以患者为中心的出院小结以支持安全性和个体健康素养：奥地利的一项双盲随机对照试验。

Patient-centered discharge summaries to support safety and individual health literacy: a double-blind randomized controlled trial in Austria.

机构信息

Research Unit for Safety and Sustainability in Healthcare, c/o, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery , Medical University of Graz, Graz, Austria.

Executive Department for Quality and Risk Management, University Hospital of Graz, Auenbruggerplatz 1/3, Graz, EG, A-8036, Austria.

出版信息

BMC Health Serv Res. 2024 Jul 9;24(1):789. doi: 10.1186/s12913-024-11183-w.

DOI:10.1186/s12913-024-11183-w

PMID:38982360

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC11234775/

Abstract

BACKGROUND

To ensure a safe patient discharge from hospital it is necessary to transfer all relevant information in a discharge summary (DS). The aim of this study was to evaluate a bundle of measures to improve the DS for physicians, nurses and patients.

METHODS

In a double-blind, randomized, controlled trial, four different versions of DS (2 original, 2 revised) were tested with physicians, nurses and patients. We used an evaluation sheet (Case report form, CRF) with a 6-point Likert scale (1 = completely agree; 6 = strongly disagree).

RESULTS

In total, 441 participants (physicians n = 146, nurses n = 140, patients n = 155) were included in the study. Overall, the two revised DS received significant better ratings than the original DS (original 2.8 ± 0.8 vs. revised 2.1 ± 0.9, p < 0.001). Detailed results for the main domains are structured DS (original 1.9 ± 0.9 vs. revised 2.2 ± 1.3, p = 0.015), content (original 2.7 ± 0.9 vs revised 2.0 ± 0.9, p < 0.001) and comprehensibility (original 3.8 ± 1.2vs. revised 2.3 ± 1.2, p < 0.001).

CONCLUSION

With simple measures like avoiding abbreviations and describing indications or therapies with fixed contents, the DS can be significantly improved for physicians, nurses and patients at the same time.

TRIAL REGISTRATION

First registration 13/11/2020 NCT04628728 at www.

CLINICALTRIALS

gov , Update 15/03/2023.

摘要

背景

为确保患者安全出院，有必要在出院小结（DS）中传递所有相关信息。本研究的目的是评估一整套措施，以改善医生、护士和患者的 DS。

方法

在一项双盲、随机、对照试验中，使用 6 点 Likert 量表（1=完全同意；6=强烈不同意）对医生、护士和患者测试了 4 种不同版本的 DS（2 种原始版本、2 种修订版本）。

结果

共有 441 名参与者（医生 n=146，护士 n=140，患者 n=155）参与了研究。总体而言，两个修订后的 DS 得到了明显更高的评分，而原始 DS 的评分较低（原始 DS 2.8±0.8 与修订后 DS 2.1±0.9，p<0.001）。主要领域的详细结果为结构化 DS（原始 DS 1.9±0.9 与修订后 DS 2.2±1.3，p=0.015）、内容（原始 DS 2.7±0.9 与修订后 DS 2.0±0.9，p<0.001）和易理解性（原始 DS 3.8±1.2 与修订后 DS 2.3±1.2，p<0.001）。