Clinical Decision Support for Nurses: A Fall Risk and Prevention Example
Clinical Decision Support for Nurses: A Fall Risk and Prevention Example
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护士的临床决策支持：跌倒风险和预防示例
DOI：
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发表时间：
2015
期刊：
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通讯作者：
Monica M. Horvath
中科院分区：
文献类型：
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作者：
K. S. Lytle;N. Short;R. Richesson;Monica M. Horvath
电子健康记录中的临床决策支持工具已经证明了过程测量和临床医生绩效的改善，主要是针对提供者。临床决策支持工具可以改善患者跌倒风险识别和预防计划，这是护理工作的共同关注点。该质量改进项目使用临床决策支持来提高护士对记录的跌倒风险评估的依从性，并为16个成人住院单位的高风险患者制定跌倒预防护理计划。干预前和干预后的数据进行了比较，使用季度审计，回顾性图表审查，安全性报告，和福尔斯和跌倒受伤率。根据季度审计数据（P = 0.05），16个单位的跌倒风险评估文件有显着改善，而护理计划的文件没有。对两个单位的回顾性图表审查表明，入院跌倒风险评估有所改善（P = .05），轮班护理计划的记录有所减少（P = .01）;一个单位入院时护理计划的记录有统计学显著减少（P = .00）。对跌倒患者的安全性报告的检查显示，所有患者在临床决策支持之前和之后都记录了跌倒风险评估。福尔斯和福尔斯伴损伤的跌倒在临床决策支持干预前后没有显著变化。
Clinical decision support tools in electronic health records have demonstrated improvement with process measures and clinician performance, predominantly for providers. Clinical decision support tools could improve patient fall risk identification and prevention plans, a common concern for nursing. This quality-improvement project used clinical decision support to improve the rate of nurse compliance with documented fall risk assessments and, for patients at high risk, fall prevention plans of care in 16 adult inpatient units. Preintervention and postintervention data were compared using quarterly audits, retrospective chart review, safety reports, and falls and falls-with-injury rates. Documentation of fall risk assessments on the 16 units improved significantly according to quarterly audit data (P = .05), whereas documentation of the plans of care did not. Retrospective chart review on two units indicated improvement for admission fall risk assessment (P = .05) and a decrease in the documentation of the shift plan of care (P = .01); one unit had a statistically significant decrease in documentation of plans of care on admission (P = .00). Examination of safety reports for patients who fell showed all patients before and after clinical decision support had fall risk assessments documented. Falls and falls with injury did not change significantly before and after clinical decision support intervention.