从纸质到无纸化：电子系统是否能确保 DNACPR 决策的安全有效沟通和记录？
From paper to paperless: Do electronic systems ensure safe and effective communication and documentation of DNACPR decisions?
机构信息
University College London Hospitals NHS Foundation Trust, London, UK
University Hospital Lewisham, London, UK.
出版信息
Clin Med (Lond). 2020 May;20(3):329-333. doi: 10.7861/clinmed.2019-0450.
INTRODUCTION
An electronic resuscitation system, implemented in 2015, within electronic patient records (EPR) at King's College Hospital NHS Foundation Trust was studied, aiming to review and improve decision documentation and communication.
METHOD
The study (January 2018 - June 2018) included all gerontology inpatients with electronic do not attempt cardiopulmonary resuscitation (e-DNACPR) decisions. Cases were identified weekly, followed by retrospective analysis of discharges. Amendments to the electronic system and improvements were implemented between cycles. CYCLE 1: One-hundred and thirty-three patients were included; 85% had an e-DNACPR form; 86% of all forms had senior doctor involvement; 68% evidenced patient/relative discussion; 13% documented multidisciplinary team (MDT) discussion.
INTERVENTIONS
A mandatory 'named nurse' field was added to the form and trust-wide education programme implemented. CYCLE 2: One-hundred and twenty-six patients were included; 100% had an e-DNACPR form; 93% evidenced senior doctor involvement; 71% evidenced patient/relative discussion; 57% documented MDT discussion.
CONCLUSION
Changes to the process and trust-wide education resulted in more robust documentation and communication.
简介
本研究旨在回顾和改进决策文件记录和沟通，调查了 2015 年在国王学院医院 NHS 基金会信托基金的电子病历（EPR）中实施的电子复苏系统。
方法
该研究（2018 年 1 月至 2018 年 6 月）纳入了所有老年科有电子不尝试心肺复苏术（e-DNACPR）决策的住院患者。每周识别病例，然后对出院病例进行回顾性分析。在各周期之间实施了电子系统的修改和改进。周期 1：纳入了 133 例患者；85%的患者有 e-DNACPR 表格；所有表格中 86%有高级医生参与；68%有患者/家属讨论的证据；13%有记录多学科团队（MDT）讨论。
干预措施
在表格中添加了强制性的“指定护士”字段，并实施了全信托范围的教育计划。周期 2：纳入了 126 例患者；100%的患者有 e-DNACPR 表格；93%有高级医生参与；71%有患者/家属讨论的证据；57%有记录 MDT 讨论。
结论
流程的改变和全信托范围的教育导致了更有力的文件记录和沟通。
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