在电子医疗记录中评估困难的气道警报的有效性:质量改进研究
Wen-Shen Lee1,2, Luke R Fletcher3,4,5, Shervin Tosif3
1Department of Anaesthesia, Austin Hospital, Heidelberg, VIC, 3084, Australia. wenshen.lee92@gmail.com.
BMC anesthesiology
|October 24, 2024
概括
困难的气道警报通常是合适的,但缺乏紧急使用的质量. 改进文档对于未来有效的气道管理和患者安全至关重要.
科学领域:
- 麻醉学 麻醉学
- 患者安全 患者安全
- 临床文档 临床文档
背景情况:
- 呼吸道遇到困难,虽然不常见,但在麻醉中存在重大风险.
- 有效记录困难的气道事件对于减轻未来风险至关重要.
- 现有的电子医疗记录 (EMR) 预警系统旨在改善气道管理.
研究的目的:
- 评估困难的气道警报的完整性,实用性和有效性.
- 评估这些警报对随后的气道管理事件的影响.
- 确定难以实现的气道文档化流程需要改进的领域.
主要方法:
- 从2011年至2021年在EMR中记录的困难气道警报的回顾性分析.
- 麻醉专家审查警报质量,适当性和对未来管理的影响.
- 分析包括141名患者及其相关的气道管理文件.
主要成果:
- 大多数警报 (83%) 是适当的,但只有28%的质量足以应急使用.
- 47%的患者有随后的呼吸道管理事件,56%的患者经历了管理变化.
- 73%的警报被修改,以提高它们的质量,以便在未来遇到.
结论:
- 虽然最困难的气道警报是适当的,但质量的显著异质性限制了临床实用性.
- 改善当地文档流程是必要的,以提高警报系统的有效性.
- 标准化难以实现的呼吸道文档可以改善整个麻醉社区的患者安全.
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