Schriger D L, Baraff L J, Rogers W H, Cretin S
UCLA Emergency Medicine Center, University of California, Los Angeles, School of Medicine, USA.
JAMA. 1997 Nov 19;278(19):1585-90.
While clinical guidelines are considered an important mechanism to improve the quality of medical care, problems with implementation may limit their effectiveness. Few empirical data exist about the effect of computer-based systems for application of clinical guidelines on quality of care.
To determine whether real-time presentation of clinical guidelines using an electronic medical record can increase compliance with guidelines.
Prospective off-on-off, interrupted time series with intent-to-treat analysis.
University hospital emergency department.
Patients were 280 health care workers (50 in the baseline control phase, 156 in the intervention phase, and 74 in the postintervention control phase) who presented for initial treatment of occupational body fluid exposures, including 89% (248/280) who sustained punctures and 81% (208/257) who were exposed to blood. Physicians included resident physicians and attending physicians working in the emergency department during the study.
Implementation of a computer charting system that provides real-time information regarding history and recommendations for laboratory testing, treatment, and disposition based on rules derived from clinical guidelines.
Quality of care as determined by essential items documented in the medical record and in aftercare instructions, compliance with testing and treatment guidelines, and total charges and percentage of charges attributable to guideline-endorsed activities.
Mean percent documentation of 7 essential items regarding patient history in the medical record increased from 57% during the baseline period to 98% in the intervention phase (42% increase; 95% confidence interval [CI], 34%-49%) and 11 items in aftercare instruction increased from 31 % at baseline to 93% during the intervention phase (62% increase; 95% CI, 51%-74%), but both decreased to baseline when the computer system was removed. Percent compliance with 4 laboratory testing guidelines increased from 63% at baseline to 83% during the intervention phase (20% increase; 95% CI, 9%-31 %) but decreased to 52% when the computer system was removed. Compliance with 5 treatment guidelines increased from 83% at baseline to 96% during the intervention phase (13% increase; 95% CI, 9%-17%) and decreased to 84% following the intervention. Percentage of charges incurred for indicated laboratory tests and treatment increased from 44% at baseline to 81% during the intervention phase (37% increase; 95% CI, 22%-52%) and decreased to 36% following the intervention. Average total per-patient charges were $460, $384, and $373 in each phase, respectively.
Use of a computer-based system for clinical guidelines for management of patients with occupational exposure to body fluids improved documentation, compliance with guidelines, and percentage of charges spent on indicated activities, while decreasing overall charges. The parameters returned to baseline when the computer system was removed.
虽然临床指南被认为是提高医疗质量的重要机制，但实施过程中存在的问题可能会限制其有效性。关于基于计算机的临床指南应用系统对医疗质量影响的实证数据很少。
确定使用电子病历实时呈现临床指南是否能提高对指南的依从性。
前瞻性的开-关-开、中断时间序列并进行意向性分析。
大学医院急诊科。
280名医护人员（基线对照阶段50人，干预阶段156人，干预后对照阶段74人），他们前来接受职业体液暴露的初始治疗，其中89%（248/280）有穿刺伤，81%（208/257）接触过血液。医生包括研究期间在急诊科工作的住院医师和主治医师。
实施一个计算机图表系统，该系统根据临床指南得出的规则提供有关病史以及实验室检查、治疗和处置建议的实时信息。
通过病历和后续护理指导中记录的基本项目确定的医疗质量、对检查和治疗指南的依从性、总费用以及指南认可活动产生的费用百分比。
病历中关于患者病史的7项基本项目的平均记录百分比从基线期的57%增加到干预阶段的98%（增加42%；95%置信区间[CI]，34%-49%），后续护理指导中的11项从基线时的31%增加到干预阶段的93%（增加62%；95%CI，51%-74%），但在移除计算机系统后两者均降至基线水平。对4项实验室检查指南的依从百分比从基线时的63%增加到干预阶段的83%（增加20%；95%CI，9%-31%），但在移除计算机系统后降至52%。对5项治疗指南的依从性从基线时的83%增加到干预阶段的96%（增加13%；95%CI，9%-17%），干预后降至84%。指定实验室检查和治疗产生的费用百分比从基线时的44%增加到干预阶段的81%（增加37%；95%CI，22%-52%），干预后降至36%。每个阶段每位患者的平均总费用分别为460美元、384美元和373美元。
使用基于计算机的系统来管理职业体液暴露患者的临床指南，改善了记录、对指南的依从性以及指定活动的费用百分比，同时降低了总费用。移除计算机系统后，各项参数恢复到基线水平。
