Parsons Leigh Jeanna, Brown Kyla, Buchner Denise, Stelfox Henry T
Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada Alberta Health Services, Calgary, Alberta, Canada.
W21C Research and Innovation Centre, Institute of Public Health, University of Calgary, Calgary, Alberta, Canada.
BMJ Open. 2016 Jul 8;6(7):e012200. doi: 10.1136/bmjopen-2016-012200.
Effective communication during hospital transitions of patient care is fundamental to ensuring patient safety and continuity of quality care. This study will describe text-based communication included in patient medical records before, during and after patient transfer from the intensive care unit (ICU) to a hospital ward (n=10 days) by documenting (1) the structure and focus of physician progress notes within and between medical specialties, (2) the organisation of subjective and objective information, including the location and accessibility of patient data and whether/how this changes during the hospital stay and (3) missing, illegible and erroneous information.
This study is part of a larger mixed methods prospective observational study of ICU to hospital ward transfer practices in 10 ICUs across Canada. Medical records will be collected and photocopied for each consenting patient for a period of up to 10 consecutive days, including the final 2 days in the ICU, the day of transfer and the first 7 days on the ward (n=10 days). Textual analysis of medical record data will be completed by 2 independent reviewers to describe communication between stakeholders involved in ICU transfer.
Research ethics board approval has been obtained at all study sites, including the coordinating study centre (which covers 4 Calgary-based sites; UofC REB 13-0021) and 6 additional study sites (UofA Pro00050646; UBC PHC Hi4-01667; Sunnybrook 336-2014; QCH 20140345-01H; Sherbrooke 14-172; Laval 2015-2171). Findings from this study will inform the development of an evidence-based tool that will be used to systematically analyse the series of notes in a patient's medical record.
在患者医疗护理的医院转接过程中，有效的沟通对于确保患者安全和优质护理的连续性至关重要。本研究将通过记录以下内容，描述患者从重症监护病房（ICU）转至医院病房期间（n = 10天）及前后患者病历中基于文本的沟通情况：（1）不同医学专科内部及之间医生病程记录的结构和重点；（2）主观和客观信息的组织方式，包括患者数据的位置和可获取性，以及在住院期间这是否/如何发生变化；（3）缺失、难以辨认和错误的信息。
本研究是一项更大规模的混合方法前瞻性观察性研究的一部分，该研究涉及加拿大10个ICU的ICU至医院病房转接实践。将为每位同意参与的患者收集并复印病历，为期最多连续10天，包括在ICU的最后2天、转科当天及在病房的前7天（n = 10天）。两名独立评审员将完成病历数据的文本分析，以描述参与ICU转接的利益相关者之间的沟通情况。
所有研究地点均已获得研究伦理委员会的批准，包括协调研究中心（涵盖卡尔加里的4个地点；卡尔加里大学研究伦理委员会13 - 0021）以及另外6个研究地点（阿尔伯塔大学Pro00050646；英属哥伦比亚大学PHC Hi4 - 01667；桑尼布鲁克336 - 2014；魁北克市综合医院20140345 - 01H；舍布鲁克14 - 172；拉瓦尔2015 - 2171）。本研究的结果将为开发一种基于证据的工具提供信息，该工具将用于系统分析患者病历中的一系列记录。
