruling issued by the House of Lords in 1985.
Lord Fraser delivered judgement based upon a child’s maturity and level of understanding regarding the nature of procedure and consent required. This ruling demonstrates in part Children’s Rights in the modern healthcare system.
PROCEDURE & PATIENT
Planning and implementing individualised care are key factors in care planning for children in the perioperative setting. My recent case study of seven year old “David”, a pseudonym to protect his true identity, seeks to consider if effective individualised care planning is carried out in my trust and takes regard of accurate care plan recording together with effective communication within the documentation and has consideration for the safety and consent issues of the patient.
Accompanied by his father David was to have a foreign body removed from his ear to be carried out under general anaesthesia following a routine pre assessment several days prior. This process was to determine David’s suitability and fitness for the planned procedure and to establish his medical background. Previous bronchial illness as a baby was noted but otherwise he had no other serious medical history. These details are recorded in pages four to eight of the attached copy care plan documentation.
PAPERWORK/PLAN OF CARE
The need for care planning is accepted practice among healthcare professionals. However in the perioperative phase of a patients care the planning becomes critical to the patients ultimate outcome. It can perhaps be the most difficult phase of care planning to record thoroughly due to time constraints imposed in a busy operating department and may become a process of procedural documentation highlighting only certain elements of the process that are perhaps a little out of the ordinary.
Care documentation should include full patient details, name, birthdate, address and patient hospital number together with any allergies. Printed patient stickers are used for this in my trust.
Documenting the process of care is well organised in our day surgery unit. A step by step tick box document is used ensuring that each element in the patient’s journey is considered. Pre-assessment, consent, and continuation of the process through to discharge in a simple format ensures a smooth process. However whilst it may aid in the speed and efficiency of patient care planning in a busy department does it really make for a realistic plan of care for an individual patient.
Detailing the patient’s perioperative care should provide a complete picture of that care and eventual outcomes. It therefore relies heavily on conscientious completion throughout, providing an accurate and detailed record of the care given from patient admission to discharge (Spry & Jenkins 1991).
Documentation should be designed as the core to providing planning and delivery of individual patient care and as a basis for evaluating the care provided. Continuity of care should be factored in so that the information contained within can be easily communicated to other healthcare professionals who may need to continue care of the patient in their journey. Concise documentation becomes an essential tool so that continuity and outcomes are maintained.
Patient assessment is important within the planning process and should be ongoing throughout each phase of the perioperative journey with modifications made to the plan if necessary. Medical history and pre-assessment details together with the patient’s clinical status should be accounted for, as it was with David. It is also important to consider other factors such as a patient’s cultural, ethnic and spiritual requirements. Patients personal elements maybe important to their psychological wellbeing and should not be overlooked. Healthcare practitioners must consider their patient’s spiritual needs in order to provide total patient care (Govier 2000).
I have yet to witness in my trust where these elements are accounted for within the care documentation and planning. It is almost certainly an area that could be improved by the inclusion of an additional page with relevant questions. However it seems that many healthcare practitioners have a difficulty in giving thought to this element of care resulting in non consideration of this element (McSherry 2000).
Collaboration in care planning within the perioperative setting is essential to ensure safe and positive patient outcomes. Few members of the team work independently, with team members often relying heavily on their colleagues so ensuring correct and concise completion of the care plan documentation is paramount.
Preoperative checklists are used in my trust care documentation to ensure that routine procedures are completed prior to the patient arriving in theatre. This checklist has a dual purpose being used to communicate information to the theatre practitioner about care regimes that have been completed prior to patient delivery in theatre. Theatre practitioners may then validate the information with the patient, and parent prior to procedure.
This information will encompass a number of elements but should include such detail as, patient identification, consent, vital signs, procedure details and medical history.
In addition to these checks the trust implements the surgical safety check list in line with the World Health Organisation (WHO) under their Safe Surgery Saves Lives Challenge (WHO 2009).
Currently my Trust employs a separate WHO safety check list but discussion is ongoing relating to its printed inclusion within the care document itself.
