Choo Melissa C, Thennakon Shyamica, Shapey Jonathan, Tolias Christos M
Department of Neurosurgery, King's College NHS Hospital Trust, London, SE5 9RS, UK.
Br J Neurosurg. 2011 Jun;25(3):384-7. doi: 10.3109/02688697.2011.566381. Epub 2011 Apr 18.
Accurate handover is very important in the running of all modern neurosurgical units. Referrals are notoriously difficult to track and review due to poor quality of written paper-based recorded information for handover (illegibility, incomplete paper trail, repetition of information and loss of patients). We have recently introduced a web-based referral system to three of our referring hospitals.
To review the experience of a tertiary neurosurgical unit in using the UK's first real time online referral system and to discuss its strengths and weaknesses in comparison to the currently used written paper-based referral system.
A retrospective analysis of all paper-based referrals made to our unit in March 2009, compared to 14 months' referrals through the web system. Patterns of information recorded in both systems were investigated and advantages and disadvantages of each identified.
One hundred ninety-six patients were referred using the online system, 483 using the traditional method. Significant problems of illegibility and missing information were identified with the paper-based referrals. In comparison, 100% documentation was achieved with the online referral system. Only 63% penetrance in the best performing trust was found using the online system, with significant delays in responding to referrals.
Traditional written paper-based referrals do not provide an acceptable level of documentation. We present our experience and difficulties implementing a web-based system to address this. Although our data are unable to show improved patient care, we believe the potential benefits of a fully integrated system may offer a solution.
在所有现代神经外科科室的运营中，准确的交接非常重要。由于用于交接的纸质记录信息质量不佳（字迹模糊、纸质记录不完整、信息重复以及患者信息丢失），转诊情况 notoriously 难以追踪和审查。我们最近已将基于网络的转诊系统引入到我们的三家转诊医院。
回顾一家三级神经外科科室使用英国首个实时在线转诊系统的经验，并与当前使用的纸质转诊系统相比，讨论其优缺点。
对2009年3月转诊至我们科室的所有纸质转诊进行回顾性分析，并与通过网络系统进行的14个月的转诊情况作比较。调查两个系统中记录的信息模式，并确定各自的优缺点。
196名患者通过在线系统转诊，483名患者使用传统方法转诊。纸质转诊中发现了字迹模糊和信息缺失等重大问题。相比之下，在线转诊系统的文档记录率达到了100%。使用在线系统时，在表现最佳的信托机构中发现只有63%的渗透率，并且对转诊的回应存在显著延迟。
传统的纸质转诊无法提供可接受的文档记录水平。我们介绍了我们在实施基于网络的系统以解决此问题方面的经验和困难。尽管我们的数据无法表明患者护理得到改善，但我们相信完全集成系统的潜在益处可能会提供一个解决方案。
