Rakenteinen kirjaaminen aikuispsykiatrisessa hoitotyössä : käyttöönoton loppumittaus

Tämä tutkimus on osa Turun Sosiaali- ja terveystoimen HoiDok-hanketta, jonka tarkoituksena on kehittää hoitotyön rakenteista kirjaamista. Hankkeen tavoitteena on käyttöönottaa valtakunnallisesti luotu kirjaamisen perusmalli, jonka avulla voidaan parantaa kirjaamisen ja hoitotyön laatua, sekä parantaa tiedonkulkua hoitoprosessin aikana. Lisäksi mallin avulla saadaan laadukasta tietoa hoitotyön johtamisen perustiedostoon. Rakenteisen kirjaamisen kehittymistä on arvioitu vuosittain opinnäytetöillä. Hankkeen ensimmäinen opinnäytetyö on tehty vuonna 2008. Tämän tutkimuksen tarkoituksena oli tehdä psykiatrisessa hoitotyössä toteutuvan rakenteisen kirjaamisen tilan loppumittaus aiempien hankkeen tutkimustuloksia vertaillen. Tutkimusaineistona olivat 40 potilaan hoitokertomukset, jotka analysoitiin deduktiivista sisällönanalyysiä käyttäen, minkä jälkeen saadut arvot syötettiin SPSS 19.0-tilastointiohjelmaan. Hoitokertomukset olivat Turun Sosiaali- ja Terveystoimen psykiatrian tulosalueen vuodeosastoilta. Potilasaineiston ikäjakauma oli 19–60 vuotta. Hankkeen aikana rakenteisessa kirjaamisessa on havaittu tapahtuneen kehitystä parempaan suuntaan. Hankkeen aikana huomattiin esimerkiksi hoitosuunnitelman käytön yleistyminen, potilaan hoidon tavoitteiden kirjaamisen lisääntyminen sekä potilaan näkemysten huomioiminen kirjaamisessa oli osittain parantunut. Tämän viimeisimmän tutkimuksen osalta on hahmottunut selkeitä kehittämiskohteita, joista tärkeimpiä olivat hoitosuunnitelman ajan tasalla pitäminen, potilaan hoidon loppuarvioinnin tekeminen sekä täsmällisempi ja potilaslähtöisempi kirjaaminen. Lisäksi havaittiin opetuksen/ohjauksen kirjaamisessa olevan vielä kehitettävää. Näitä kehittämällä kirjaamisesta saataisiin tarkoituksenmukaisempaa ja siten laadukkaampaa. Rakenteisen kirjaamismallin toteutumisesta on syytä tehdä jatkotutkimuksia vasta sitten, kun hoitajat ovat saaneet riittävästi tietoa ja kokemusta sen käytöstä. Tämä hanke on ajoittunut juuri sellaiseen ajankohtaan, kun hoitajat eivät välttämättä ole vielä ehtineet sisäistää täysin uuden kirjaamismallin toteuttamista.This research is part of Turku Municipal Social and Health Department of HoiDok-project, which purpose is to develop the structured documentation of nursing. The aim of the project is to introduce a nationally created basic model of the recording, which can be used to improve the quality of documentation and nursing as well as the communication during the nursing process. In addition, this model gives high-quality information for administrative nursing. The development of the structured documentation has been evaluated annually by bachelor’s thesis. The first research part has been done in 2008.The purpose of this study was to make the final measurement in psychiatric nursing based on previous years’ studies. The research material consisted of 40 patient records, which were analyzed using a deductive content method. After this the results were entered into statistics program SPSS 19.0. The patient records were from the psychiatric ward of Turku’s Municipal Health Care and Social Services Department. During the project a good development of the structured recording has been noticed. There was noticed for example that the care plan’s use became widely used, patient’s goals of care were more recorded and recording of patient’s views improved. This last study has led to highlighting clear development targets, like for example updating the care plan, carrying out patient`s final evaluation and generally recording more specifically and patient-focused. In addition was noticed that there were need to develop recording of the teaching/guidance. By developing these details the structured documentation would be more appropriate and thus it would also have a higher quality. Further researches about the structured documentation should take place only after the nurses have got sufficient information about it. This project happened in a phase when the nurses have not maybe yet totally internalized the new recording model

Tyytyväinen potilas = laadukas terveydenhuolto?

