通过减少文档负担,提高了中风护士对评估标准的合规性:一项实施科学研究
Anjali Perera1, Lisa Smith, Brianna Garza
1At University of Texas Southwestern Medical Center in Dallas, TX, Anjali Perera is Assistant Nurse Manager, Neuroscience Intensive Care Unit; Lisa Smith is Assistant Nurse Manager, Neuroscience Intensive Care Unit; Brianna Garza is Staff Nurse, Neuroscience Intensive Care Unit; Donald Stout is Nurse Manager, Neuroscience Intensive Care Unit; Moez M. I. Bashir is Clinical Research Associate II; Samanta Allen is Staff Nurse, Neuroscience Intensive Care Unit; Amber Salter is Associate Professor, Department of Neurology; and DaiWai M. Olson is Professor, Department of Neurology.
自动化文档显著增加了量化学生计 (QP) 的采用,这是一个基于证据的实践. 减少文档负担是实施新临床工具的关键.
科学领域:
- 临床实施科学 临床实施科学
- 医疗信息学 医疗信息学
- 医疗器械的采用 医疗器械的采用
背景情况:
- 定量瞳孔测量 (QP) 是一种优越的,基于证据的方法,用于评估与主观测量相比,瞳孔的反应性.
- 尽管QP可用,但其在临床实践中的采用是不一致的,文档负担可能是一个重要的障碍.
- 实施研究旨在确定影响采用基于证据的实践的因素.
研究的目的:
- 调查自动化文档技术是否有助于实施定量学生计 (QP).
- 评估减少文档负担对采用QP的影响.
主要方法:
- 使用了比较性研究设计,分析了手动输入队列和自动上传队列的数据.
- 在重症监护病房停留期间,在4小时的间隔内测量了对单位学生评估政策的遵守.
- 该研究获得了机构审查委员会的批准.
主要成果:
- 在手动输入 (122名患者) 和自动输入 (229名患者) 队列之间没有发现显著的人口差异.
- 自动输入队列表现出明显更高的合规性 (65.0%) 与手动输入队列 (47.7%) 相比 (t = -6.42,P < 0.0001).
- 这表明,自动化文档的学生评估协议的遵守率大幅增加.
结论:
- 减少文档负担与增加采用和遵守QP等基于证据的实践直接相关.
- 自动化文档系统可以成为实施新临床技术的促进者.
- 简化文档流程对于改进使用先进的医疗评估工具至关重要.
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