Introduction of a section for recording dementia improves data capture on the ambulance electronic patient record: evidence from a regional quality improvement project.

Abstract

Introduction: Dementia is a common co-morbidity in older people who require urgent or emergency ambulance attendance and influences clinical decisions and care pathways. Following an initial audit of dementia data and consultation with staff, a specific section (tab) to record dementia was introduced on an ambulance service electronic patient record (ePR). This includes a dementia diagnosis button and a free-text section. We aimed to assess whether and how this improved recording.

Methods: To re-audit the proportion of ambulance ePRs where dementia is recorded for patients aged ≥65 years, and to describe the frequency of recording in patients aged <65; to analyse discrepancies in the place of recording dementia on the ePR by comparing data from the new dementia tab and other sections of the ePR.

Results: We included 112,193 ePRs of patients aged ≥65 with ambulance attendance from a six-month period. The proportion with dementia recorded in patients aged ≥65 was 16.5%, increasing to 19.9% in patients aged ≥75, as compared to 13.5% (≥65) and 16.5% (≥75) in our previous audit. In this audit, of the 16.5% (n = 18,515) of records with dementia recorded, 69.9% (n = 12,939) used the dementia button and 25.4% (n = 4704) recorded text in the dementia tab. Dementia was recorded in ePR free-text fields (but not the dementia tab) in 29.7% of records. Eighteen other free-text fields were used in addition to, or instead of, the dementia tab, including the patient's social history, previous medical history and mental health. Dementia was present on the ePR of 0.4% (n = 461) of patients aged <65.

Conclusions: An ePR dementia tab enabled ambulance clinicians to standardise the location of recording dementia and may have facilitated increased recording. We would recommend other ambulance trusts capture this information in a specific section to improve information sharing and to inform care planning for this patient group.