在儿科急诊室改善结构化交换文档
Deborah Hammett1,2, Rebecca Matta3, Jody Kieffer1,2
1From the Division of Emergency Medicine, Nemours Children's Health, Wilmington, Del.
Pediatric quality & safety
|February 25, 2026
概括
实施标准化的笔记模板显著改善了医疗服务提供者在儿科急诊室遵守I-PASS交付工具,改善了患者护理过渡.
科学领域:
- 医疗信息学 医疗信息学
- 患者安全 患者安全
- 儿科急救医学 儿科急救医学
背景情况:
- 在急诊室 (EDs) 中,护理的转换是常见的,在那里,不可预测的环境可能会破坏结构化的交接.
- I-PASS交付工具旨在指导提供者沟通,并减少患者转移期间的不良事件.
- 在ED中存在的挑战需要改进结构化提供者移交的方法.
研究的目的:
- 在六个月内将包含I-PASS工具所有四个组件的交付笔记的百分比增加20%.
- 在儿科ED环境中实施和评估标准化交付笔记模板.
- 提高在重症监护过渡期间提供者交接的质量和完整性.
主要方法:
- 一个包含四个关键I-PASS元素 (疾病严重程度,患者护理摘要,行动清单,情境意识/应急计划) 的交付笔记模板是为儿科ED开发的.
- 使用了实施前 (2021年8月至2022年7月) 和实施后 (2022年8月至2024年1月) 的研究设计,每月分析20张图表.
- 使用Plan-Do-Study-Act循环进行代过程改进,包括模板修改和EMR集成.
主要成果:
- 实施后,63.0%的交付说明包括所有四个I-PASS元素,比预实施的0%大幅增加.
- 标准化交付纸条模板的使用率从干预前的0%上升到82.0%.
- 在没有文件的交付率上没有观察到显著的变化,这表明干预的重点是笔记质量.
结论:
- 一个标准化的笔记模板有效地提高了儿科ED内部对I-PASS交付工具的坚持.
- 该干预表明,在高精度环境中,改善结构化提供者交接的成功策略.
- 标准化工具对于优化沟通和在紧急医疗的护理过渡期间的患者安全至关重要.
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