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2022年苏丹沙阿卜医院出院小结的质量:临床审计的第一个周期

The Quality of Discharge Summaries at Al-Shaab Hospital, Sudan, in 2022: The First Cycle of a Clinical Audit.

作者信息

Eissa Abdullatif Yasir H, Mohamed Elhassan Ahmed Zaki W, Ahmed Almothanna Zaki H, Elgadi Ammar, Manhal Gaffar Alemam A, Fadul Mohamed H, Ahmed Mohamed Ishag, Fadul Abdalla, Mekki Islah Ismail

机构信息

Faculty of Medicine, University of Khartoum, Khartoum, SDN.

Department of Internal Medicine, Hamad Medical Corporation, Doha, QAT.

出版信息

Cureus. 2023 Jul 10;15(7):e41620. doi: 10.7759/cureus.41620. eCollection 2023 Jul.

Abstract

Background The discharge summary is a vital component of the modern health system. It is defined as a synopsis of information regarding events occurring during the inpatient care of a patient, to allow for a safe, quick, and effective patient-centered discharge process. It contains important information about the patient's hospital stay, including the reason for admission, treatment received, and follow-up needed. Low-quality discharge summaries pose a great risk to patient healthcare since the most frequent reason for error in clinical settings is poor communication. In the United Kingdom, the Professional Record Standards Body (PRSB) has adopted the Academy of Medical Royal Colleges (AoMRC) "Standards for the Clinical Structure and Content of Patient Records" and produced a standard discharge summary form. This study aimed to assess the quality of discharge summaries at Al-Shaab Hospital in Sudan in terms of information, filling adequacy, and adherence to international guidelines and evaluate the discharge interviews. Methods A cross-sectional institution-based study was conducted in the period of September to December 2022 at Al-Shaab Teaching Hospital in Khartoum, Sudan. Systematic random sampling was used to select the study participants from the discharged patients. A total of 70 patients were met in their wards over a period of two months, and the contents of their discharge cards were compared to items on an online checklist based on the Professional Record Standards Body (PRSB) and the Academy of Medical Royal Colleges (AoMRC) standard discharge summary. The patients were also interviewed to assess their knowledge regarding their discharge information. Results The hospital's discharge summary form contained only four headings: date, patient name, age, and ID number. The assessed cards were found to be missing valuable information, including date of admission (missing in 83%), filling doctor's name (missing in 71%), and medication changes (missing in 70%). Only half of the summaries were clearly readable. The majority of patients had poor knowledge regarding their medication side effects (89%) and how to act in an emergency (86%), while knowledge of medication doses and follow-up details was good in 80% and 66%, respectively. Conclusion The patients are discharged with inadequately filled discharge forms. This may be due to the poor design of the form, so a newly designed form will be proposed, based on international standards. The discharge interview is also in need of improvement, to make sure patients are fully aware of their condition.

摘要

背景

出院小结是现代医疗系统的重要组成部分。它被定义为关于患者住院治疗期间所发生事件的信息概要,以实现安全、快速且以患者为中心的有效出院流程。它包含有关患者住院情况的重要信息,包括入院原因、接受的治疗以及所需的随访。低质量的出院小结对患者医疗保健构成巨大风险,因为临床环境中最常见的错误原因是沟通不畅。在英国,专业记录标准机构(PRSB)采用了皇家医学院(AoMRC)的“患者记录临床结构和内容标准”并制定了标准出院小结表格。本研究旨在从信息、填写完整性以及对国际指南的遵循情况方面评估苏丹沙阿卜医院出院小结的质量,并评估出院访谈情况。

方法

2022年9月至12月期间,在苏丹喀土穆的沙阿卜教学医院进行了一项基于机构的横断面研究。采用系统随机抽样从出院患者中选取研究参与者。在两个月的时间里,在病房共接触到70名患者,并将他们出院卡的内容与基于专业记录标准机构(PRSB)和皇家医学院(AoMRC)标准出院小结的在线检查表中的项目进行比较。还对患者进行了访谈,以评估他们对出院信息的了解情况。

结果

医院的出院小结表格仅包含四个标题

日期、患者姓名、年龄和身份证号码。经评估发现这些卡片缺少重要信息,包括入院日期(83%缺失)、填写医生姓名(71%缺失)以及用药变化(70%缺失)。只有一半的小结清晰可读。大多数患者对药物副作用(89%)以及如何应对紧急情况(86%)了解不足,而对药物剂量和随访细节的了解分别有80%和66%的患者情况良好。

结论

患者出院时出院表格填写不完整。这可能是由于表格设计不佳,因此将根据国际标准提出新设计的表格。出院访谈也需要改进,以确保患者充分了解自己的病情。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/1615/10410477/ff65a68fa42b/cureus-0015-00000041620-i01.jpg

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