急诊危重患者信息化转科交接单的研发及应用效果评价  

Development and application effect of an information-based transfer form for critically ill patients in emergency department

作　　者：郭美英[1] 王莎[1] 王红红 赵婷 沈志莹 曹敦[4] 肖雪玲 肖涛[2] Guo Meiying;Wang Sha;Wang Honghong;Zhao Ting;Shen Zhiying;Cao Dun;Xiao Xueling;Xiao Tao(Department of Emergency,The Third Xiangya Hospital,Central South University,Changsha 410013,China)

机构地区：[1]中南大学湘雅三医院急诊科,湖南长沙410013 [2]中南大学湘雅三医院护理部,湖南长沙410013 [3]中南大学湘雅护理学院 [4]长沙理工大学计算机通讯学院

出　　处：《护理学杂志》2023年第16期100-104,共5页Journal of Nursing Science

基　　金：湖南省自然科学基金面上项目(2021JJ30991);湖南省卫健委课题(202214054477)。

摘　　要：目的研发急诊危重患者信息化转科交接单,评价其应用效果。方法组建研发团队,设计新增、填写、统计三大功能模块的信息化转科交接单。以便利抽样法选择急诊抢救室200例患者,按照住院时间分为对照组及试验组各100例。对照组应用传统纸质版转科交接单,试验组应用信息化转科交接单。结果试验组转科交接单书写质量显著高于对照组,应用后,交接班护士满意度显著优于应用前,且再次核对/确定患者信息的频次显著降低(均P<0.05)。结论急诊危重患者信息化转科交接单的应用有利于提升交接单书写质量,降低护士反复核对患者信息次数,从而提升护士工作效率及满意度。Objective To develop an information-based transfer form for critically ill patients in emergency department,and to evaluate its application effect.Methods A research team was set up,and an information-based transfer form with three function modules(adding,filling,analyzing)was designed.Then 200 patients in the emergency room were selected by conve-nience sampling and were chronologically divided into a control group and an experimental group,with 100 patients in each group.The control group used traditional paper transfer form,while the experimental group utilized the designed information-based transfer form.Results The writing quality of the transfer form in the experimental group was significantly higher than that of the control group,after application of the information-based transfer form,shifts nurses′satisfaction on handing-off was significantly better than that before application,and the frequency of re-checking or confirming patients′information was significantly reduced(all P<0.05).Conclusion Application of the information-based transfer form for emergency critically ill patients can improve the writing quality of the transfer form,reduce the number of re-checking patients′information repeatedly,and improve nurses′work efficiency and satisfaction.

关 键 词：急诊科 危重患者 转科 交接单 护理信息化 信息化管理 患者安全 

分 类 号：R472.2[医药卫生—急诊医学]