Griffey Richard T, Wittels Kathleen, Gilboy Nicki, McAfee Andrew T
Division of Emergency Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO 63110-1010, USA.
Ann Emerg Med. 2009 Apr;53(4):469-76. doi: 10.1016/j.annemergmed.2008.05.035. Epub 2008 Jul 21.
We evaluate the effect of a computerized order entry system forcing function on improving timely renewal of restraint orders.
In this prospective study of 2 successive interventions, physicians received computerized reminders to renew or discontinue restraint orders before their expiration. The initial intervention allowed acknowledgement of this reminder without further consequence, changing at 6 months to deny computer access until addressed. We performed chart review on emergency department visits with restraint orders in 3 consecutive 6-month periods (A, B, C) separated by these 2 interventions, determining time to order renewal, number of restraint orders, renewal orders per hour in restraints, and time in restraints and evaluating variability in these values across study intervals. Statistical analysis for our primary outcome used the Mann-Whitney and variance ratio tests.
Median time to order renewal decreased in periods B and C versus A by 64 and 56 minutes, respectively, with variability in this measure decreasing across all periods. Mean number of restraint orders in periods B and C significantly increased versus those in A (1.46 to 1.89 to 2.34), with corresponding increases in variability. Mean renewal orders per hour in restraint significantly increased in period C versus A and B, from 0.08 to 0.23 to 0.89, with increasing variability across all periods. Decreases in median time spent in restraints observed in periods B and C versus A of 45 and 105 minutes, respectively, trended toward but did not achieve significance, with significantly decreasing variability compared with baseline.
The forcing function improved restraint reordering and variability in practice and may have contributed to nonsignificant reductions observed in time in restraint.
我们评估计算机化医嘱录入系统强制功能对改善约束医嘱及时续签的效果。
在这项针对连续两次干预措施的前瞻性研究中，医生在约束医嘱到期前收到计算机提醒以续签或停用该医嘱。最初的干预措施允许对该提醒进行确认而不产生进一步后果，6个月后改为在问题解决之前拒绝计算机访问。我们对由这两次干预措施分隔的连续3个6个月期间（A、B、C）内有约束医嘱的急诊科就诊病例进行病历审查，确定医嘱续签时间、约束医嘱数量、约束状态下每小时的续签医嘱数量以及约束时间，并评估这些值在各研究期间的变异性。对我们的主要结局进行的统计分析采用了曼-惠特尼检验和方差比检验。
与A期相比，B期和C期医嘱续签的中位时间分别减少了64分钟和56分钟，且该指标的变异性在所有期间均有所降低。与A期相比，B期和C期约束医嘱的平均数量显著增加（从1.46增至1.89再增至2.34），变异性也相应增加。与A期和B期相比，C期约束状态下每小时的平均续签医嘱数量显著增加，从0.08增至0.23再增至0.89，且各期间的变异性不断增加。与A期相比，B期和C期约束时间的中位时间分别减少了45分钟和105分钟，虽有下降趋势但未达到显著水平，与基线相比变异性显著降低。
强制功能改善了约束医嘱的重新开具情况及实际操作中的变异性，可能促使约束时间出现了虽不显著但有所减少的情况。
