Riggio Jeffrey M, Sorokin Rachel, Moxey Elizabeth D, Mather Paul, Gould Stuart, Kane Gregory C
Division of Internal Medicine, Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
Acad Med. 2009 Dec;84(12):1719-26. doi: 10.1097/ACM.0b013e3181bf51d6.
Many of the quality measures for patients with heart failure (HF) or acute myocardial infarction (AMI) require the completion of comprehensive discharge instructions, including instructions about medications to be taken after discharge. To improve compliance in a tertiary care teaching hospital with these evidence-based quality measures, a clinical-decision-support system (CDSS) that uses an electronic checklist was developed. The CDSS prompts clinicians at every training level to consistently create comprehensive discharge instructions addressing quality measures. The authors compared compliance during the 15-month preintervention and postintervention periods. Compliance with discharge measures for AMI (i.e., aspirin, beta-blocker, angiotensin-converting enzyme inhibitor [ACEI], or angiotensin receptor blocker [ARB] use) and for HF (i.e., discharge instructions, left ventricular systolic function [LVSF] evaluation, and ACEI/ARB use) was assessed. The delivery of discharge instructions showed significant improvement from the preintervention period to the postintervention period (37.2% to 93.0%; P < .001). Compliance with prescription of ACEI or ARB also improved significantly for HF (80.7% to 96.4%; P < .001) and AMI (88.1% to 100%; P = .014) patients. Compliance with the remaining measures was higher before intervention, and, thus, the modest improvement in the postintervention period was not statistically significant (AMI patients: aspirin, 97.5% to 98.8%; P = .43; and beta-blocker, 97.9% to 98.7%; P = .78; HF patients: LVSF, 99.3% to 99.1%; P = .78). Implementation of a CDSS with computerized electronic prompts improved compliance with selected cardiac-care quality measures. The design of quality-improvement decision-support tools should incorporate educational missions in their message and design.
许多针对心力衰竭（HF）或急性心肌梗死（AMI）患者的质量指标要求完成全面的出院指导，包括出院后用药指导。为提高一家三级护理教学医院对这些循证质量指标的依从性，开发了一种使用电子检查表的临床决策支持系统（CDSS）。该CDSS促使各级培训水平的临床医生始终如一地制定针对质量指标的全面出院指导。作者比较了干预前和干预后15个月期间的依从性。评估了AMI（即阿司匹林、β受体阻滞剂、血管紧张素转换酶抑制剂[ACEI]或血管紧张素受体阻滞剂[ARB]的使用）和HF（即出院指导、左心室收缩功能[LVSF]评估以及ACEI/ARB的使用）出院指标的依从性。出院指导的提供情况从干预前期到干预期有显著改善（37.2%至93.0%；P <.001）。HF（80.7%至96.4%；P <.001）和AMI（88.1%至100%；P =.014）患者对ACEI或ARB处方的依从性也显著提高。对其余指标的依从性在干预前较高，因此，干预期的适度改善无统计学意义（AMI患者：阿司匹林，97.5%至98.8%；P =.43；β受体阻滞剂，97.9%至98.7%；P =.78；HF患者：LVSF，99.3%至99.1%；P =.78）。实施带有计算机化电子提示的CDSS可提高对选定心脏护理质量指标的依从性。质量改进决策支持工具的设计应在其信息和设计中纳入教育任务。