Accurate recording keeping is essential to ensure correct outcomes. Additionally correct completion of care documentation is equally important for purposes such as legal process. Patient litigation increases annually with patient records becoming evidential documents in court so accurate and effective recording of information is important (Kemmy 1993). Failure to document correctly the care given may give rise for courts to assume that the correct level of care was not given. Additionally non documentation may itself be construed as negligence (Murphy 1987).
Each of the components described thus far are relevant to all patient care planning and incorporate practices for both adult and paediatric care plans. My Trusts approach to the documentation is the same for all patients and makes no differentiation for paediatric patients. The question this raises is should this be the case? As we have learned children are not small adults and as such varying approaches to their own particular circumstances need individual consideration.
Colleagues confirm to me that paediatric surgery can raise special challenges and therefore it is important to recognise and meet the broad spectrum of needs that can be a requirement of the paediatric patient. This then must mean that attention to these needs should be met within the care planning process from the point of pre-assessment.
David exhibited considerable anxiety in regards his impending procedure and was quite physically resistant. According to his pre-assessment documentation nothing in this regard was noted at that time and his father confirmed that he was fine and relaxed during this process. However upon our greeting David in the reception area he immediately exhibited his anxiety which promoted levels of anxiety in his father, displayed as mild anger at the child.
Page ten of the care documentation provides a short section in relation to patient anxiety and scores this from one to three, three being severe. David was a three and it took some considerable time to calm him down and provide premedication in the form of Temasepam.
David’s anxiety was noted in the care plan and duly scored together with only a brief note as to why he was so anxious but does not communicate sufficient information for the line of staff that he was to meet on his journey, in particular the anaesthetic team. Missing in the dialogue were details surrounding his physical behaviour which may have helped the anaesthetic team appreciate prior to his arrival how he may potentially react.
His induction was inhalational and very difficult. He cried out and struggled considerably needing restraint by four members of staff and his father. In my opinion I feel that the stress encountered by David in this process was too great causing him excessive levels of anxiety and creating higher levels of anger in his father, created I suspect in part by his embarrassment at his son’s behaviour and concern for his child.
After the procedure I voiced my concerns to the anaesthetist about the level of restraint used in this case and that it is essential for all parties involved to act in the best interests of the child. The response was almost dismissive of the matter although she agreed that the situation had gotten somewhat out of hand.
General concensus suggests that it is acceptable to use techniques to keep children from moving during a procedure, thus ensuring the success of treatment (Tomlinson 2004). However guidelines in respect of this are somewhat unclear and it seems that the decision is made almost as a matter of process in that the more a child struggles the greater the level of restraint until anaesthetised.
Safety and consent are elements of the Childrens Act and additionally warrant mention in the Governments Every Child Matters initiatives. Level of restraint is a grey area and I believe beyond a certain level it becomes unsafe to physically restrain a struggling child.
On speaking to David’s father about the anaesthetic process he confirmed that he was unaware that the process might include such a level of restraint and although he was part of the process, by default, he was left feeling somewhat upset and believed that he could have been advised of the possibility beforehand.
Clearly each patient, and their parent, should have a basic understanding of what will happen to them and why, with their feelings and wishes given regard (Hinchliff 2003).
Interestingly after his procedure and subsequent waking in the recovery room David exhibited no further signs of anxiety. He was happy to chat with the recovery staff and once returned to the ward played contentedly with his own toy brought from home until discharge.
SUGGESTIONS FOR IMPROVEMENT
In reviewing my Trust’s day surgery unit paperwork it generally fulfils the requirements of a short day case scenario by covering the full patient journey as it naturally proceeds from pre-assessment to discharge.
However that said it will only be as good as the people responsible for its completion and in this I noted certain discrepancies across a number of care plans completed by various members of staff that I reviewed on the day of my case study. Concise completion of the notes is important irrespective of how small the detail maybe, as it is often small information that can perhaps go towards making up the bigger picture.
Accurate and comprehensive record keeping can be a challenge in a busy operating theatre department but it is important to ensure that the plan of care for patients is adhered too and that a positive outcome is achieved. The legal implications of inaccurate recording keeping can be enormous, and this element is considered within the document used by my department.
