转让流程的转变:一个质量改进项目,以评估和改进转让笔记.
Robert J DeGrazia1,2, Meher Kalkat1, Leslie Miller3
1Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA.
概括
一项质量改善计划显著提高了从重症监护室 (ICU) 转移到一般医院楼层的患者转移说明 (TNs) 的完成率和质量. 这提高了在重症监护过渡期间的患者安全.
科学领域:
- 医疗质量改善 改善医疗质量
- 患者安全研究的研究.
- 医疗保健信息学 医疗保健信息学
背景情况:
- 转移笔记 (TNs) 对于在住院病房之间标准化患者转移至关重要,特别是对于从重症监护室 (ICU) 转移的高急性患者.
- 支持当前转账票实践的安全性和有效性的证据仍然有限,特别是在ICU降级期间.
- 优化转移笔记的质量和完整性对于确保患者在护理过渡期间的安全至关重要.
研究的目的:
- 评估质量改进 (QI) 计划对转移说明的完成率和质量的影响.
- 评估在实施标准化QI干预后转让说明文档的变化.
主要方法:
- 一个回顾性图表审查分析了76个医疗重症监护室 (MICU) 的转移笔记到干预前和干预期间的73个楼层转移.
- 为了确定转让笔记的质量,使用了一种新的评估工具,经过准确性验证.
- 奇方位分析比较了QI倡议之前和之后的转账票的存在和质量.
主要成果:
- 转让备忘录的完成率显著增加,从19.7%上升到42.5% (p < 0.003).
- 完成的转让笔记的平均质量评分也显示出了统计学上显著的改善,从10.3升至12.3 (最高评分为15,p=0.005).
- 质量信息干预表明,它对转移文件的一致性和质量产生了积极影响.
结论:
- 实施的质量改进计划成功提高了ICU到地板患者转移的转移说明的完整性和质量.
- 这些改进的转移说明文档预计将有助于在从MICU过渡期间提供更安全,更有效的患者护理.
- 对标准化交接程序的进一步研究可以在不同的护理环境中优化患者安全.
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