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Using a Structured Checklist to Improve the Orthopedic Ward Round: A Prospective Cohort Study

机译：使用结构化清单来改善骨科病房：一项潜在的队列研究

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摘要

Comprehensive and timely documentation on orthopedic ward rounds continues to be problematic, leading to delayed or inappropriate patient care and miscommunication between health care providers. The authors introduced a simple checklist to improve the documentation on orthopedic ward rounds in their institution. A prospective cohort study was performed. Standard care was provided for cohort A. During a 2-week period, the documentation of patient care by physicians following a ward round was assessed in terms of venous thromboembolism prophylaxis, fasting status, wound or dressing plan, weight-bearing status, and important surgical details. The physicians were blinded to this initial review. For cohort B, a structured ward round checklist was introduced during a 2-week period. A total of 132 patient encounters were recorded in cohort A. Important issues that were rarely discussed included vital signs (11.4%), venous thromboembolism prophylaxis (9.8%), and bowel status (3.8%). Issues that were poorly documented included fasting status (9.1%), wound or dressing plan (6.8%), and weight-bearing status (11.4%). After introduction of the checklist, daily documentation of surgical details improved from 38.6% to 85.3% of patient encounters. Fasting status documentation improved from 9.1% to 70.6% of patient encounters. Venous thromboembolism prophylaxis discussion increased from 9.8% to 45.6% of the time, while its documentation improved from 6.8% to 92.6%. Documentation of weight-bearing status improved from 11.4% to 83.8% (all P < .0001). The use of a structured checklist during orthopedic ward rounds led to significant improvement in both the consideration and the documentation of key aspects of surgical care.
机译：全面及时的矫形病房回合的文件仍然存在问题，导致卫生保健提供者之间延迟或不恰当的患者护理和不适当的信息。作者介绍了一个简单的清单，可以改善其机构的骨科区回合的文件。进行了一个预期的队列研究。标准护理是为群组A提供的。在2周期间，在病房循环后医生患者护理文件的文件在静脉血栓栓塞预防，禁食状态，伤口或敷料计划，负重状态和重要的方面进行了评估手术细节。医生因这次初步审查而被蒙蔽。对于COHORT B，在2周期间推出了一个结构化的病房圆形清单。共有132例患者遭遇遇到的群体A.很少讨论的重要问题包括生命体征（11.4％），静脉血栓栓塞预防（9.8％）和肠状况（3.8％）。记录不足的问题包括禁食状态（9.1％），伤口或敷料计划（6.8％）和负重状态（11.4％）。在引入清单后，手术细节的日常文件从38.6％提高到85.3％的患者遭遇。禁食状态文档从9.1％提高到70.6％的患者遭遇。静脉血栓栓塞的预防讨论从9.8％增加到45.6％的时间，而其文件从6.8％提高到92.6％。负重状态的文档从11.4％提高到83.8％（所有P <.0001）。在矫形病房回合期间使用结构化清单导致了对手术护理的关键方面的考虑和文件的重大改进。

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  • 来源
    《Orthopedics》 |2017年第4期|共5页
  • 作者

    Talia Adrian J.; Drummond James; Muirhead Cameron; Phong Tran;

  • 作者单位

    Footscray Hosp Western Hlth Dept Orthopaed Surg Level 1 South Gordon St Melbourne Vic 3011;

    Footscray Hosp Western Hlth Dept Orthopaed Surg Level 1 South Gordon St Melbourne Vic 3011;

    Footscray Hosp Western Hlth Dept Orthopaed Surg Level 1 South Gordon St Melbourne Vic 3011;

    Footscray Hosp Western Hlth Dept Orthopaed Surg Level 1 South Gordon St Melbourne Vic 3011;

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  • 原文格式 PDF
  • 正文语种 eng
  • 中图分类 骨科学（运动系疾病、矫形外科学）;
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