在使用基于电子健康记录的干预措施的选择性内镜后恢复抗血栓剂的文档化率的提高
Jeffrey Than1, Terrance Rodrigues1, Mary Kwasny2
1Division of Gastroenterology and Hepatology, Department of Medicine (1)Northwestern University, Chicago, Illinois, USA.
iGIE : innovation, investigation and insights
|February 6, 2026
概括
电子健康记录干预显著改善了内镜后抗凝剂和抗血小板药物恢复建议的文档. 这通过确保明确的术后药物指导来提高患者的安全性.
科学领域:
- 胃肠病学 胃肠病学
- 临床信息学 临床信息学
- 患者安全 患者安全
背景情况:
- 反凝血剂 (AC) 和抗血小板药物 (APA) 的恢复建议在内镜后的不一致的文档与不良事件有关.
- 有效的临床决策支持系统需要适当的实施,以实现高采用率和适当的使用.
研究的目的:
- 为了提高AC和APA恢复建议的文档化率.
- 将基于电子健康记录 (EHR) 的干预集成到内镜工作流程中.
主要方法:
- 实施了软停止 EHR 警报,以迅速记录恢复建议.
- 在接受选择性门诊内镜检查的AC和APA患者的干预前和干预后期间,比较了记录率.
主要成果:
- 干预显著提高了记录率,从AC的47.1%增加到70.5% (P < .001),以及APA的41.6%增加到73.1% (P < .001).
- 没有观察到AC/APA使用的变化;对于结肠镜检查来说,文档更高,对于EUS/ERCP来说更低.
- 患者人口统计学 (年龄,性别) 影响了文档,但镇静类型和同伴的存在没有.
结论:
- 基于EHR的干预有效地改善了在内镜检查后恢复抗血栓药物建议的文档.
- 这种干预无地集成到临床工作流程中,提高了患者的安全性.
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