Dexter Eloise, Walshaw Josephine, Brown Ayla, Nadeem Tehmina, Yiasemidou Marina, Lo Terence
Department of General Surgery, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom.
Department of Health Sciences, Faculty of Sciences, University of York, York, United Kingdom.
Front Surg. 2023 Oct 6;10:1263502. doi: 10.3389/fsurg.2023.1263502. eCollection 2023.
Effective documentation and transfer of clinical information are vital for the continuity of care, patient safety, and maintaining medico-legal records, as outlined by the Royal College of Surgeons "Safe Handover: Guidance from the Working Time Directive working party". Our elective surgery weekend team cross-covers both Colorectal and Upper Gastrointestinal surgical specialties across multiple wards, which poses a significant challenge. The aim of this study was to improve the documentation of patients' weekend plans through the introduction of a weekend handover proforma.
We reviewed the weekend plans of 199 patients overall. 41 records were initially reviewed over a 2-week period. The surgical multidisciplinary team was then surveyed to establish the need for an improved weekend handover. Following this, a weekend handover proforma was introduced as part of the Friday ward round and education on the expectations were provided at a local Surgery Clinical Governance meeting. The documentation of the weekend plan was reviewed for 158 patients over a 6-week period and a post-intervention survey was disseminated.
The preliminary survey highlighted concerns for delayed discharges and patient safety over the weekend, with 88.2% of respondents agreeing a weekend handover proforma would be beneficial. The initial data confirmed inadequate documentation of diagnosis (19.5%), operation/procedure (28.1%), and weekend plans for blood tests (19.5%), discharge planning (2.4%), diet (46.3%), antibiotics (19.5%), intravenous (IV) fluids (22.0%), mobility (19.5%) and drain/wound care (37.5%). After education and implementing a weekend handover proforma, these results increased for documentation of diagnosis (61.2%), operation/procedure (83.2%), blood tests (59.7%), and discharge planning (85.8%). However, there was little improvement in diet (53.0%) and no improvement in the weekend plans for antibiotics (14.2%), IV fluids (17.2%), mobility (14.9%) and drain/wound care (20.2%). The post-intervention survey showed an improvement across all areas, notably continuity of care and patient safety, with 95.5% of individuals finding the weekend handover proforma aided in patient care over the weekend.
Education of the ward team and implementation of a weekend handover proforma resulted in a marked improvement in the documentation of patients' weekend plans, which is essential to ensure the continuation of safe and effective patient care.
如皇家外科医学院《安全交接：工作时间指令工作小组指南》所述，有效的临床信息记录与传递对于医疗护理的连续性、患者安全以及维护医疗法律记录至关重要。我们的择期手术周末团队负责多个病房的结直肠和上消化道外科专科交叉覆盖工作，这带来了巨大挑战。本研究的目的是通过引入周末交接表格来改善患者周末计划的记录。
我们总共审查了199名患者的周末计划。在两周内初步审查了41份记录。随后对手术多学科团队进行了调查，以确定是否需要改进周末交接。在此之后，引入了周末交接表格作为周五病房查房的一部分，并在当地外科临床治理会议上提供了关于期望内容的培训。在六周内对158名患者的周末计划记录进行了审查，并开展了干预后调查。
初步调查突出了对周末延迟出院和患者安全的担忧，88.2%的受访者认为周末交接表格会有所帮助。初始数据证实，诊断（19.5%）、手术/操作（28.1%）以及血液检查（19.5%）、出院计划（2.4%）、饮食（46.3%）、抗生素（19.5%）、静脉输液（22.0%）、活动能力（19.5%）和引流/伤口护理（37.5%）的周末计划记录不充分。经过培训并实施周末交接表格后，诊断（61.2%）、手术/操作（83.2%）、血液检查（59.7%）和出院计划（85.8%）的记录情况有所改善。然而，饮食方面改善不大（53.0%），抗生素（14.2%））、静脉输液（17.2%）、活动能力（14.9%）和引流/伤口护理（20.2%）的周末计划没有改善。干预后调查显示所有领域都有改善，尤其是医疗护理的连续性和患者安全，95.5%的人认为周末交接表格有助于周末的患者护理。
对病房团队的培训以及周末交接表格的实施，使患者周末计划的记录有了显著改善，这对于确保安全有效的患者护理的持续进行至关重要。
