Tanabe Paula, Freiermuth Caroline E, Cline David M, Silva Susan
Jt Comm J Qual Patient Saf. 2017 Mar;43(3):116-126. doi: 10.1016/j.jcjq.2016.12.005. Epub 2017 Jan 13.
Guidelines recommend rapid, aggressive management of vaso-occlusive crisis (VOC) for patients with sickle cell disease (SCD). A large prospective research and quality improvement (QI) project was conducted to measure changes in clinical outcomes in two EDs-academic medical centers with emergency medicine residency programs and Level 1 trauma centers-during a 2.5-year time period (October 2011-March 2014).
A QI team used a Plan-Do-Study-Act approach to modify and implement changes to opioid analgesic protocols for the emergency department (ED) treatment of VOC. Data were collected quarterly; the team reviewed the results and made modifications to improve outcomes. A structured health record review was conducted to assess clinical outcomes (10 records/quarter/site). Patient interviews were conducted to measure satisfaction with pain management. Outcomes were compared before (T1) and after (T2) implementation of an electronic health record (EHR).
One hundred ninety-six ED health records (118 unique patients, mean age = 32 [standard deviation, 11], 51% male) were analyzed. Before implementation, trends in decreasing time to initial analgesic administration were noted. There was a statistically significant increase in arrival to administration of first analgesic time between T1 and T2 at Site 1 but not at Site 2. Neither site showed significant changes in time between the administration of the first and second opioid doses, total opioid dose administered, or patient satisfaction.
While QI efforts initially shortened door-to-analgesic times, these gains were not sustained. The lessons learned can help other EDs improve the timely delivery of analgesics to patients with SCD.
指南建议对镰状细胞病(SCD)患者的血管闭塞性危机(VOC)进行快速、积极的管理。一项大型前瞻性研究和质量改进(QI)项目在2.5年时间内(2011年10月至2014年3月),对两家急诊科——设有急诊医学住院医师培训项目的学术医疗中心和一级创伤中心——的临床结局变化进行了测量。
一个QI团队采用计划-执行-研究-行动方法,对急诊科治疗VOC的阿片类镇痛药方案进行修改和实施。每季度收集数据;团队审查结果并进行修改以改善结局。进行结构化健康记录审查以评估临床结局(每个地点每季度10份记录)。进行患者访谈以测量对疼痛管理的满意度。在实施电子健康记录(EHR)之前(T1)和之后(T2)比较结局。
分析了196份急诊科健康记录(118名不同患者,平均年龄=32岁[标准差,11岁],51%为男性)。在实施之前,已注意到首次给予镇痛药时间减少的趋势。在地点1,T1和T2之间首次镇痛药给药时间从到达至给药有统计学显著增加,但在地点2没有。两个地点在首次和第二次阿片类药物给药时间、阿片类药物总给药剂量或患者满意度方面均未显示出显著变化。
虽然QI努力最初缩短了从就诊到给予镇痛药的时间,但这些进展并未持续。吸取的经验教训可帮助其他急诊科改善对SCD患者镇痛药的及时给药。