使用电子医疗记录提醒,以改善新生儿急性损伤的记录
Arwa Nada1,2, Amy Bagwell3
1Department of Pediatrics, Division of Pediatric Nephrology, The University of Tennessee Health Science Center (UTHSC), 50 N Dunlap St., Memphis, TN, 38105, USA. anada@uthsc.edu.
Pediatric nephrology (Berlin, Germany)
|March 23, 2024
概括
实施电子医疗记录 (EMR) 预警系统显著改善了新生儿急性损伤 (AKI) 的记录. 这项质量改善计划提高了诊断准确度,并简化了弱势婴儿的护理途径.
科学领域:
- 新生儿医学 新生儿医学
- 腎臟病學 (nephrology) 是一種醫學.
- 医疗信息学 医疗信息学
背景情况:
- 新生儿急性损伤 (AKI) 是新生儿中普遍存在且经常被诊断不足的疾病.
- 不充分识别和记录AKI可能导致遗漏脏病诊所和长期不理想的脏健康结果.
研究的目的:
- 通过质量改进项目,提高新生儿AKI的记录率.
- 增加脏病咨询和转介到专门的新生儿脏病诊所.
主要方法:
- 在新生儿重症监护室 (NICU) 实施了基于实时电子医疗记录 (EMR) 的AKI警报系统.
- 该系统自动标记新生儿血清肌素 (SCr) > 1.5 mg/dL,促使AKI诊断和医生采取行动.
- 首要目标是与基线相比,AKI文档的提高25%.
主要成果:
- 在EMR警报实施后,AKI文档从基线的7%升至100% (p < 0.001).
- 虽然脏病咨询没有显著增加 (p = 0.5),但新生儿脏病诊所的转诊显著增加 (p = 0.005).
结论:
- 自动化EMR警报系统提供了一种高效和具有成本效益的方法,可以改善新生儿AKI的诊断和记录.
- 这种方法提高了医疗保健提供者的参与度,优化了临床工作流程,并支持新生儿护理的持续质量改进.
- 广泛采用可以提高患者的治疗结果和新生儿AKI管理的诊断准确性.
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