Conroy Karena M, Elliott Doug, Burrell Anthony R
NSW Intensive Care Co-ordination and Monitoring Unit, Agency for Clinical Innovation, Chatswood, Australia,
Ann Intensive Care. 2015 Dec;5(1):60. doi: 10.1186/s13613-015-0060-1. Epub 2015 Aug 4.
To improve the delivery of important care processes in the ICU, morning ward round checklists have been implemented in a number of intensive care units (ICUs) internationally. Good quality evidence supporting their use as clinical support tools is lacking. With increased use of technology in clinical settings, integration of such tools into current work practices can be a challenge and requires evaluation. Having completed preliminary work revealing variations in practice and evidence supporting the construct validity of a process-of-care checklist, the need to develop, test and further validate an e(lectronic)-checklist in an ICU was identified.
A prospective, before-after study was conducted in a 19-bed general ICU within a tertiary hospital. Data collection occurred during baseline and intervention periods for 6 weeks each, with education and training conducted over a 4-week period prior to intervention. The e-checklist was used at baseline by ICU research nurses conducting post-ward round audits. During intervention, senior medical staff completed the e-checklist after patient assessments during the morning ward rounds, and research staff conducted post-ward round audits for validity testing (via concordance measurement). To examine changes in compliance over time, checklist-level data were analysed using generalised estimating equations that factored in confounding variables, and statistical process control charts were used to evaluate unit-level data. Established measures of concordance were used to evaluate e-checklist validity.
Compliance with each care component improved significantly over time; the largest improvement was for pain management (42% increase; adjusted odds ratio = 23, p < 0.001), followed by glucose management (22% increase, p < 0.001) and head-of-bed elevation (19% increase, p < 0.001), both with odds ratios greater than 10. Most detected omissions were corrected by the following day. Control charts illustrated reduced variability in care compliance over time. There was good concordance between physician and auditor e-checklist responses; seven out of nine cares had kappa values above 0.8.
Improvements in the delivery of essential daily care processes were evidenced after the introduction of an e-checklist to the morning ward rounds in an ICU. High levels of agreement between physician and independent audit responses lend support to the validity of the e-checklist.
为改善重症监护病房（ICU）重要护理流程的执行情况，国际上许多重症监护病房已实施晨间查房检查表。目前缺乏高质量证据支持将其用作临床支持工具。随着临床环境中技术使用的增加，将此类工具整合到当前工作实践中可能具有挑战性，需要进行评估。在完成初步工作，揭示了护理流程检查表的实践差异及支持其结构效度的证据后，确定了在ICU中开发、测试并进一步验证电子检查表的必要性。
在一家三级医院的19张床位的综合ICU中进行了一项前瞻性前后对照研究。在基线期和干预期各进行6周的数据收集，在干预前4周进行教育和培训。在基线期，ICU研究护士在晨间查房后使用电子检查表进行审核。在干预期，高级医务人员在晨间查房期间对患者进行评估后完成电子检查表，研究人员进行晨间查房后审核以进行效度测试（通过一致性测量）。为了检查随时间推移依从性的变化，使用考虑混杂变量的广义估计方程分析检查表级别的数据，并使用统计过程控制图评估科室级别的数据。使用既定的一致性测量方法评估电子检查表的效度。
随着时间的推移，每个护理环节的依从性都有显著提高；改善最大的是疼痛管理（提高42%；调整后的优势比=23，p<0.001），其次是血糖管理（提高22%，p<0.001）和床头抬高（提高19%，p<0.001），两者的优势比均大于10。大多数检测到的遗漏在第二天得到纠正。控制图显示随着时间的推移护理依从性的变异性降低。医生和审核员的电子检查表回复之间有良好的一致性；九项护理中有七项的kappa值高于0.8。
在ICU晨间查房中引入电子检查表后，有证据表明日常基本护理流程的执行情况有所改善。医生和独立审核回复之间的高度一致性支持了电子检查表的效度。
