Primary Care Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
BMC Med Inform Decis Mak. 2014 Mar 20;14:20. doi: 10.1186/1472-6947-14-20.
Clinical decision support (CDS) has been shown to be effective in improving medical safety and quality but there is little information on how telephone triage benefits from CDS. The aim of our study was to compare triage documentation quality associated with the use of a clinical decision support tool, ExpertRN©.
We examined 50 triage documents before and after a CDS tool was used in nursing triage. To control for the effects of CDS training we had an additional control group of triage documents created by nurses who were trained in the CDS tool, but who did not use it in selected notes. The CDS intervention cohort of triage notes was compared to both the pre-CDS notes and the CDS trained (but not using CDS) cohort. Cohorts were compared using the documentation standards of the American Academy of Ambulatory Care Nursing (AAACN). We also compared triage note content (documentation of associated positive and negative features relating to the symptoms, self-care instructions, and warning signs to watch for), and documentation defects pertinent to triage safety.
Three of five AAACN documentation standards were significantly improved with CDS. There was a mean of 36.7 symptom features documented in triage notes for the CDS group but only 10.7 symptom features in the pre-CDS cohort (p < 0.0001) and 10.2 for the cohort that was CDS-trained but not using CDS (p < 0.0001). The difference between the mean of 10.2 symptom features documented in the pre-CDS and the mean of 10.7 symptom features documented in the CDS-trained but not using was not statistically significant (p = 0.68).
CDS significantly improves triage note documentation quality. CDS-aided triage notes had significantly more information about symptoms, warning signs and self-care. The changes in triage documentation appeared to be the result of the CDS alone and not due to any CDS training that came with the CDS intervention. Although this study shows that CDS can improve documentation, further study is needed to determine if it results in improved care.
临床决策支持（CDS）已被证明可有效提高医疗安全性和质量，但有关电话分诊如何受益于 CDS 的信息却很少。我们的研究目的是比较使用临床决策支持工具 ExpertRN© 前后分诊文档的质量。
我们在使用 CDS 工具进行护理分诊前和后检查了 50 份分诊文档。为了控制 CDS 培训的影响，我们还有一个额外的对照组，该组由接受过 CDS 工具培训但在选定的笔记中未使用该工具的护士创建的分诊文档组成。将 CDS 干预组的分诊笔记与预 CDS 笔记和 CDS 培训（但未使用 CDS）组进行比较。使用美国门诊护理护理学院（AAACN）的文档标准比较了队列。我们还比较了分诊记录的内容（与症状、自我护理说明和要注意的警告信号相关的阳性和阴性特征的记录），以及与分诊安全相关的文档缺陷。
在五个 AAACN 文档标准中有三个得到了显著改善。在 CDS 组的分诊记录中有 36.7 个症状特征，但在预 CDS 队列中只有 10.7 个症状特征（p <0.0001），在接受 CDS 培训但未使用 CDS 的队列中则有 10.2 个症状特征（p <0.0001）。在预 CDS 中记录的 10.2 个症状特征的平均值和 CDS 培训但未使用的 10.7 个症状特征的平均值之间的差异没有统计学意义（p = 0.68）。
CDS 显著提高了分诊记录的文档质量。 CDS 辅助的分诊记录具有更多有关症状、警告信号和自我护理的信息。分诊文档的变化似乎是 CDS 本身的结果，而不是 CDS 干预带来的任何 CDS 培训的结果。尽管这项研究表明 CDS 可以改善文档记录，但还需要进一步研究以确定它是否可以改善护理。
