Thomson R, Gray J, Madhok R, Mordue A, Mendelow A D
Medical School, University of Newcastle upon Tyne.
Qual Health Care. 1994 Jun;3(2):86-91. doi: 10.1136/qshc.3.2.86.
To compare record keeping and decision making in accident and emergency departments before and after distribution of guidelines on head injury management as indices of implementation.
Before (1987) and after (1990) study of accident and emergency medical records.
Two accident and emergency departments in England.
1144 adult patients with head injury in department 1 (533 in 1987, 613 in 1990) and 734 in department 2 (370, 364 respectively).
Recording of relevant symptoms and signs as determined in the guidelines; presence of, indications for, and rates and appropriateness of skull x ray examination and admission.
The median number of guidelines variables recorded for all study periods ranged from 7 to 9 out of a possible maximum of 27. For key decision making variables the presence or absence of penetrating injury was least likely to be recorded (< or = 1%) and that of loss of consciousness most likely (> or = 75%). Altogether, the proportion of patients receiving skull x ray examination or admitted varied from 25%-60% and 7%-23% respectively; overall, 69% (1280/1856) and 64% (1177/1851) of patients were managed appropriately. However, no consistent change occurred in the departments between the study periods. For instance, in department 1 the proportion of appropriate x ray examinations rose significantly after distribution of the guidelines (from 61% (202/330) to 73% (305/417)) and appropriate decisions on whether to x ray or not also rose (from 65% (340/522) to 72% (435/608)). There was no significant change in department 2, although the proportion of appropriate admissions fell (from 33% (55/166) to 15% (19/130)).
Recording practice and decision making were variable and had not consistently improved after dissemination of the guidelines. Strategies are required to ensure effective implementation of guidelines.
比较在分发头部损伤管理指南前后，急诊部门的记录保存及决策情况，以此作为指南实施的指标。
对1987年（之前）和1990年（之后）的急诊医疗记录进行研究。
英国的两个急诊部门。
第一部门1144例成年头部损伤患者（1987年533例，1990年613例），第二部门734例（分别为370例和364例）。
记录指南中确定的相关症状和体征；颅骨X光检查的存在情况、指征、比例及合理性，以及住院情况。
在所有研究期间记录的指南变量中位数，在可能的最多27项中为7至9项。对于关键决策变量，穿透性损伤的有无最不可能被记录（≤1%），意识丧失的有无最有可能被记录（≥75%）。总体而言，接受颅骨X光检查或住院的患者比例分别为25% - 60%和7% - 23%；总体上，69%（1280/1856）和64%（1177/1851）的患者得到了恰当处理。然而，在研究期间各部门之间没有出现一致的变化。例如，在第一部门，指南分发后恰当X光检查的比例显著上升（从61%（202/330）升至73%（305/417）），关于是否进行X光检查的恰当决策也有所上升（从65%（340/522）升至72%（435/608））。在第二部门没有显著变化，尽管恰当住院的比例下降了（从33%（55/166）降至15%（19/130））。
记录做法和决策存在差异，在指南分发后并未持续改善。需要采取策略以确保指南的有效实施。
