Reschen Michael Edward, Vaux Emma
Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital, Reading, UK.
BMJ Open Qual. 2017 Oct 9;6(2):e000022. doi: 10.1136/bmjoq-2017-000022. eCollection 2017.
Acute kidney injury (AKI) is common in hospitalised patients, often mandates changes to regular medications and can be unresolved at hospital discharge. General practitioners (GPs) require apposite AKI-related information in electronic discharge letters (EDLs). In 2015 NHS England introduced a care quality standard that all EDLs should include four items of information for patients with AKI. We performed a 12-month quality improvement project (QIP) aimed at achieving above 90% compliance with the quality standard.
Hospital-wide episodes of AKI were detected using the nationally approved electronic AKI alerts system. 25 patient AKI episodes were audited per month for 12 months using the electronic patient record. The target compliance rate was staggered at 35%, 65% and 90% for each subsequent 3-month block. Baseline compliance was 22%. Measures taken to improve compliance included email information, grand rounds, ward-level meetings, computer screensavers, nurse support, clinical governance meetings, and face-to-face rapid education. Annotation of AKI within the computer EDL system was progressively enhanced such that in the final quarter the presence of an AKI-alert mandated the user to complete the AKI annotation before the EDL could be signed off.
The completion rate improved to 37% in the second quarter, 51% in the third quarter and 92% in the fourth quarter. This change has been sustained in the 14 months since.
By the end of the study, omissions relating to AKI information were reduced from 78% to less than 10%, indicating our QIP was highly effective-meeting the quality standard. The single most important factor in improving documentation was to mandate user review of AKI aftercare in patients with electronic AKI alerts. Our study encompassed hospital-wide inpatients, and our results could be replicated at other acute hospitals that have implemented an EDL system connected to an AKI alert system.
急性肾损伤（AKI）在住院患者中很常见，常常需要调整常规用药，且在出院时可能尚未解决。全科医生（GP）需要在电子出院小结（EDL）中获取恰当的与AKI相关的信息。2015年，英国国民医疗服务体系（NHS）英格兰地区引入了一项护理质量标准，即所有EDL都应包含针对AKI患者的四项信息。我们开展了一项为期12个月的质量改进项目（QIP），旨在使符合质量标准的比例达到90%以上。
使用国家批准的电子AKI警报系统在全院范围内检测AKI病例。连续12个月，每月通过电子病历审核25例患者的AKI病例。随后的每个3个月时间段的目标合规率分别设定为35%、65%和90%。基线合规率为22%。为提高合规率采取的措施包括电子邮件通知、全院大查房、病房级会议、电脑屏保、护士支持、临床治理会议以及面对面快速教育。计算机EDL系统中对AKI的标注逐步强化，以至于在最后一个季度，出现AKI警报时要求用户在签署EDL之前完成AKI标注。
第二季度完成率提高到37%，第三季度为51%，第四季度为92%。此后的14个月里这一变化一直持续。
到研究结束时，与AKI信息相关的遗漏从78%降至不到10%，表明我们的QIP非常有效——达到了质量标准。改进记录的最重要单一因素是要求用户在电子AKI警报提示下对AKI患者的后续护理进行审核。我们的研究涵盖了全院住院患者，我们的结果可以在其他已实施与AKI警报系统相连的EDL系统的急性医院中复制。