At the top of page two it is indicated that accurate completion of the care documentation is necessary for “Legal Reasons”. Additionally it states that the document is required for “Clinical Audit”. Interestingly however it does not suggest that the document needs accurate completion for the benefit of the patients care planning. Is this an assumption therefore that Healthcare Professionals will complete the document with the patient’s best interests at heart or are they merely being reminded of what the trust deems to be the most important elements of an administrative process?
Careful and accurate care documenting is important and the onus is on healthcare practitioners to ensure their practice is legal (Corfield L & Pomeroy A 2008).
Also on page two there is a note to Doctors and Surgeons which discusses consent for procedure and if the patient provides consent or chooses to withdraw at anytime. The form in my case study was duly signed by the father because of David’s age, but could his physical demeanour not be construed as a sign of his not consenting to treatment despite his age? After all, consent can be withdrawn at any time. Was the method employed in his best interests? Legally he cannot give or withdraw his consent and the decision was his fathers.
The consent form is page three of the document, and is correctly placed at the beginning of the care document for if you are unable to gain consent the balance of the document becomes irrelevant. This document was not signed until the day of procedure and did not form part of the pre-assessment process four days previously although this is standard practice within the Trust.
Page eight, the anaesthetic operative record, includes a very short area for notes and instructions, and in this case fails to detail the difficulties experienced within the anaesthetic room at the time of induction other than a brief not at the top of the page stating that David was a “very difficult child”.
These experiences should be noted more fully in order that post operative staff can take such difficulties into account when waking the patient in the recovery room as they may continue to experience anxieties in addition to further fears of the recovery room environment. An extra page could be included here to allow anaesthetists to record additional information relating to the anaesthetic element of a procedure thus providing a better line of information to recovery staff.
A supplementary sheet is provided at page eighteen in the document but is “after the event” and therefore does not fall into a logical sequence.
Continuity of the care plan should provide such details to ensure a continued line of communication and cooperation between recovery and other departments (Wicker & O’Neill 2006).
Additionally the National Health Service Executive (NHSE 1999) suggests that “the purpose of health records is to ensure those coming after you can see what has been done, or not done and why and by whom”.
The recovery process is recorded on page fourteen and is relatively short in its time scale allowed. This is in line with a straightforward day case but should the need arise for a patient to remain in recovery for an extended period of time a continuation sheet is available in the same format. Again little room is given on this page for extensive recovery notes based on the anticipated short stay, although it is feasible to continue onto the following nursing care record page.
Discharge details form the balance of the document with a removable section for the patient or parents to take home with post operative instructions should they be necessary.
It is apparent that the documentation under review seeks to cover all elements of day case surgery, and appears to do so quite well with a few exceptions as noted. These exceptions seem to be a lack of available pages for noting and therefore communication may fail when it is most needed. Verbal communication of events during procedure is usual, however as we have considered will not be satisfactory should a legal issue arise in the future. Memory is no substitute for concise notes.
Individualised careful care planning and documentation is clearly a necessary element in the journey of the paediatric patient especially in the perioperative environment.
There exists many examples of care plan documents varying in design and content across differing NHS Trusts with certain levels of importance given to the elements contained within but with very little standardisation amongst them.
The care plan is a written record of care given to a patient and is only as good as the person who has completed it. Entries can be difficult to read and may not be fully representative of the actions taken and the problems encountered during the patient journey. In David’s case further detail regarding his considerable anxieties and the problems encountered within the anaesthetic room should have been detailed. Perhaps this is a combined problem in that a lack of space available in the care document and the team’s lack of skill and understanding in the importance of documenting such issues is the failure.
Criticising care documentation is easy and has been by many authors for numerous reasons including being difficult to read or understand, being difficult to use and for not providing enough information (Allen 1998). Effective care planning is not an optional extra in the care planning process. It forms a professional, legal and morally ethical requirement and should therefore be uppermost in the minds of all healthcare professionals who are responsible for the process.
All practitioners must ensure that they are fully conversant with the practice of clear concise care planning and recording for the benefit of the patient, their colleagues, professional practice standards, legal requirements and their own peace of mind.