Implementation of clinical guidelines using a computer charting system. Effect on the initial care of health care workers exposed to body fluids.
Implementation of clinical guidelines using a computer charting system. Effect on the initial care of health care workers exposed to body fluids.
复制标题
使用计算机图表系统实施临床指南。
DOI：
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发表时间：
1997
期刊：
影响因子：
--
通讯作者：
S. Cretin
中科院分区：
文献类型：
--
作者：
D. Schriger;L. Baraff;W. Rogers;S. Cretin
上下文
虽然临床指南被认为是提高医疗服务质量的重要机制，但实施方面的问题可能会限制其有效性。很少有经验数据存在的影响，计算机为基础的系统应用临床指南的护理质量。
目的
确定使用电子病历实时呈现临床指南是否可以提高指南依从性。
设计
前瞻性停-开-停、中断时间序列及意向治疗分析。
设置
大学医院急诊科。
科目
患者为280名医疗保健工作者（50名处于基线对照阶段，156名处于干预阶段，74名处于干预后对照阶段），他们因职业性体液暴露而接受初始治疗，其中89%（248/280）的患者持续穿刺，81%（208/257）的患者暴露于血液。医生包括研究期间在急诊科工作的住院医师和主治医师。
干预措施
实施计算机制图系统，根据临床指南中的规则，提供有关历史的实时信息和实验室检测、治疗和处置的建议。
主要观察指标
护理质量，由医疗记录和善后指导中记录的基本项目、对检测和治疗指南的遵守情况以及可归因于指南认可活动的总费用和费用百分比确定。
结果
病历中关于患者病史的7个基本项目的平均记录百分比从基线期的57%增加到干预期的98%（增加42%; 95%置信区间[CI]，34%-49%）和11项善后指导从基线的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。4项实验室检测指南的依从性百分比从基线时的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时下降到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%），并在干预后下降到84%。在干预阶段，指定实验室检查和治疗的费用百分比从基线时的44%增加到81%（增加37%; 95% CI，22%-52%），并在干预后下降到36%。每名患者的平均总费用分别为460美元、384美元和373美元。
结论
使用基于计算机的系统来管理职业性接触体液的患者的临床指南，改善了文件记录、对指南的遵守情况以及用于指定活动的费用百分比，同时降低了总体费用。当计算机系统被移除时，参数恢复到基线。
CONTEXT
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.
OBJECTIVE
To determine whether real-time presentation of clinical guidelines using an electronic medical record can increase compliance with guidelines.
DESIGN
Prospective off-on-off, interrupted time series with intent-to-treat analysis.
SETTING
University hospital emergency department.
SUBJECTS
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.
INTERVENTIONS
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.
MAIN OUTCOME MEASURES
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.
RESULTS
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.
CONCLUSIONS
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.
影响因子：
6.2
作者：
Go,GW;Baraff,LJ;Schriger,DL
通讯作者：
Schriger,DL