在急诊普通外科人群中实施三级调查：模仿是最诚挚的奉承。
Implementing a tertiary survey in the emergency general surgery population: Imitation is the sincerest form of flattery.
机构信息
University of Maryland, R Adams Cowley Shock Trauma Center, Division of Acute Care Surgery, 22 South Greene St, Baltimore, MD, 21201, USA.
University of Maryland, R Adams Cowley Shock Trauma Center, Division of Acute Care Surgery, 22 South Greene St, Baltimore, MD, 21201, USA; Department of Head and Neck Surgical Oncology, Baptist MD Anderson Cancer Center, 1301 Palm Avenue, Jacksonville, FL, 32207, USA.
出版信息
Am J Surg. 2022 Jul;224(1 Pt A):85-89. doi: 10.1016/j.amjsurg.2022.02.047. Epub 2022 Feb 17.
OBJECTIVES
The inherent complexity of the Emergency General Surgery (EGS) patient may preclude precise documentation at admission. To obviate lapses in documentation, an EGS tertiary survey (EGS-TS) was developed to enable early recognition of relevant omissions in documentation and clinical findings. We theorized that the creation of the EGS-TS would promote more thorough clinical documentation.
METHODS
A prospective observational study was performed utilizing an EGS-TS from February 2019 through May 2019. The EGS-TS included physical exam, medication reconciliation, analysis of documentation for accuracy, and review of diagnostic imaging for incidental findings.
RESULTS
There were 139 EGS admissions during the study period and 108 (78%) received an EGS-TS. Of those who received the EGS-TS, incorrect medication reconciliations (72%), incidental findings (12%), undocumented wounds (11%), and undocumented indwelling catheters were identified (6%).
CONCLUSION
Implementation of an EGS-TS triggers a detailed evaluation and reveals opportunities for education, improved adherence to documentation standards, and further research that may guide quality improvement initiatives.
目的
急诊普通外科（EGS）患者的固有复杂性可能导致入院时无法进行精确记录。为了避免记录中的疏漏，我们开发了 EGS 三级调查（EGS-TS），以尽早发现记录和临床发现中遗漏的相关内容。我们推测 EGS-TS 的创建将促进更全面的临床记录。
方法
利用 2019 年 2 月至 2019 年 5 月期间的 EGS-TS 进行了一项前瞻性观察研究。EGS-TS 包括体格检查、药物重整、记录准确性分析以及对偶然发现的诊断性影像学检查进行审查。
结果
研究期间共有 139 例 EGS 入院，其中 108 例（78%）接受了 EGS-TS。在接受 EGS-TS 的患者中，发现了错误的药物重整（72%）、偶然发现（12%）、未记录的伤口（11%）和未记录的留置导管（6%）。
结论
实施 EGS-TS 会触发详细的评估，并为教育、提高对记录标准的依从性以及可能指导质量改进计划的进一步研究提供机会。
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