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提高胸部外科病房周围的质量,提高推中心的患者安全
Mark Boyle1,2, Aina Pons2, Abdullah Alshammari2
1Department of Surgery and Cancer, Imperial College London, London, GBR.
Cureus
|September 4, 2023
概括
实施新的电子病房周记录系统显著提高了胸部手术患者的报告率. 这通过标准化文档和优化结果来增强患者护理.
科学领域:
- 医疗信息学 医疗信息学
- 胸部外科手术 胸部外科手术
- 临床审计 临床审计
背景情况:
- 病房巡视对于胸部手术住院患者的日常管理至关重要.
- 当前的文档实践往往缺乏细节和统一性,可能会影响患者的护理.
- 需要对胸部外科病房周围的文档进行标准化,以满足商定的标准.
研究的目的:
- 对当前的胸部外科病房周围的文档进行审核,并根据当地标准进行审核.
- 设计和实施一个改进的文档模板,以提高患者护理.
- 为了比较文档质量和患者在模板实施之前和之后的结果.
主要方法:
- 在三个审计期内回顾性和前性数据收集.
- 分析了199个最初的病房圆周笔记,以确保完整性.
- 开发和实施电子临床评估 (eCARE) 模板.
- 统计分析包括千平方和费舍尔的精确测试.
主要成果:
- 最初的审计显示,对成像结果 (19%) 和排放计划 (23%) 的报告率很低.
- 该eCARE模板显著提高了排放规划报告率 (23.3%与41%相比,p<0.001).
- 新的文档方法还显示了并发症率的改善 (32.6%与21.9%,p=0.03) 和停留时间的减少 (7.0与5.0天,p<0.001).
结论:
- 胸部外科病房周围的文档需要改进,以满足国家和地方的标准.
- 实施eCARE电子模板有效提高了文档统一性和报告率.
- 这种对病房周围文档的标准化方法优化了患者护理和术后结果.
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