Pediatrics, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
BMJ Open Qual. 2020 Dec;9(4). doi: 10.1136/bmjoq-2020-001020.
Inadequate handover communication is responsible for many adverse events during the transfer of care, which can be attributed to many factors, including incomplete documentation or lack of standardised documentation process. The quality improvement project aimed to standardise the handover documentation process during patient transfer from paediatric intensive care unit (PICU) to the general paediatric ward.
Data analysis revealed lack of proper handover documentation with the omission of vital information when transferring patients from PICU to general ward. The quality improvement team assessed the current handover documentation practice using a brainstorming technique during multiple meetings. The team evaluated the process for possible causes of incomplete handover documentation, framed the existing challenges, and proposed improvement interventions, including a standardised handover form and conducting education sessions for the new proposed process. The main quality measures included physician's compliance with handover documentation elements, physician's satisfaction and PICU emergency readmission rate within 48 hours.
Physician compliance to handover documentation improved from 29.5% to 95.5% before and after implanting the improvement interventions, respectively. The level of physician satisfaction with the quality of communicated information during the handover process improved from 47.5% to 84%, and the PICU emergency readmission rate declined from 3.8% to zero after all improvement interventions were implanted.
Implementation of standardised handover form is essential to improve physician compliance for clear handover documentation and to avoid data omission during the patient transfer process. Documented handover in patient's medical record has positive impact on physician satisfaction when managing patients recently discharged from PICU.
由于交接过程中的沟通不足，导致许多不良事件发生，这可以归因于许多因素，包括文档不完整或缺乏标准化的文档流程。质量改进项目旨在标准化儿科重症监护病房（PICU）向普通儿科病房转移患者时的交接文档流程。
数据分析显示，在将患者从 PICU 转移到普通病房时，交接文档中存在重要信息缺失，说明交接文档流程存在问题。质量改进团队在多次会议上使用头脑风暴技术评估当前的交接文档实践。团队评估了交接文档流程可能出现的不完整情况，确定了现有的挑战，并提出了改进措施，包括标准化交接表和为新流程提供教育课程。主要质量指标包括医生对接班文档元素的遵守情况、医生的满意度和 PICU 在 48 小时内的急诊再入院率。
在实施改进措施前后，医生对接班文档的遵守情况分别从 29.5%提高到 95.5%。医生对交接过程中沟通信息质量的满意度从 47.5%提高到 84%，在实施所有改进措施后，PICU 的急诊再入院率从 3.8%下降到 0。
实施标准化交接表对于提高医生对接班文档的遵守情况和避免患者转移过程中的数据缺失至关重要。在管理最近从 PICU 出院的患者时，记录在患者病历中的交接文档对医生的满意度有积极影响。
