Improvement in Documentation of Compartment Syndrome With a Chart Insert

Abstract

To improve documentation of compartment syndrome, an educational program was instituted and a chart insert consisting of a preprinted checklist of history and physical examination parameters for at-risk patients was created. From October 2004 to May 2005, a total of 45 consecutive at-risk patients were identified. Progress notes were divided into group 1 (educational program alone) and group 2 (educational program and checklist). Group 2 showed more complete documentation than group 1. The combination of a chart insert and an educational program proved to be more effective than an educational program alone for improving the documentation of compartment syndrome.

A recently published symposium on Medicolegal Issues in Orthopedics included a review of specific aspects of acute compartment syndrome; one of these aspects was documentation,¹ which also has been called the common denominator in defense malpractice.² A review of the symposium in The American Academy of Orthopaedic Surgeons Bulletin recommended documentation of compartment syndrome be thorough enough to allow another physician to recognize a developing compartment syndrome.³

However, even with growing recognition of the importance of documentation, there is room for improvement. A recent study at our institution showed progress notes for 70% (21 of 30 patients) of patients with compartment syndrome were inadequate in at least one of the core history and physical examination findings; in addition, the notes for 53% (16 of 30 patients) were at least partially illegible.⁴

The evaluation, documentation, and treatment of compartment syndrome comprise a complex system. We addressed the inadequacy of compartment syndrome documentation at our institution with an organizational systems approach, which included an educational program and the introduction of a chart insert. The chart insert consisted of a preprinted progress note with a checklist of established history and physical examination parameters of compartment syndrome (Figure). Checklists have been shown to be an effective way of aiding complex task completion.⁵ This study evaluated the effectiveness of the education program alone versus the education program combined with a chart insert as a means of improving compartment syndrome documentation at our institution and then compared each of these groups to a historical control.

Materials and Methods

This study was given an exempt status by our institutional review board. After a review of compartment syndrome patient documentation showed room for improvement, our department addressed the problem with an organizational systems analysis. Although compartment syndrome education was part of the curriculum prior to this study, an intensive compartment syndrome educational system was initiated at our institute. This educational system consisted of lectures, patient reviews, supervised patient evaluation, hands-on instruction in evaluation of the core history and physical examination parameters of compartment syndrome (including grading strength and measuring compartment pressures), and discussions of the literature. A compartment syndrome evaluation checklist also was developed and made available to residents on staff.

Figure: The compartment syndrome documentation chart insert.

Data collection for the study began 3 months after the educational program was initiated and after residents were directed to use the chart insert whenever patients were at risk for compartment syndrome. Risk factors included swelling and/or pain in the extremity associated with vascular, traumatic, or surgical causes. Use of the chart insert was encouraged but was not mandatory. Parameters measured included date, time, level of consciousness, presence of paresthesia, pain at rest, pain on passive stretch, diastolic blood pressure, pulses, pallor, tenseness, and motor and sensory examinations. Legibility was not specifically assessed.

From October 2004 to May 2005, a total of 45 consecutive adult patients (21 men and 24 women) at risk for compartment syndrome were identified at 2 trauma centers affiliated with our institution. Mean patient age was 32 years (range, 18-53 years). The most common location of evaluation was the leg, and the most common reason for the patient being at risk was trauma.

Progress notes for these patients were divided into 2 groups: group 1 (63) represented the educational program alone and group 2 (34) represented the educational program and insert. The notes were evaluated for the following core elements of the history and physical examination^6-8: date, time, level of consciousness, presence of paresthesia, pain at rest, pain on passive stretch, diastolic blood pressure, pulses, pallor, tenseness, motor examination, and sensory examination. Individual progress notes rather than patients were used for analysis because each progress note represented a documentation event.

Groups 1 and 2 were compared to each other and to a previously published historical control.⁴ Statistical analysis was performed with the Pearson chi square test with Yates correction. Significance was set at P≥.05. Patient outcomes were not evaluated.

Results

Although groups 1 and 2 showed more complete documentation than the historical control, use of the checklist along with the education program (group 2) provided more complete documentation than the education program alone (group 1) (Table). Specifically, documentation completeness for pain at rest, pain on passive stretch, diastolic blood pressure, pulses, pallor, motor examination, level of consciousness, and tenseness was significantly higher in group 2 than in group 1 (Table). Documentation for date, time, paresthesias, and sensory examination also was more complete in group 2 than in group 1; however, this difference was not statistically significant.

Group 2 showed significantly higher rates of completeness than the historical control for all parameters except pain and tenseness. Group 1 showed significantly more complete documentation than the historical control for fewer parameters than group 2, specifically, date, time, paresthesias, pain, pulses, and tenseness. Group 1 did not show more complete documentation than the historical control for diastolic blood pressure, pallor, motor examination, sensory examination, and presence of pain on passive stretch.

