Chen Jasper J, Blanchard Michele A, Finn Christine T, Plunkett Margaret L, Homa Karen, Fournier Debra A, Gregoire James F, Handley Miranda M, Stedina Elizabeth A, Suresh Gautham K, Nugent William C
Jt Comm J Qual Patient Saf. 2014 Sep;40(9):389-97. doi: 10.1016/s1553-7250(14)40051-5.
Guardianship may be necessary when inpatients lack medical decision-making capacity and are unwilling to go home to be cared for by interested proxy decision makers. Interventions, centered on a clinical pathway, were conducted at Dartmouth-Hitchcock Medical Center (DHMC; Lebanon, New Hampshire). Because guardianship occurs at the interface of clinical care and governmental bureaucracy, quality improvement efforts focused on "in-hospital" processes, while actions were taken to improve communication between clinical teams and the legal system.
A multidisciplinary quality improvement team mapped the DHMC guardianship process and analyzed the causes for delays before creating the clinical pathway. Specific interventions were designed and implemented to address the identified improvement areas.
For the 26 guardianship patients during a two-year period (May 1, 2011-May 1, 2013), the charges incurred totaled approximately $4,000,000--for an average of more than $150,000 per patient. The medically unnecessary days of their length of hospital stay decreased from an average of 27.8 to 11.3, a statistically significant result as demonstrated by statistical process control analysis. The shorter hospitalizations of the last 13 patients amounted to 214.5 medically unnecessary hospital days saved and more than $1.2 million in charges reduced during the two-year period.
Guardianship is a complex process that generates significant delays in appropriate care and increases in charges. The redesigned, standardized guardianship process, as defined in the clinical pathway, reduced associated medically unnecessary days of hospitalization.
当住院患者缺乏医疗决策能力且不愿回家由感兴趣的替代决策者照顾时，监护可能是必要的。以临床路径为中心的干预措施在达特茅斯-希区柯克医疗中心（DHMC；新罕布什尔州黎巴嫩）开展。由于监护发生在临床护理与政府官僚机构的交接点，质量改进工作集中在“院内”流程，同时采取行动改善临床团队与法律系统之间的沟通。
一个多学科质量改进团队绘制了DHMC的监护流程，并在创建临床路径之前分析了延误的原因。设计并实施了具体干预措施以解决已确定的改进领域。
在两年期间（2011年5月1日至2013年5月1日）的26名监护患者中，总费用约为400万美元，平均每位患者超过15万美元。他们住院时间中不必要的天数从平均27.8天降至11.3天，统计过程控制分析表明这是一个具有统计学意义的结果。最后13名患者缩短的住院时间共计节省了214.5个不必要的住院天数，并在两年期间减少了超过120万美元的费用。
监护是一个复杂的过程，会导致适当护理的显著延误和费用增加。临床路径中定义的重新设计的标准化监护流程减少了相关的不必要住院天数。
