Yu Zhuowen, Zhang Yuxia, Gu Ying, Xu Xiaofeng, McArthur Alexa
1Gastroenterology Department, Children's Hospital of Fudan University, Shanghai China 2Fudan University Centre for Evidence-based Nursing: a Joanna Briggs Institute Center of Excellence, Fudan University, Shanghai, China 3Nursing Department, Children's Hospital of Fudan University, Shanghai, China 4The Joanna Briggs Institute, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.
JBI Database System Rev Implement Rep. 2017 Oct;15(10):2585-2596. doi: 10.11124/JBISRIR-2016-003296.
Communication of information between and among healthcare providers is an essential element of patient care. Poor clinical handover has been associated with inaccurate clinical assessment and diagnosis, delays in diagnosis, medication errors and decreased patient satisfaction. Effective and efficient transition of patient care information requires an evidence-based handover approach.
The aim of this evidence implementation project was to make a contribution to promote evidence-based practice in clinical handover in a pediatric setting and thereby enhance patient safety and service delivery.
Seven criteria identified by the Joanna Briggs Institute were used to conduct an audit in the Gastroenterology Department, Children's Hospital of Fudan University, Shanghai, People's Republic of China. Twelve nurses and 260 handover sessions were involved. The JBI Practical Application of Clinical Evidence System and Getting Research into Practice audit tools for promoting change in health practice were used to ascertain compliance with the criteria before and after the implementation of best practice. The program included three phases and was conducted over six months.
There were improvements with compliance for each criterion. Face-to-face communication, standardized documentation, identification of patients, care plan handover and transfer of responsibility reached 100% compliance. Detailed observations of the patient improved from 93% to 98%, and there was an 18% improvement for relevant history handover.
This project has demonstrated that handover sessions can be more effective by translating evidence into practice through ongoing evidence-based audit. Nursing inter-shift handover requires the use of a highly valuable and important standardized tool. Further audits will need to be carried out in order to maintain the practice change, and ensure the sustainability of the project.
医疗服务提供者之间的信息交流是患者护理的重要组成部分。临床交接不当与临床评估和诊断不准确、诊断延误、用药错误以及患者满意度降低有关。有效且高效地传递患者护理信息需要采用循证交接方法。
本循证实施项目旨在为促进儿科临床交接中的循证实践做出贡献，从而提高患者安全和服务质量。
采用乔安娜·布里格斯研究所确定的七项标准，对中华人民共和国上海市复旦大学附属儿科医院消化内科进行审核。共有12名护士参与，涉及260次交接过程。运用乔安娜·布里格斯研究所临床证据系统实用应用工具和促进卫生实践变革的将研究转化为实践审核工具，以确定在实施最佳实践前后对标准的遵守情况。该项目包括三个阶段，为期六个月。
各项标准的合规性均有所提高。面对面沟通、标准化文件记录、患者识别、护理计划交接和责任移交的合规率达到100%。对患者的详细观察从93%提高到98%，相关病史交接提高了18%。
该项目表明，通过持续的循证审核将证据转化为实践，交接过程可以更有效。护理班次间的交接需要使用非常有价值且重要的标准化工具。为维持实践变革并确保项目的可持续性，需要进一步开展审核。
