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标准和指南的记录依从性:一项审计

Documented adherence to standards and guidelines: an audit.

作者信息

Bhardwaj Rashmi, Pickard Robert, Rees Jackie

机构信息

(Catheter Study), Newcastle‑upon-Tyne Hospitals NHS Foundation Trust.

出版信息

Br J Nurs. 2010;19(18):S26-30. doi: 10.12968/bjon.2010.19.Sup8.79066.

DOI:10.12968/bjon.2010.19.Sup8.79066
PMID:20948485
Abstract

The authors conducted a cross-sectional audit within Newcastle-upon-Tyne Hospitals NHS Foundation Trust to determine the prevalence of urethral catheterisation and documented adherence to relevant NHS standards. An on-line audit questionnaire was completed for all 80 inpatient wards within the Trust on a single day during the third week in June 2009. The tool collected data on prevalence and care requirements detailed in the Department of Health's (DH) Saving Lives High Impact Intervention 6 (2007). Data were analysed using Snap survey software. Overall, 172 of 1187 (14.5%) inpatients were catheterized and all were using a closed drainage system or catheter valve. Evidence of correct continuing catheter care was documented for 168 (98%) patients, while details of catheter insertion were identified in 153 (89%) patient records. Eight (4.5%) patients were being treated for a urinary tract infection. The authors found satisfactory adherence to basic documentation standards with regard to catheter care. This was associated with a low prevalence rate of catheterization and catheter-associated urinary infection within the Trust relative to previously published figures. Details of catheter insertion were missing from 10% of patient records, requiring further development of accessible and transferable documentation tools. Provision of relevant information to patients is also a target for development.

摘要

作者在泰恩河畔纽卡斯尔医院国民保健服务基金会信托基金内部开展了一项横断面审计,以确定导尿术的普及率,并记录对相关国民保健服务标准的遵守情况。2009年6月的第三周,在一天内为该信托基金内的所有80个住院病房完成了一份在线审计问卷。该工具收集了卫生部(DH)《拯救生命高影响力干预措施6》(2007年)中详细阐述的普及率和护理要求的数据。使用Snap调查软件对数据进行了分析。总体而言,1187名住院患者中有172名(14.5%)进行了导尿,且均使用了密闭引流系统或导尿管阀门。168名(98%)患者有正确持续导尿管护理的记录,而153名(89%)患者记录中明确了导尿管插入的细节。8名(4.5%)患者正在接受尿路感染治疗。作者发现,在导尿管护理的基本文件记录标准方面,遵守情况令人满意。相对于之前公布的数据,该信托基金内的导尿术和导尿管相关尿路感染的普及率较低。10%的患者记录中缺少导尿管插入的细节,需要进一步开发便于获取和可转移的文件记录工具。向患者提供相关信息也是一个有待发展的目标。

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