Hoidon laadun luotettava mittaaminen on laadun kehittämisen ja hoitolaitosten välisten vertailujen edellytys. Kokonaispotilas­tyytyväisyys ei sovellu yksinään hoidon laadun sijaismuuttujaksi

Aivoleikkauspotilaiden leikkausta edeltävät riskinarviointimenetelmät, lyhytaikaisennuste ja potilastyytyväisyys

Background: Preoperative risk assessment and reliable outcome reporting are vital for improving quality of care and patient safety. Studies on neurosurgical patients are surprisingly scarce, and no prospective reports on unselected elective craniotomy patients exist. The objectives of this study were to review the literature on the use of preoperative risk-assessment scores in elective cranial neurosurgery and to study preoperative risk prediction, short-term outcome reporting, and patient satisfaction in the first unselected, prospective cohort of adult elective craniotomy patients. Patients and Methods: We performed a systematic review of 25 studies on five preoperative scores [The American Society of Anesthesiologists physical status classification (ASA) score, the Karnofsky Performance Score (KPS), the modified Rankin Scale (mRS), the Sex, Karnofsky, ASA, Location, and Edema (SKALE) score, and the Charlson comorbidity score] in predicting outcome in elective cranial neurosurgery. We enrolled a prospective, unselected cohort of 418 adult elective craniotomy patients in the Department of Neurosurgery, Helsinki University Hospital. Evaluation of routinely collected preoperative data, original ASA score, Helsinki ASA score, and their combinations revealed their ability to predict in-hospital new central nervous system (CNS) deficits as well as systemic and infectious complications after elective craniotomy. We evaluated the reliability and accuracy of patient-reported outcomes, postoperative mRS scores, and mRS-score differences in reflecting short-term outcome. Overall patient satisfaction rate was determined, as were associations between high or low patient satisfaction and short-term postoperative outcome. Results: Evidence as to the applicability of preoperative risk-assessment scores in elective cranial neurosurgery is scarce, with KPS receiving the most support in the literature. None of the scores predicted all postoperative outcomes; the most applicable risk score varied with the outcome measure selected. The in-hospital mortality rate was 1.0% and the 30-day rate was 2.4%. In-hospital systemic and infectious complications occurred in 6.7% of patients, and new CNS deficits in 11.2%. Advanced age, preoperatively elevated C-reactive protein (CRP) level, and high Helsinki ASA class were independent predictors of systemic and infectious complications. A combination of these variables identified one-fourth of the patients with systemic and infectious complications (p=0.005, OR 4.8, CI 1.5-15.9, AUC 0.766) and was associated with prolonged intensive care unit (ICU) stay (p=0.018) and hospital stay (p=0.004). The rate of overall complications was 46.4%, and the rate of major complications was 18.2%. Perioperative changes in mRS scores were inconsistent: among patients with no complications, the mRS score increased for 17.1% at hospital discharge and for 23.8% at 30 days. Moreover, 28.0% of patients with major complications showed no increase in mRS scores at hospital discharge. Associations between patient-reported postoperative subjective deterioration in functional status and both major and overall morbidity were significant. Furthermore, a simple unweighted composite score of PROs was more sensitive and specific than was 30-day dependent functional status (mRS score ≥3) in detecting both major and overall morbidity. In our cohort, 93.8% rated their overall satisfaction as good or excellent. Even 9 of 10 patients with postoperative major morbidity rated their satisfaction as high. Low patient satisfaction was associated neither with major (p=0.054) nor with overall (p=0.215) morbidity. Conclusions: Strong evidence supporting the use of any preoperative risk score in elective cranial neurosurgery is lacking. The Helsinki ASA score seems more suitable than the original ASA score for elective craniotomy patients, especially in combination with other preoperative risk predictors, but only for systemic and infectious complications. The rate of major complications in our cohort was moderately low considering the average age, comorbidities and operated lesions of the patients in our unselected study cohort. The postoperative mRS score and mRS-score differences were inconsistent with recorded complications, whereas PROs seem promising tools for outcomes reporting. Overall patient satisfaction was high, even in patients with complicated outcomes, and thus patient satisfaction is a poor proxy for treatment outcome and quality of care in elective cranial neurosurgery.Leikkausta edeltävä riskinarviointi ja luotettava hoitotulosten mittaaminen ovat välttämättömiä hoidon laadun kehittämiseksi ja potilasturvallisuuden parantamiseksi. Aiheeseen liittyvää tutkimusta neurokirurgisilla potilailla on tehty yllättävän vähän, ja prospektiiviset tutkimukset valikoimattomilla aivoleikkauspotilailla puuttuvat. Tutkimuksemme tavoitteina oli arvioida tutkimusnäyttöä leikkausta edeltävien riskinarviointiluokitusten käytöstä aivoleikkauspotilailla ja tutkia leikkausta edeltävää riskinarviointia, lyhytaikaisennustetta sekä potilastyytyväisyyttä elektiiviseen eli suunniteltuun aivoleikkaukseen tulevilla potilailla. Teimme systemaattisen katsauksen 25 tutkimuksen tuloksista koskien viiden luokituksen käyttöä aivoleikkausta edeltävässä riskinarvioinnissa. Lisäksi keräsimme 418 elektiiviseen aivoleikkaukseen tulevaa aikuispotilasta Helsingin yliopistollisen keskussairaalan Neurokirurgian klinikassa. Leikkausta edeltäviä, leikkauksenaikaisia ja leikkauksenjälkeisiä tutkimustietoja kerättiin potilaskyselylomakkeilla, tutkimuslomakkeilla ja sairaalan tietokannoista. Potilastyytyväisyyttä ja toipumista arvioitiin puhelinhaastattelulla 30 vuorokautta leikkauksen jälkeen. Tieteellistä näyttöä riskinarviointiluokitusten käytöstä suunnitellussa aivokirurgiassa on vähän. Ennustearviontiin parhaiten soveltuva luokitus vaihteli valitun tulosmuuttujan mukaan. Kuolleisuus sairaalahoidon aikana oli 1,0 % ja 30 vuorokauden sisällä leikkauksesta 2,4 %. Haittatapahtumia todettiin 46,4 % ja merkittäviä haittatapahtumia 18,2 % potilaista. Joka neljäs iäkäs potilas, jolla oli leikkausta edeltävästi korkea Helsinki ASA (American Society of Anesthesiologists Physical Status) -luokitus ja kohonnut C-reaktiivinen proteiini (CRP) -tulehdusarvo, sai elin- tai tulehdushaittatapahtuman ja tarvitsi pidempää tehohoito- ja sairaalahoitojaksoa. Leikkauksenjälkeiset muutokset modified Rankin Scale (mRS) -toimintakykyluokituksessa olivat epäjohdonmukaisia suhteessa haittatapahtumiin ja potilaslähtöisesti ilmoitetut muutokset terveydessä ja toimintakyvyssä vaikuttavat lupaavilta tulosmuuttujilta elektiivisessä aivokirurgiassa. Valtaosa (93,8 %) potilaista oli hyvin tai erittäin tyytyväisiä saamaansa hoitoon. Tyytymättömyys hoitoon ei liittynyt todettuihin haittatapahtumiin. Vahva tieteellinen näyttö leikkausta edeltävien riskinarviointiluokitusten käytöstä aivokirurgiassa puuttuu. Merkittäviä haittatapahtumia on elektiivisessä aivokirurgiassa suhteellisen vähän huomioiden tutkimuspotilaiden ikä, sairaudet ja leikkausaiheet. Leikkauksenjälkeinen mRS-luokka tai mRS-luokan muutos eivät ole luotettavia tulosmuuttujia aivoleikkauspotilailla. Potilaslähtöisesti ilmoitetut hoitotulokset ovat lupaavia tulevaisuuden hoitotulosmittareita. Potilastyytyväisyys on korkea jopa merkittäviä haittatapahtumia saaneilla potilailla, eikä tyytyväisyys siksi sovellu hoidon laadun mittariksi aivoleikkauspotilailla

