Optimizing Endoscopy Procedure Documentation Improves Guideline-Adherent Care in Upper Gastrointestinal Bleeding

Area of Science:

• Gastroenterology
• Quality Improvement Science
• Health Informatics

Background:

• Upper GI bleeding (UGIB) is a frequent reason for inpatient esophagogastroduodenoscopy (EGD).
• Adherence to clinical guidelines for post-EGD care is crucial for reducing UGIB-related morbidity.
• Optimizing documentation is key to improving patient outcomes in UGIB care.

Purpose of the Study:

• To standardize and optimize post-EGD documentation for UGIB patients.
• To improve clinical care processes and outcomes through enhanced documentation.
• To implement and assess the impact of electronic health record (EHR) note templates.

Main Methods:

• A prospective quality improvement study was conducted at an academic tertiary referral center.
• Etiology/severity-specific EHR note templates were developed based on existing guidelines.
• Training was provided to 39 faculty and 15 trainees on template use, with pre/post-intervention data collection on documentation compliance.

Main Results:

• Compliance with inpatient proton pump inhibitor (PPI) prescriptions increased from 53.4% to 77.9% (p<0.001).
• Compliance with discharge PPI prescriptions rose from 31.3% to 61.0% (p<0.001).
• Documentation of follow-up EGD orders improved significantly (61.3% to 87.1%, p<0.001), with 82.6% of cases utilizing templates.

Conclusions:

• Leveraging endoscopy software for standardized documentation improved clinical care and efficiency.
• The intervention demonstrated low maintenance burden and sustained high utilization.
• The developed endoscopy templates offer a scalable model for improving care in other health systems and procedures.