Improving ReSPECT Documentation During Emergency General Surgical Clerking: A Quality Improvement Project

Introduction

The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form supports advance care planning by documenting wishes for emergency treatment. This is particularly important for patients living with frailty who are susceptible to deterioration and loss of decision-making capacity. Documentation of ReSPECT status on admission is often missed.  

This project aimed to improve ReSPECT documentation during emergency general surgical clerking, and determine how often existing ReSPECT forms are going unnoticed. Additionally, documentation was analysed for patients with a Clinical Frailty Score (CFS) ≥5.

Method

Fifty patients aged ≥65 admitted to surgical wards in Lincoln County Hospital were selected for each audit cycle by applying inclusion and exclusion criteria. Emergency Clerking booklets were reviewed retrospectively checking for completion of ReSPECT documentation, while ‘CarePortal’ was used to check for existing ReSPECT forms. An educational session was delivered to resident doctors to improve awareness of ReSPECT documentation and how to identify existing ReSPECT forms. 

Results

ReSPECT documentation was completed in 10% (5/50) of cases. 60% (30/50) of the cohort were identified as having a CFS  ≥5, and in 13% (4/30) of these cases, ReSPECT status was documented. In 20% (9/45) of cases with no documentation, an already existing ReSPECT form was discovered that had not been recognised. This number increased to 27% (7/26) within the CFS  ≥5 subgroup. After intervention, documentation compliance was 12% (6/50), and 14% (4/28) in the frailer subgroup. The overall number of unrecognised ReSPECT forms was 20% (9/44), but 35% (8/24) in the frail subgroup.

Conclusions 

Following the educational session, documentation compliance saw little improvement, with numbers remaining low. Existing ReSPECT forms, including those for highly frail patients, continue to be overlooked. Future work should focus on improving identification of existing ReSPECT forms during clerking to ensure previously documented care wishes are recognised.