遵循循证指南及设计导尿管电子文档时的注意事项
Adherence to Evidence-Based Guidelines and Implications When Designing Electronic Documentation for Urinary Catheters.
作者信息
Janine Bothe, Sheena Lagat, Crellin Rebecca, Hahn Kelly-Ann, Vicki Patton
机构信息
Department of Surgery, St George Hospital Sydney, Kogarah, New South Wales, Australia.
Curtin University School of Nursing, Bentley, Western Australia, Australia.
出版信息
J Clin Nurs. 2025 Jul;34(7):2737-2747. doi: 10.1111/jocn.17459. Epub 2024 Oct 6.
AIM
The aim of this study was to investigate the point prevalence and the rate of adherence to evidence-based guidelines for patients who had indwelling urinary catheters in three Australian acute care hospitals.
DESIGN
A cross-sectional observational design was used.
METHODS
A multisite cross-sectional observational design was utilised in three acute hospitals across Australia. Data were collected from each site in a single day directly from observation of the patient, the bedside notes and medical records. The data collected included observations of clinical care and scrutiny of the documentation of the insertion details and catheter care using best practice guidelines.
RESULTS
Of the 1730 patients audited, 47% were female. The mean point prevalence of catheters in situ across three sites was 12.9%. Correct documentation compliance was reported to be, on average, 40%. Documentation was significantly better when a template was available to guide information recorded: this was regardless of whether it was hard copy or electronic. Overall, clinical care compliance with best practices was 77%. Of note for improvement was the fixing of the urinary catheter to the thigh in highly dependent patients.
CONCLUSION
It was identified that there is a need for improvement across all three sites: specifically regarding securement of the urinary catheter to the patient's thigh within the ICU. In addition, it was identified that there is a need for documentation of the urine bag change in ward areas. Documentation may be improved by incorporating templates into healthcare documentation systems in the future. Further work is needed to ensure nurses are aware of the adverse effects of urinary catheters and thus, the need to adhere to best practice guidelines.
PATIENT OR PUBLIC CONTRIBUTION
There has been no patient or public contribution.
REPORTING METHOD
We have adhered to the STROBE guidelines for reporting.
目的
本研究旨在调查澳大利亚三家急性护理医院中留置导尿管患者的时点患病率以及遵循循证指南的比率。
设计
采用横断面观察性设计。
方法
在澳大利亚的三家急性医院采用多地点横断面观察性设计。一天内从每个地点直接收集数据，这些数据来自对患者的观察、床边记录和病历。收集的数据包括临床护理观察以及使用最佳实践指南对导尿管插入细节和导管护理记录的审查。
结果
在接受审核的1730名患者中，47%为女性。三个地点导尿管在位的平均时点患病率为12.9%。据报告，正确记录的依从性平均为40%。当有模板可用于指导信息记录时，记录明显更好：无论模板是纸质版还是电子版。总体而言，临床护理对最佳实践的依从性为77%。值得改进的是在高度依赖的患者中将导尿管固定在大腿上。
结论
确定所有三个地点都需要改进：特别是在重症监护病房内将导尿管固定到患者大腿上方面。此外，确定病房区域需要记录尿袋更换情况。未来可通过将模板纳入医疗文档系统来改进记录。需要进一步开展工作以确保护士了解导尿管的不良影响，从而认识到遵循最佳实践指南的必要性。
患者或公众参与
无患者或公众参与。
报告方法
我们遵循了STROBE报告指南。
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