Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
BMJ Open Qual. 2023 Oct;12(4). doi: 10.1136/bmjoq-2023-002327.
An institution-wide protocol for uncomplicated acute appendicitis was created to improve compliance with best practices between the emergency department (ED), radiology and surgery. Awareness of the protocol was spread with the publication of a smartphone application and communication to clinical leadership. On interim review of quality metrics, poor protocol adherence in diagnostic imaging and antimicrobial stewardship was observed. The authors hypothesised that two further simple interventions would result in more efficient radiographic diagnosis and antimicrobial administration.
Surgery residents received targeted in-person education on the appropriate antibiotic choices and diagnostic imaging in the protocol. Signs were placed in the emergency and radiology work areas, immediately adjacent to provider workstations highlighting the preferred imaging for patients with suspected appendicitis and the preferred antibiotic choices for those with proven appendicitis. Protocol adherence was compared before and after each intervention.
Targeted education was associated with improved antibiotic stewardship within the surgical department from 30% to 91% protocol adherence before/after intervention (p<0.005). Visible signs in the ED were associated with expedited antimicrobial administration from 50% to 90% of patients receiving antibiotics in the ED prior to being brought to the operating room before/after intervention (p<0.005). Diagnostic imaging after the placement of signs showed improved protocol adherence from 35% to 75% (p<0.005).
This study demonstrates that smartphone-based applications and communication among clinical leadership achieved suboptimal adherence to an institutional protocol. Targeted in-person education reinforcement and visible signage immediately adjacent to provider workstations were associated with significantly increased adherence. This type of initiative can be used in other aspects of acute care general surgery to further improve quality of care and hospital efficiency.
为了提高急诊科、放射科和外科之间遵循最佳实践的一致性，创建了一项针对单纯性急性阑尾炎的全院性方案。通过发布智能手机应用程序和向临床领导层传达，提高了对该方案的认识。在对质量指标进行中期审查时，发现诊断影像学和抗菌药物管理方面存在较差的方案依从性。作者假设，再进行两项简单的干预，将导致更有效的放射学诊断和抗菌药物管理。
对外科住院医师进行了有关方案中适当抗生素选择和诊断影像学的针对性面对面教育。在急诊室和放射科工作区域，在紧邻医生工作站的地方放置了标识，突出显示了疑似阑尾炎患者的首选影像学检查方法和确诊阑尾炎患者的首选抗生素选择。在每次干预前后比较方案的依从性。
针对性教育与外科部门抗生素管理的改善相关，干预前后抗生素管理的方案依从性从 30%提高到 91%（p<0.005）。在急诊室显眼的标识与在将患者带到手术室之前在急诊室接受抗生素治疗的患者中，从 50%提高到 90%的抗菌药物管理相关（p<0.005）。放置标识后的诊断影像学显示方案依从性从 35%提高到 75%（p<0.005）。
本研究表明，基于智能手机的应用程序和临床领导层之间的沟通对机构方案的依从性并不理想。针对性的面对面教育强化和紧邻医生工作站的显眼标识与显著增加的依从性相关。这种类型的倡议可用于急性普通外科的其他方面，以进一步提高护理质量和医院效率。
