Harl Felicity N R, Saucke Megan C, Greenberg Caprice C, Ingraham Angela M
Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
J Surg Res. 2017 Jun 15;214:86-92. doi: 10.1016/j.jss.2017.02.069. Epub 2017 Mar 6.
Poor communication causes fragmented care. Studies of transitions of care within a hospital and on discharge suggest significant communication deficits. Communication during transfers between hospitals has not been well studied. We assessed the written communication provided during interhospital transfers of emergency general surgery patients. We hypothesized that patients are transferred with incomplete documentation from referring facilities.
We performed a retrospective review of written communication provided during interhospital transfers to our emergency department (ED) from referring EDs for emergency general surgical evaluation between January 1, 2014 and January 1, 2016. Elements of written communication were abstracted from referring facility documents scanned into the medical record using a standardized abstraction protocol. Descriptive statistics summarized the information communicated.
A total of 129 patients met inclusion criteria. 87.6% (n = 113) of charts contained referring hospital documents. 42.5% (n = 48) were missing history and physicals. Diagnoses were missing in 9.7% (n = 11). Ninety-one computed tomography scans were performed; among 70 with reads, final reads were absent for 70.0% (n = 49). 45 ultrasounds and x-rays were performed; among 27 with reads, final reads were missing for 80.0% (n = 36). Reasons for transfer were missing in 18.6% (n = 21). Referring hospital physicians outside the ED were consulted in 32.7% (n = 37); consultants' notes were absent in 89.2% (n = 33). In 12.4% (n = 14), referring documents arrived after the patient's ED arrival and were not part of the original documentation provided.
This study documents that information important to patient care is often missing in the written communication provided during interhospital transfers. This gap affords a foundation for standardizing provider communication during interhospital transfers.
沟通不畅会导致医疗服务碎片化。对医院内部及出院时的医疗交接研究表明存在显著的沟通缺陷。医院之间转诊过程中的沟通尚未得到充分研究。我们评估了急诊普通外科患者在院间转诊时提供的书面沟通情况。我们假设患者从转诊机构转出时文件记录不完整。
我们对2014年1月1日至2016年1月1日期间从转诊急诊科转至我院急诊科进行急诊普通外科评估的院间转诊过程中提供的书面沟通进行了回顾性研究。使用标准化的提取方案从扫描到病历中的转诊机构文件中提取书面沟通的要素。描述性统计总结了所传达的信息。
共有129例患者符合纳入标准。87.6%（n = 113）的病历包含转诊医院文件。42.5%（n = 48）的病历缺少病史和体格检查记录。9.7%（n = 11）的病历缺少诊断信息。共进行了91次计算机断层扫描；在70份有报告的扫描中，70.0%（n = 49）没有最终报告。进行了45次超声和X线检查；在27份有报告的检查中，80.0%（n = 36）没有最终报告。18.6%（n = 21）的病历缺少转诊原因。32.7%（n = 37）的病例咨询了急诊科以外的转诊医院医生；89.2%（n = 33）没有会诊医生的记录。12.4%（n = 14）的病例中，转诊文件在患者到达急诊科后才到达，不属于最初提供的文件记录一部分。
本研究表明，院间转诊时提供的书面沟通中往往缺少对患者护理至关重要的信息。这一差距为规范院间转诊时医护人员的沟通提供了基础。
