Implementing a tertiary survey in the emergency general surgery population: Imitation is the sincerest form of flattery

B. Eaton, L. Bonenclark, L. O'Meara, N. Tobin, B. Bruns, J. Diaz

Research output: Contribution to journalArticlepeer-review

Abstract

Objectives: The inherent complexity of the Emergency General Surgery (EGS) patient may preclude precise documentation at admission. To obviate lapses in documentation, an EGS tertiary survey (EGS-TS) was developed to enable early recognition of relevant omissions in documentation and clinical findings. We theorized that the creation of the EGS-TS would promote more thorough clinical documentation. Methods: A prospective observational study was performed utilizing an EGS-TS from February 2019 through May 2019. The EGS-TS included physical exam, medication reconciliation, analysis of documentation for accuracy, and review of diagnostic imaging for incidental findings. Results: There were 139 EGS admissions during the study period and 108 (78%) received an EGS-TS. Of those who received the EGS-TS, incorrect medication reconciliations (72%), incidental findings (12%), undocumented wounds (11%), and undocumented indwelling catheters were identified (6%). Conclusion: Implementation of an EGS-TS triggers a detailed evaluation and reveals opportunities for education, improved adherence to documentation standards, and further research that may guide quality improvement initiatives.

Original languageEnglish (US)
JournalAmerican journal of surgery
DOIs
StateAccepted/In press - 2022
Externally publishedYes

Keywords

  • Advanced practice provider
  • Emergency general surgery
  • Structured patient assessment
  • Tertiary survey

ASJC Scopus subject areas

  • Surgery

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