In Reply : Simple Preoperative Patient-Reported Factors Predict Adverse Outcome After Elective Cranial Neurosurgery

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Simple Preoperative Patient-Reported Factors Predict Adverse Outcome After Elective Cranial Neurosurgery

Peer reviewe

Quality of British and American Nationwide Quality of Care and Patient Safety Benchmarking Programs : Case Neurosurgery

BACKGROUND: Multiple nationwide outcome registries are utilized for quality benchmarking between institutions and individual surgeons. OBJECTIVE: To evaluate whether nationwide quality of care programs in the United Kingdom and United States can measure differences in neurosurgical quality. METHODS: This prospective observational study comprised 418 consecutive adult patients undergoing elective craniotomy at Helsinki University Hospital between December 7, 2011 and December 31, 2012.We recorded outcome event rates and categorized them according to British Neurosurgical National Audit Programme (NNAP), American National Surgical Quality Improvement Program (NSQIP), and American National Neurosurgery Quality and Outcomes Database (N(2)QOD) to assess the applicability of these programs for quality benchmarking and estimated sample sizes required for reliable quality comparisons. RESULTS: The rate of in-hospital major and minor morbidity was 18.7% and 38.0%, respectively, and 30-d mortality rate was 2.4%. The NSQIP criteria identified 96.2% of major but only 38.4% of minor complications. N(2)QOD performed better, but almost one-fourth (23.2%) of all patients with adverse outcomes, mostly minor, went unnoticed. For NNAP, a sample size of over 4200 patients per surgeon is required to detect a 50.0% increase in mortality rates between surgeons. The sample size required for reliable comparisons between the rates of complications exceeds 600 patients per center per year. CONCLUSION: The implemented benchmarking programs in the United Kingdom and United States fail to identify a considerable number of complications in a high-volume center. Health care policy makers should be cautious as outcome comparisons between most centers and individual surgeons are questionable if based on the programs.Peer reviewe

