引入外科出院总结框架,以提高一个繁忙的地区总医院的准确性和简洁性
Eesaa Longden1, Aashna Sikka2, Ashwin Bobby3
1Psychiatry, Royal Blackburn Hospital, Blackburn, GBR.
Cureus
|October 21, 2024
概括
实施标准化框架显著提高了外科出院摘要 (TTO) 的质量,提高了患者护理沟通. 需要进一步培训,以解决后续细节中持续存在的遗漏.
科学领域:
- 医疗信息学 医疗信息学
- 改善医疗保健质量 改善医疗保健质量
- 手术沟通手术沟通
背景情况:
- 退院摘要 (TTO) 对于初级-二级护理沟通至关重要,特别是对于需要特殊的退院后指令的手术患者.
- 在一个地区综合医院过渡到电子记录后,观察到不合格的TTO质量.
- 在TTO的不一致性可能会对患者的结果和护理的连续性产生负面影响.
研究的目的:
- 提高外科出院总结 (TTO) 的准确性和清晰度.
- 实施和评估一个有针对性的框架,以改善TTO内容.
主要方法:
- 制定了一个框架,重点关注五个关键的TTO组件:入院原因,干预,手术细节,出院计划和后续指示.
- 对60个TTO进行了基线审计,随后通过教育和集成到电子病历 (EPR) 系统实现了框架实施.
- 通过两次计划-做-研究-行动 (PDSA) 周期收集数据来评估影响.
主要成果:
- 基线审计显示,70%的TTO至少缺少一个关键元素,最常见的是后续细节.
- 干预后,所有基本数据的TTO百分比在第一个PDSA周期后增加了30%.
- 在第二个周期后,人们注意到了进一步的改善,尽管后续信息仍然是最被遗漏的元素. 居民反表明,TTO质量和效率有所提高.
结论:
- 一个标准化的框架显著提高了外科出院总结的质量和完整性.
- 解决本科和基础水平的TTO写作培训缺口是持续质量改善的必要条件.
- 需要继续努力,以确保在TTO中全面包含所有关键患者信息.
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