在儿科创伤患者中改善宫脊椎清除文档:质量改善项目
Megan M Reichert1, Emily M Rheaume, Jesse M Skoch
1Author Affiliations: Division of Pediatric General & Thoracic Surgery, Department of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (Mmes Reichert, Rheaume, Daugherty, Beiting, and Bailey, Drs Brown, Falcone, and Kotagal); Division of Pediatric Neurosurgery, Department of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (Dr Skoch); and Division of Emergency Medicine, Department of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (Dr Johnson).
实施标准化椎脊柱清除笔记显著改善了儿科创伤患者的记录率,确保了更安全的护理,并减少了多学科团队的不确定性.
科学领域:
- 儿科创伤护理 儿童创伤护理
- 提高医疗保健的质量 改善医疗保健的质量
- 临床文档 临床文档
背景情况:
- 一致的宫脊椎清除文档对于安全的儿科创伤护理至关重要.
- 当前的文档化实践往往不一致和不合适.
- 这种不一致性给多学科创伤团队带来了挑战.
研究的目的:
- 为了评估椎脊柱清除文档倡议的影响.
- 评估文档遵守率的改善情况.
- 提高儿童创伤患者的护理质量.
主要方法:
- 一个使用Plan-Do-Study-Act周期的质量改进研究.
- 从2022年5月到2023年9月在一级儿科创伤中心收集未来的数据.
- 一个多组件干预,包括一个标准化的电子笔记,多学科教育,更新的指导方针和图表审查.
主要成果:
- 该研究包括550名儿童创伤患者 (0-18岁),需要放置宫项圈.
- 宫脊椎文档的遵守度从基线10%提高到实施后的85%.
- 在超过13个月的时间里,观察到持续的坚持率.
结论:
- 一个标准化的椎脊柱清除说明有效增加了适当的文件.
- 这一举措减少了关于安全移除宫项圈的不确定性.
- 改进的文档支持更安全,更一致的患者护理.
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