Please confirm that an ethics committee approval has been applied for or granted: Not relevant

Background and Aims Effective documentation of regional anaesthetic catheters is crucial for patient safety and continuity of care. At St George’s Hospital, London, the gold standard for documentation is a dedicated template on iClip (our main patient administration system). However, catheter information is often recorded in various forms, including anaesthetic charts, free text documents, procedure notes, ED records, and sometimes not documented at all. This study aims to assess the impact of interventions designed to improve the consistency and accuracy of regional anaesthetic catheter documentation by encouraging the use of the standardized template.

Methods An audit was conducted comparing documentation practices over a three-month period in two consecutive years, from January to March of both 2023 and 2024. Interventions included attempts to reposition the template within the hospital’s documentation system to increase its visibility and ease of use. Efforts to engage with system administrators and clinical staff were made to facilitate these changes.

Results The audit showed that the use of the template for regional catheter insertions remained consistent, being used in 47% of cases in 2023 and 50% in 2024. However, non-standard documentation formats continue to be prevalent, and there are still instances of missing documentation across both years.

Conclusions Despite efforts to improve the placement and accessibility of the documentation template on the iClip system, there were multiple hurdles when engaging with system management. The persistence of suboptimal documentation practices indicates a need for further strategies to instigate rapid changes to integrated NHS computer systems.