McKee Christopher, Brines Conor, O'Brien Scarlett, Espey Robert, Acton Danny
Trauma and Orthopaedics, Altnagelvin Area Hospital, Londonderry, GBR.
Orthopaedic Surgery, Belfast Health and Social Care Trust, Belfast, GBR.
Cureus. 2023 Jul 22;15(7):e42295. doi: 10.7759/cureus.42295. eCollection 2023 Jul.
Accurate medical documentation is important in the perioperative period, ensuring the safe transfer of information between teams involved in the surgical patient's care. This has been highlighted by multiple standards of care guidelines within the United Kingdom. The use of standardized pre-templated documents has displayed significant success in minimizing errors during the admission and operative stages. The aim of this study is to evaluate whether a similar proforma for the post-operative stage is successful in orthopedic patients.
A retrospective review of 25 consecutive orthopedic elective patients was conducted during the first cycle. Exclusion criteria included patients who were under 16, day case procedures, and admission due to trauma. The second cycle consisted of a prospective review of 25 patients a month following the implementation of the new proforma. Both cycles were scored against 10 inclusion parameters as outlined by national guidelines.
Implementation of the proforma resulted in a significant improvement in post-operative note compliance. A total of six parameters showed a statistically significant improvement (p<0.05). This included wound assessment (58.3%-100%, p<0.001), post-operative imaging (37.5%-92%, p<0.001), neurovascular assessment (83.3%-100%, p=0.017), National Early Warning Score (25.0%-100%, p<0.001), venous thromboembolism prophylaxis (29.2%-96.0%, p<0.001), and antibiotic administration (4.2%-84.0%, p<0.001).
Monitoring of important clinical parameters significantly improved following the implementation of the post-operative proforma. These results will hopefully cause the introduction of other proformas in other surgical specialties and other units.
准确的医疗记录在围手术期至关重要，可确保参与手术患者护理的各团队之间信息的安全传递。这一点在英国的多项护理标准指南中已得到强调。使用标准化的预模板文件在减少入院和手术阶段的错误方面已显示出显著成效。本研究的目的是评估类似的术后阶段模板在骨科患者中是否成功。
在第一个周期对25例连续的骨科择期手术患者进行回顾性研究。排除标准包括16岁以下患者、日间手术以及因创伤入院的患者。第二个周期包括在新模板实施后每月对25例患者进行前瞻性研究。两个周期均根据国家指南列出的10项纳入参数进行评分。
模板的实施使术后记录的合规性有了显著改善。共有6项参数显示出统计学上的显著改善（p<0.05）。这包括伤口评估（58.3%-100%，p<0.001）、术后影像学检查（37.5%-92%，p<0.001）、神经血管评估（83.3%-100%，p=0.017）、国家早期预警评分（25.0%-100%，p<0.001）、静脉血栓栓塞预防（29.2%-96.0%，p<0.001）以及抗生素使用（4.2%-84.0%，p<0.001）。
术后模板实施后，重要临床参数的监测有了显著改善。这些结果有望促使在其他外科专科和其他科室引入其他模板。
