电子产前记录从办公室有效传输到医院的结果。

Outcomes of effective transmission of electronic prenatal records from the office to the hospital.

机构信息

Departments of Obstetrics and Gynecology, Dublin Center, Palo Alto Medical Foundation, Dublin, California, Drexel University College of Medicine, Philadelphia, Pennsylvania, and Massachusetts General Hospital, Boston, Massachusetts.

出版信息

Obstet Gynecol. 2014 Aug;124(2 Pt 1):317-322. doi: 10.1097/AOG.0000000000000349.

DOI:10.1097/AOG.0000000000000349

PMID:25004337

Abstract

OBJECTIVE

To investigate the outcomes associated with improved transmission of prenatal test results between the outpatient and inpatient obstetric setting after implementation of an electronic prenatal record system.

METHODS

Admission paper charts of patients admitted to our labor and delivery unit were reviewed before and after implementation of an electronic prenatal record system. The availability of maternal hepatitis B and human immunodeficiency virus (HIV) serology on admission, the occurrence of repeat hepatitis B surface antigen and rapid HIV blood testing, and the occurrence of hepatitis B immunoglobulin administration to the newborns of mothers without available hepatitis B serology was recorded. Fisher's exact tests were performed to determine differences in availability of prenatal test results, the occurrence of repeat blood testing, and the occurrence of immunoglobulin administration before and after implementation.

RESULTS

A total of 460 admission charts were reviewed, 229 preimplementation and 231 postimplementation. Of the preimplementation charts, 78.2% contained maternal hepatitis B and HIV serology results, whereas all postimplementation charts contained such results (P<.001). Although repeat hepatitis B surface antigen testing was performed in 3.1% of patients preimplementation, no patients required repeat testing postimplementation (P=.007). Similarly, rapid HIV blood testing was performed in 3.5% of patients preimplementation, but no patients required repeat testing postimplementation (P=.003). Increased availability of testing results prevented unnecessary administration of hepatitis B immunoglobulin postimplementation.

CONCLUSION

Implementation of an electronic perinatal record system was associated with improved transmission of prenatal test results between the outpatient and inpatient obstetric setting and a decreased rate of unnecessary maternal testing and newborn interventions.

LEVEL OF EVIDENCE

III.

摘要

目的

调查在实施电子产前记录系统后，改善门诊和住院产科环境中产前检查结果传输的结果。

方法

在实施电子产前记录系统前后，回顾了入住我院分娩病房患者的入院病历。记录入院时乙型肝炎和人类免疫缺陷病毒（HIV）血清学的可用性、乙型肝炎表面抗原重复检测和快速 HIV 血液检测的发生情况，以及对无乙型肝炎血清学检测结果的母亲的新生儿进行乙型肝炎免疫球蛋白注射的情况。采用 Fisher 确切检验比较实施前后产前检查结果、重复血液检测和免疫球蛋白注射的发生情况。

结果

共回顾了 460 份入院病历，229 份实施前，231 份实施后。在实施前的病历中，78.2%包含了母亲的乙型肝炎和 HIV 血清学结果，而所有实施后的病历都包含了这些结果（P<.001）。虽然在实施前的 3.1%患者中进行了乙型肝炎表面抗原重复检测，但实施后没有患者需要重复检测（P=.007）。同样，在实施前的 3.5%患者中进行了快速 HIV 血液检测，但实施后没有患者需要重复检测（P=.003）。检测结果可用性的提高防止了实施后乙型肝炎免疫球蛋白的不必要使用。