Discussion
In the present observational study, we demonstrate that an implementation package including introduction of an updated credible insertion template, delegated information responsibility to every separate department and follow-up of every insertion template during a limited time, is highly effective in reducing missing data in CVC documentation. The hypothesis that the implementation package would decrease the proportion of missing data was confirmed. This high-quality documentation is a good basis for quality control of the CVC insertions and care as well as for the analyses of independent risk factors for mechanical complications within the ongoing observational study "CVC-MECH".11
Although the updated template was decided in a top-down manner it was well received. The CVC responsible physicians at each hospital were responsible for the update and for the information at each site. Further, also a bottom-up procedure was applied as all CVC inserting physicians were informed of the importance of feedback on the newly introduced template. An opportunity that many used, which further contributed to a high-quality template and a broad participation in the final design of the template.
There was a significant increase in the proportion of completely filled in templates between the first and second quarters, indicating that the implementation measures did not have effect immediately but with some delay. This may at least partly be explained by a delayed effect of the individual feedback to the inserting physician, given by dedicated research nurses or researchers.
It should also be noted that a relatively small share of the inserting physicians (17%) accounted for all incomplete templates indicating that individual feedback and further reminders could be of use. It has previously been shown that the effect of such reminders is worthwhile and depend on frequency and timing.13
In implementation science the importance of a well-developed proposal to changes, strategies and maintenance of change, a planned time schedule and tasks, continuous monitoring, form of media or channel of distribution and determined responsibilities, are stressed.13 In the present implementation project, we have applied most of these principles. However, there are aspects which could be fine-tuned. For instance, a more structured dissemination strategy where affected personnel are updated regularly through means of talks and periodic emails containing progress and/or results of the implementation.
To the best of our knowledge this is the first report on the effectiveness of an implementation package on CVC-documentation. However, in accordance with the present study, a few studies in other fields of medicine have demonstrated that implementation of various types of EHR templates are an effective way to improve journal record quality. In a prospective study, implementation bundles including individual feedback improved readability of discharge instructions in a paediatric EHR from 13% to 98%.14 Further, Dean et al demonstrated the importance of discharge summaries in the EHR and that these can be effectively implemented hospital-wide using evidence-based implementation strategies with both author and user satisfaction.15
Since many physicians involved in CVC insertions were aware of the fact that the templates were reviewed it is possible that a Hawthorne effect contributed to a higher share completed templates.16 It could also be argued that the Hawthorne effect has introduced a bias when comparing the proportion of filled out terms between the two time periods which in some sense is true but also a welcome effect that was consciously used to increase efficiency of the implementation.
As mentioned in the introduction, strong international and national recommendations on documentation and monitoring of central venous catheterisation exist. Further, according to the Swedish National Board of Health and Welfare, it’s mandatory for physicians in Sweden to record invasive procedures like CVC insertions in the patient’s medical record.17 The electronic CVC insertion template is the clinical documentation tool that all CVC operators at the participating hospitals are obligated to use. Since continuous recording and monitoring of CVC insertions is essential for quality improvements, it is very important that persistent high-quality documentation is established.
We believe that the CVC insertion template implemented in this study enables high-quality prospective recording of relevant clinical data associated with central venous catheterisation. Adequate data registration in EHRs will in turn facilitate future studies and likely yield better results. Increased knowledge regarding complication rates and associated risk factors will contribute to quality improvements of CVC insertions and increased patient safety.
Limitations
The study is a post hoc analysis in a single healthcare system and hence there is a risk of bias and limited external validity. Even though there is a strong tradition in the studied departments to document every CVC insertion in the EHR, there may be a small number of CVCs that are not entered at all and therefore the number of incomplete entries may be underestimated. An estimation of the true number of undocumented CVC insertions could not be performed.
Further, due to an older insertion template in the study by Björkander et al.8 with data through 2016, it was not possible to compare the completion of all 13 key terms before and after the introduction of the implementation package. Although we have no reason to suspect that the baseline from 2016 to the start of the present study has changed, this cannot definitely be ruled out.
Finally, it should be noted that the observational time may have been too short to definitely rule out a short-lived Hawthorne effect.