■临床信息的有效记录和传输对于护理的连续性至关重要,患者安全,保持医疗记录,正如皇家外科医学院概述的“安全移交:工作时间指令工作组的指导”。我们的择期手术周末团队交叉涵盖多个病房的结直肠和上消化道外科专业,这构成了重大挑战。这项研究的目的是通过引入周末交接形式来改善患者周末计划的记录。
■我们回顾了199例患者的周末计划。最初在2周内审查了41条记录。然后对外科多学科小组进行了调查,以确定需要改进周末交接。在此之后,作为周五病房的一部分,引入了周末交接形式,并在当地外科临床治理会议上提供了有关期望的教育。在为期6周的时间内,对158名患者的周末计划文件进行了审查,并分发了干预后调查。
■初步调查强调了周末对延迟出院和患者安全的担忧,88.2%的受访者同意周末交接形式将是有益的。初步数据证实诊断记录不足(19.5%),操作/程序(28.1%),和周末血液测试计划(19.5%),出院计划(2.4%),饮食(46.3%),抗生素(19.5%),静脉(IV)液体(22.0%),流动性(19.5%)和引流/伤口护理(37.5%)。在接受教育并实施周末交接形式后,这些结果增加了诊断记录(61.2%),操作/程序(83.2%),验血(59.7%),和出院计划(85.8%)。然而,饮食改善不大(53.0%),抗生素周末计划没有改善(14.2%),静脉输液(17.2%),流动性(14.9%)和引流/伤口护理(20.2%)。干预后调查显示,所有领域都有所改善,特别是护理和患者安全的连续性,95.5%的人发现周末交接形式在周末帮助病人护理。
病房团队的教育和周末交接形式的实施使患者周末计划的记录得到了显着改善,这对于确保持续安全有效的患者护理至关重要。
UNASSIGNED: Effective documentation and transfer of clinical information are vital for the continuity of care, patient safety, and maintaining medico-legal records, as outlined by the Royal College of Surgeons \"Safe
Handover: Guidance from the Working Time Directive working party\". Our elective surgery weekend team cross-covers both Colorectal and Upper Gastrointestinal surgical specialties across multiple wards, which poses a significant challenge. The aim of this study was to improve the documentation of patients\' weekend plans through the introduction of a weekend
handover proforma.
UNASSIGNED: We reviewed the weekend plans of 199 patients overall. 41 records were initially reviewed over a 2-week period. The surgical multidisciplinary team was then surveyed to establish the need for an improved weekend
handover. Following this, a weekend
handover proforma was introduced as part of the Friday ward round and education on the expectations were provided at a local Surgery Clinical Governance meeting. The documentation of the weekend plan was reviewed for 158 patients over a 6-week period and a post-intervention survey was disseminated.
UNASSIGNED: The preliminary survey highlighted concerns for delayed discharges and patient safety over the weekend, with 88.2% of respondents agreeing a weekend handover proforma would be beneficial. The initial data confirmed inadequate documentation of diagnosis (19.5%), operation/procedure (28.1%), and weekend plans for blood tests (19.5%), discharge planning (2.4%), diet (46.3%), antibiotics (19.5%), intravenous (IV) fluids (22.0%), mobility (19.5%) and drain/wound care (37.5%). After education and implementing a weekend
handover proforma, these results increased for documentation of diagnosis (61.2%), operation/procedure (83.2%), blood tests (59.7%), and discharge planning (85.8%). However, there was little improvement in diet (53.0%) and no improvement in the weekend plans for antibiotics (14.2%), IV fluids (17.2%), mobility (14.9%) and drain/wound care (20.2%). The post-intervention survey showed an improvement across all areas, notably continuity of care and patient safety, with 95.5% of individuals finding the weekend handover proforma aided in patient care over the weekend.
UNASSIGNED: Education of the ward team and implementation of a weekend handover proforma resulted in a marked improvement in the documentation of patients\' weekend plans, which is essential to ensure the continuation of safe and effective patient care.