Boyle Mark, Pons Aina, Alshammari Abdullah, Kaniu Daniel, Athanasios Asonitis, Bashir Mohamed Ryan, Alvarez Gallesio Jose, Chavan Hemangi, Buderi Silviu
Department of Surgery and Cancer, Imperial College London, London, GBR.
Department of Thoracic Surgery, Royal Brompton Hospital, London, GBR.
Cureus. 2023 Aug 1;15(8):e42784. doi: 10.7759/cureus.42784. eCollection 2023 Aug.
Introduction Ward rounds are vital clinical processes that facilitate an opportunity for daily review and management of thoracic surgery inpatients. The aim of this study was to compare thoracic surgery ward round documentation against locally agreed standards and design a template to improve the detail and uniformity of this process to enhance patient care. Materials and methods Data for this audit was collected retrospectively and prospectively. Data was collected during three auditing periods and managed on Microsoft Excel. Descriptive statistics were used for its analysis. Chi-square and Fisher's Exact tests were used to test for differences in reporting rates. Results and discussion Initially, a total of 199 ward round notes were reviewed. Imaging results (19%) and discharge planning (23%) were not reported. eCARE (electronic Clinical Assessment for Round Evaluation) was developed to ensure that all aspects of patient evaluation recommended by the guidelines were included. Reporting rates significantly improved after such changes. We analysed the effect of the new ward round note on discharge planning (23.3 vs 41%, p<0.001), complication rates (32.6 vs 21.9%, p=0.03), post-surgical length of stay (LOS) (7.0 vs 5.0, p<0.001). Conclusion Over a year, we audited the Thoracic Surgery Department's ward round documentation against locally agreed standards in line with national recommendations. Several important items were not regularly reported. Using closed-ended questions improved reporting rates, and patient care was optimised. Further research should explore the impact of this new documentation method on patient care and postoperative outcomes in our Trust as well as other cardiothoracic centres.
引言 查房是至关重要的临床流程，为胸外科住院患者的日常评估和管理提供了契机。本研究的目的是将胸外科查房记录与当地商定的标准进行比较，并设计一个模板，以提高该流程的详细程度和一致性，从而加强患者护理。材料与方法 本审计的数据通过回顾性和前瞻性方式收集。在三个审计期间收集数据，并在Microsoft Excel上进行管理。使用描述性统计进行分析。采用卡方检验和费舍尔精确检验来检验报告率的差异。结果与讨论 最初，共审查了199份查房记录。影像学结果（19%）和出院计划（23%）未被报告。开发了eCARE（电子查房评估临床评估）以确保指南推荐的患者评估的所有方面都被纳入。做出这些改变后，报告率显著提高。我们分析了新的查房记录对出院计划（23.3%对41%，p<0.001）、并发症发生率（32.6%对21.9%，p=0.03）、术后住院时间（LOS）（7.0对5.0，p<0.001）的影响。结论 在一年多的时间里，我们根据国家建议，对照当地商定的标准对胸外科的查房记录进行了审计。几个重要项目没有定期报告。使用封闭式问题提高了报告率，并优化了患者护理。进一步的研究应探讨这种新的记录方法对我们信托机构以及其他心胸中心的患者护理和术后结果的影响。
