# Embracing Digital Transformation: A Three-Cycle Audit on Improving Intraoperative Tourniquet Documentation Following BOAST (British Orthopaedic Association Standards for Trauma) Guidelines

## TL;DR

This study shows how implementing electronic records and staff training improved tourniquet documentation and safety in orthopedic surgery.

## Contribution

The study introduces a three-cycle audit approach using electronic templates to improve tourniquet documentation compliance with BOAST guidelines.

## Key findings

- Compliance with tourniquet documentation improved from 17% to 62% after introducing a smart phrase template.
- Key documentation aspects like skin assessment and tourniquet pressure showed significant improvements post-intervention.
- Lower limb tourniquet pressures decreased significantly, while no complications were reported across all cycles.

## Abstract

Introduction

Tourniquets are vital devices in orthopaedic surgery that aid in creating a bloodless field. While they reduce operative time and outcomes, improper use can lead to severe complications. The British Orthopaedic Association Standards for Trauma (BOAST) offers guidelines for safe intraoperative tourniquet usage, emphasising proper application and accurate documentation. With the push for a paperless National Health Service (NHS), orthopaedic units across the UK are transitioning to electronic patient records (EPR). In this audit, we aim to evaluate the impact of electronic patient records (EPR) implementation on tourniquet documentation and subsequent interventions to enhance guideline adherence.

Methods

This closed-loop audit evaluated 159 emergency trauma cases at a single UK-based district general hospital across three different cycles. The first cycle (n=50) was collected before the trust-wide adoption of an EPR system (EPIC HIVE). Upon collecting the second cycle (n=59), local intraoperative tourniquet usage results compared to BOAST were presented at a departmental audit meeting. A specialised smart phrase template was subsequently shared with the department and the results were re-audited in the third cycle (n=50). Statistical analyses were performed to compare the cycles.

Results

Following the introduction of the EPR, compliance with documentation standards (fully and partially adhered to) initially declined from 38.0% to 17.0%. Post-intervention, compliance increased to 62.0% (p=0.0005). Individual aspects of documentation revealed notable improvements, including increases in skin assessment pre- and post-tourniquet application (0% to 56% and 0% to 60%, respectively, p<0.0001), isolation method (0% to 60%, p<0.0001), exsanguination method (2% to 24%, p=0.0003), tourniquet pressure (39% to 76%, p=0.0001) and tourniquet time (59% to 94%, p=0.0001). Lower limb tourniquet pressures significantly decreased between audit cycles (mean: 287.06 vs mean: 265.91, p=0.007) while upper limb pressures remained relatively stable (mean: 236.67 vs mean: 236.56, p=0.993). No tourniquet-related complications were reported across all audit cycles.

Conclusion

While the introduction of new EPR systems may initially present challenges in upholding accurate operative records, the incorporation of specialised electronic templates and active staff engagement has shown to be instrumental in improving tourniquet safety and enhancing care standards.