背景:出院总结与药物报告有效地抵消了老年患者由于护理过渡中信息传递不足而导致的药物相关问题。然而,这需要对出院摘要进行最佳传输和使用。这项研究旨在通过出院摘要检查从医院到初级保健的信息传递。
方法:一项描述性研究,其数据包括115例患者的出院总结,75岁或以上,使用五种或更多的药物,在一周内从斯科恩县的28个不同的医院病房收集,瑞典。出院后两周,通过审查初级保健医疗记录来检查信息传递.注意到是否收到出院摘要(即扫描到初级保健医疗记录),如果药物列表随着药物的变化而更新,并且如果在初级保健医疗记录中进行了关于药物或其随访的患者图表条目。电子调查,被送到斯科恩县的151个初级保健单位,用于检查信息传递的经验。
结果:在115个出院总结中,在初级保健医疗记录中发现了47例(41%)。在53例(46%)病例中看到了有关药物治疗或随访的患者图表条目。在没有多剂量药物分配的76名患者中,有51名在住院期间出现了药物变化。在16例(31%)中,在初级保健医疗记录中更新了用药清单.在电子调查中,在107个有反应的初级保健单位中,有22个(21%)报告出院摘要通常是在出院当天收到的,而71名(66%)受访者表示,出院总结总是/经常收到,但较晚。根据61(57%)的受访者,在收到出院摘要后,总是/经常进行初级保健医疗记录中的药物清单更新和患者图表条目。
结论:信息传递往往不足,出院总结使用不足。许多出院摘要丢失了,更新的用药清单比例不足,且经常缺乏患者病历条目.这些发现可能会增加老年人在护理过渡中出现用药错误和药物相关问题的风险。
BACKGROUND: Discharge summary with medication report effectively counteracts drug-related problems among elderly patients due to insufficient information transfer in care transitions. However, this requires optimal transfer and use of the discharge summaries. This
study aimed to examine information transfer with discharge summaries from hospital to primary care.
METHODS: A descriptive
study with data consisting of discharge summaries of 115 patients, 75 years or older, using five or more drugs, collected during one week from 28 different hospital wards in Skåne county, Sweden. Two weeks after discharge, information transfer was examined via review of primary care medical records. It was noted whether the discharge summary was received (i.e. scanned to the primary care medical records), if the medication list was updated with drug changes and if a patient chart entry regarding medication or its follow-up was made in the primary care medical records. An electronic survey, which was sent to 151 primary care units in Skåne county, was used to examine experiences of the information transfer.
RESULTS: Out of 115 discharge summaries, 47 (41%) were found in the primary care medical records. Patient chart entries regarding medication or its follow-up were seen in 53 (46%) cases. Drug changes during hospitalisation were seen in 51 out of 76 patients without multidose drug dispensing. In 16 (31%) out of these cases, medication lists were updated in primary care medical records. In the electronic survey, 22 (21%) out of the 107 responding primary care units reported the discharge summary was often received on the day of discharge, while 71 (66%) respondents indicated the discharge summary was always/often received but later. Medication list updates and patient chart entries in the primary care medical records were always/often done upon receipt of the discharge summary according to 61 (57%) respondents.
CONCLUSIONS: The transfer of information was often deficient and the discharge summaries were insufficiently used. Many discharge summaries were lost, an insufficient proportion of medication lists were updated and patient chart entries were often lacking. These findings may increase the risk of medication errors and drug-related problems for elderly in care transitions.