Modified Rankin Scale and Short-Term Outcome in Cranial Neurosurgery : A Prospective and Unselected Cohort Study

BACKGROUND: The modified Rankin Scale (mRS) was developed to monitor functional recovery after stroke, but nowadays it is a treatment outcome measure in elective neurosurgery. Our objective was to study how mRS changes associate with short-term postoperative outcome. METHODS: Preoperative, in-hospital, and 30-day mRS scores came from a prospective, consecutive and unselected cohort of 418 adult elective craniotomy patients enrolled between December 2011 and December 2012 in Helsinki, Finland. Recorded data included subjective and objective postoperative in-hospital complications as well as changes in mRS score after surgery. RESULTS: Minor or major complications were detectable in 46% of the patients. In-hospital and 30-day postoperative increases in mRS score were inconsistent; among patients with no complications, 17% had a greater mRS score at discharge and 24% at 30 days, whereas 28% of the patients with major complications showed no increase in mRS score at discharge. Of individual complications, only new or worsened hemiparesis, silent stroke, and pneumonia were associated with postoperative increase (>2) in mRS score after multivariable analysis. For mRS-score difference >1 at discharge in detecting major complications (including mortality), sensitivity was 45% and specificity 94%. CONCLUSIONS: The mRS changes after elective cranial neurosurgery are inconsistent. The mRS seems to represent functional changes, which do not necessarily associate with detected in-hospital complications.Peer reviewe

Classification of electronic health record–related patient safety incidents : Development and validation study

Publisher Copyright: © Sari Palojoki, Kaija Saranto, Elina Reponen, Noora Skants, Anne Vakkuri, Riikka Vuokko.Background: It is assumed that the implementation of health information technology introduces new vulnerabilities within a complex sociotechnical health care system, but no international consensus exists on a standardized format for enhancing the collection, analysis, and interpretation of technology-induced errors. Objective: This study aims to develop a classification for patient safety incident reporting associated with the use of mature electronic health records (EHRs). It also aims to validate the classification by using a data set of incidents during a 6-month period immediately after the implementation of a new EHR system. Methods: The starting point of the classification development was the Finnish Technology-Induced Error Risk Assessment Scale tool, based on research on commonly recognized error types. A multiprofessional research team used iterative tests on consensus building to develop a classification system. The final classification, with preliminary descriptions of classes, was validated by applying it to analyze EHR-related error incidents (n=428) during the implementation phase of a new EHR system and also to evaluate this classification’s characteristics and applicability for reporting incidents. Interrater agreement was applied. Results: The number of EHR-related patient safety incidents during the implementation period (n=501) was five-fold when compared with the preimplementation period (n=82). The literature identified new error types that were added to the emerging classification. Error types were adapted iteratively after several test rounds to develop a classification for reporting patient safety incidents in the clinical use of a high-maturity EHR system. Of the 427 classified patient safety incidents, interface problems accounted for 96 (22.5%) incident reports, usability problems for 73 (17.1%), documentation problems for 60 (14.1%), and clinical workflow problems for 33 (7.7%). Altogether, 20.8% (89/427) of reports were related to medication section problems, and downtime problems were rare (n=8). During the classification work, 14.8% (74/501) of reports of the original sample were rejected because of insufficient information, even though the reports were deemed to be related to EHRs. The interrater agreement during the blinded review was 97.7%. Conclusions: This study presents a new classification for EHR-related patient safety incidents applicable to mature EHRs. The number of EHR-related patient safety incidents during the implementation period may reflect patient safety challenges during the implementation of a new type of high-maturity EHR system. The results indicate that the types of errors previously identified in the literature change with the EHR development cycle.Peer reviewe

Vapaaehtoisen vaaratapahtumajärjestelmän kehittäminen korkean kehitysasteen potilastietojärjestelmissä

Vertaisarvioitu. English abstract.Peer reviewe