Discussion

Use of the chart insert checklist, in conjunction with the educational effort, was valuable in improving documentation. Because the progress notes that did not use the checklist (group 1) were written by residents who were exposed to the departmental educational effort, those notes could be seen as reflecting that effort’s effect and not the effect of the chart insert. When compared with a historical control, the documentation of the progress notes without the chart insert showed mixed results, seemingly indicating that the education effort alone was of inconsistent value. We did not evaluate the effect of the chart insert alone (without the educational effort).

The evaluation and treatment of compartment syndrome is an example of a complex system because the complicated interplay of multiple parameters requires interpretation and consideration for intervention. Organizational systems analysis in the medical, aviation, and maritime industries has suggested methods of decreasing adverse events in complex systems include simplifying systems.⁹ Checklists and standardized forms and procedures, shown to simplify complex medical systems,⁹ are an effective error-reduction tool because they provide a list of directives or parameters that offer structure, aid memory, provide consistency, and ultimately improve safety.¹⁰

Acceptance of checklists by individual organization members can vary. Openness to the use of checklists can be influenced by the professional culture of a given industry.⁵ Resistance to checklist use accompanies a false sense of invulnerability, the underestimation of risk, and an attitude that checklists are a sign of weakness.⁵

Although the ultimate goal of a checklist is the reduction of error, the effectiveness of a checklist is not inherent in its use. The user must have a knowledge base so that a compartment syndrome checklist, for example, is appropriately completed and adequately reflects the patient’s status. The knowledge base in evaluating and treating compartment syndromes is adeptness at evaluating each of the history and physical examination findings of compartment syndrome and the ability to safely perform the surgical decompression of the threatened compartment.

Helmreich et al⁵ described different types of error in organizational systems: intentional noncompliance, procedural, communication, proficiency, and operational decision. It is interesting that experts in error management view medical systems as more complex than aviation systems.⁵ It is even more interesting that a pilot’s use of a flight checklist from memory is categorized as a “violation” and would be considered an example of intentional noncompliance error.⁵ In the medical arena, inadvertent omission of measuring one of the core history or physical examination parameters is an example of a procedural error, whereas inadvertent omission of recording the finding in the progress note is an example of a communication error.

Another benefit of using a checklist is the standardization of the progress note. Comparison of a series of progress notes for history and examination findings is more efficient when a standardized form is used than when they are listed randomly. Improved efficiency in progress note review could facilitate the recognition of a specific change in a patient’s status, which could allow the early diagnosis of an incipient compartment syndrome.

Although legibility was not specifically evaluated in the current study, a previous study⁴ showed poor legibility also was an issue. A checklist limits the need for handwriting and is potentially useful. The legibility issue is an area of ongoing investigation.

Although no compartment syndromes were missed on the orthopedic service during the study period, we evaluated the effectiveness of the checklist for documentation and not its effectiveness for improving diagnosis or patient outcome. Another study would be required to determine the effect of chart insert use on patient outcome.

This study had several limitations. The study essentially was a single-center study involving residents and staff from the same institution. The chart review was conducted only by the first author (B.M.C.). Only one emergent surgical problem (compartment syndrome) was included, and only the orthopedic service was involved. The use of the chart insert was not formally randomized because doing so could have alerted residents to the fact that a study was being conducted, thereby compromising the results.

Another potential weakness of the study was that the criteria for inclusion were lenient, with any patient deemed at risk for developing a compartment syndrome being included. However, including only patients diagnosed with impending compartment syndrome could have artificially increased the completeness of documentation because it would be expected that residents would have a heightened awareness and write a more complete note on patients scheduled for surgical compartment release than for patients who did not have an impending compartment syndrome.

Conclusion

The use of a checklist with an educational program improved the documentation of compartment syndrome more effectively than an educational program alone at our academic health care center. We recommend the value of checklists and other methods of simplifying complex medical systems undergo additional assessment, with the goal being to improve consistency, efficiency, and ultimately, safety.

References

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Authors

Drs Cascio, Pateder, Farber, Kramer, Ain, and Frassica are from the Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland.

Drs Cascio, Pateder, Farber, Kramer, Ain, and Frassica have no relevant financial relationships to disclose.

The authors thank Lynne Jones, PhD, Associate Professor, Johns Hopkins Department of Orthopaedic Surgery, for the statistical analyses.

Correspondence should be addressed to: Frank J. Frassica, MD, c/o Elaine P. Henze, BJ, ELS, Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave, #A672, Baltimore, MD 21224-2780.