利用临床决策支持来提高老年住院患者的护理质量。
Use of clinical decision support to improve the quality of care provided to older hospitalized patients.
出版信息
Appl Clin Inform. 2012 Mar 7;3(1):94-102. doi: 10.4338/ACI-2011-08-RA-0047. Print 2012.
BACKGROUND
Frail older inpatients are at risk of unintended adverse events while in hospital, particularly falls, functional decline, delirium and incontinence.
OBJECTIVE
The aim of this pragmatic trial was to pilot and evaluate a multi-component knowledge translation intervention that incorporated a nurse-initiated computerized clinical decision support tool to reduce harms in the care of older medical inpatients.
METHODS
A stepped wedge trial design was conducted on six medical units at two hospitals in Calgary, Alberta, Canada. The primary quantitative outcome was the rate of order set use. Secondary outcomes included the number of falls, the average number of days in hospital, and the total number of consults ordered for each of orthopedics, geriatrics, psychiatry and physiotherapy. Qualitative analysis included interviews with nurses to explore barriers and facilitators around the implementation of the electronic decision support tool.
RESULTS
The estimated mean rate of order set use over a 2 week period was 3.1 (95% CI 1.9-5.3) sets higher after the intervention than before. The estimated odds of a fall happening on a unit over a 2-week period was 9.3 (p = 0.065) times higher before than after the intervention. There was no significant effect of the intervention on length of hospital stay (p = 0.67) or consults to related clinical services (all p <0.2). Interviews with front-line nurses and nurse managers/educators revealed that the order set is not being regularly ordered because its content is perceived as part of good nursing care and due to the high workload on these busy medical units.
CONCLUSIONS
Although not statistically significant, a reduction in the number of falls as a result of the intervention was noted. Frontline users' engagement is crucial for the successful implementation of any decision support tool. New strategies of implementation will be evaluated before broad dissemination of this knowledge translation intervention.
背景
虚弱的老年住院患者在住院期间有发生非预期不良事件的风险，特别是跌倒、功能下降、谵妄和失禁。
目的
本实用临床试验旨在试点和评估一种多组分知识转化干预措施，该措施纳入了护士启动的计算机临床决策支持工具，以减少老年住院患者医疗护理中的伤害。
方法
在加拿大阿尔伯塔省卡尔加里的两家医院的 6 个医疗病房进行了一项逐步楔形试验设计。主要的定量结果是医嘱集使用的比率。次要结果包括跌倒的数量、平均住院天数以及骨科、老年病学、精神病学和物理治疗的总会诊次数。定性分析包括对护士的访谈，以探讨在实施电子决策支持工具时遇到的障碍和促进因素。
结果
在干预后 2 周内，医嘱集的估计平均使用比率比干预前高 3.1（95%CI 1.9-5.3）套。在干预前后的 2 周期间，一个病房发生跌倒的几率估计分别为干预前的 9.3 倍（p = 0.065）。干预对住院时间（p = 0.67）或相关临床服务的会诊次数（所有 p <0.2）均无显著影响。对一线护士和护士经理/教育者的访谈显示，医嘱集没有定期开出，因为其内容被认为是良好护理的一部分，而且这些繁忙的医疗病房的工作量很大。
结论
尽管没有统计学意义，但干预后跌倒的数量有所减少。前线用户的参与对于任何决策支持工具的成功实施都至关重要。在广泛传播这一知识转化干预措施之前，将评估新的实施策略。
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