Friesdorf W, Konichezky S, Gross-Alltag F, Federolf G, Schwilk B, Wiedeck H
ATV Section, University Clinic for Anaesthesiology, University of Ulm, Germany.
J Clin Monit. 1994 May;10(3):201-9. doi: 10.1007/BF02908862.
Our objective was to find out what is discussed during a bedside morning ward round (MWR), whether there are any weak points, and if a standard work process structure can be recommended.
An intensive care unit (ICU) consultant recorded in a predefined form the topics that were discussed in 225 bedside discussions.
The median length of discussions was 5 min. In more than 60% of the discussions, items were considered related to the respiratory, neurological, and cardiovascular systems, as well as to surgical and nursing problems. Specific variables relating to organ system conditions were seldom used (e.g., inspired O2 concentration, 35%; temperature, 28%; ventilation mode, 25%). We recorded two interruptions per MWR; only 17% of them were related to urgent decisions. Information that could not be found in the patient's file usually concerned microbiology findings (10%) or surgical procedures (6%).
We recommend the following structure: (1) Addressing the patient by saying "hello"; (2) presentation of information related to case history, acute status (findings and strategy) (including the function of the main organ systems), infection status, and nursing problems; (3) patient-related discussion; and (4) discussion of general treatment rules, triggered by individual patient condition.
我们的目的是了解床边晨间查房（MWR）期间讨论的内容，是否存在任何薄弱环节，以及是否可以推荐一种标准的工作流程结构。
一名重症监护病房（ICU）顾问以预定义的表格记录了225次床边讨论中讨论的主题。
讨论的中位数时长为5分钟。在超过60%的讨论中，讨论的项目被认为与呼吸、神经和心血管系统以及手术和护理问题有关。很少使用与器官系统状况相关的特定变量（例如，吸入氧浓度为35%；体温为28%；通气模式为25%）。我们记录到每次晨间查房有两次中断；其中只有17%与紧急决策有关。在患者病历中找不到的信息通常涉及微生物学检查结果（10%）或手术操作（6%）。
我们推荐以下结构：（1）通过说“你好”来称呼患者；（2）介绍与病史、急性状况（检查结果和策略）（包括主要器官系统的功能）、感染状况和护理问题相关的信息；（3）与患者相关的讨论；以及（4）根据个体患者情况引发的一般治疗规则的讨论。
