养老院到紧急护理过渡表格的采用量有限,但改进了文档
Peter T Serina1, Audrey Stavrand2, Margaret L Lind3
1Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA.
概括
标准化养老院到急诊室的转移表格改善了文件的完整性. 然而,标准化护理连续性 (CoC) 形式的采用率很低,这表明需要更好的实施策略来加强信息交换.
科学领域:
- 医疗保健信息学 医疗保健信息学
- 患者转移文件 患者转移文件
- 医疗保健服务研究 医疗服务研究
背景情况:
- 从养老院到急诊室 (NH-ED) 的转移存在关键的文档缺口.
- 提出了标准化表格,以减轻这些信息缺陷.
- 对于NH-ED转移,全州范围的护理连续性 (CoC) 表格是强制性的.
研究的目的:
- 评估对NH-ED转移采用标准化CoC表格的采用和有效性.
- 评估CoC表格对文件完整性和住院率的影响.
- 将实施后的文档与实施前的数据进行比较.
主要方法:
- 对2019-2022年NH-ED转移的电子健康记录数据的分析.
- 在CoC表格实施之前和之后的文件完整性 (15个关键元素) 的比较.
- 进行回归分析,以检查CoC表格的使用与记录的元素/录取之间的关联.
主要成果:
- 在203个NH-ED转账中,80.8%有表格,但只有28.6%使用标准化的CoC表格.
- 与实施前数据相比,功能基线,认知基线和转移原因的文档完整性增加.
- 标准化CoC表格的使用与更多记录的关键元素有关,但没有降低住院几率.
结论:
- 在全国范围内对CoC形式的标准化改善了NH-ED转移中关键元素的文档.
- 标准化CoC表格的低采用率凸显了实施方面的挑战.
- 需要进一步评估,以增加CoC形式的采用,并提高NH-ED信息交换质量.
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