住院醫師交接班改善方－－結構化的電子交班系統

A Structured Electronic On-line System to Improve Resident Handover

美國醫院評鑑聯合組織(Joint Commission for the Accreditation of Health Care Organization, JACHO)分析1995年至2005年3,548件警訊事件(sentinel events)，結果發現有65％是溝通不良所導致。研究發現，現有的交接班制度，並不符合醫師的期望，交接班模式缺乏結構化溝通模式，儼然已對病人持續性照護形成一個阻礙。Michael Leonard於2002年發展結構式溝通模式－SBAR（情境(Situation)，病史(Background)，評估(Assessment)，建議(Recommendation)），此種溝通模式將有助於醫生觀察病人的臨床狀況，使用結構化SBAR溝通模式在口頭及書面的溝通上明顯的改善了病人安全成效。除此之外，研究建議使用電子化交接班系統來提升交接班的品質，透過電子化交接病人可以減少浪費醫師的工作時間，因此個案醫院希望運用電子化交接班模式並結合SBAR機制提升醫師交接班完整率，以提升病人照護品質並促進病人安全。個案醫院的住院醫師交接班系統，系統開發時間於2007年8月進行，由急救加護委員會與病房主任會議進行測試，系統特色為「非同步交接班」，住院醫師可立即透過電子化交班系統進行病人資訊傳遞，使紀錄即時、正確、完整，讓作業更加便利。除了於資訊系統中新增結構化SBAR交接班模式，同時參考Gardner-Thorpe等人研究，於系統中新增臨床警示系統評分機制，臨床病人警示評分表(Early warning score)評分的項目有：收縮壓(mmhg)、脈搏(bpm)、呼吸(Respiration)、體溫(Temperature)、意識(Conscious)、尿量(Urine output)、飽和(Desaturation)、癲癇發作(Seizures)、心律失常(Cardiac arrhythmia)、胸痛(Chest pain)，與提供的建議事項等。由專責主治醫師每日進行查檢及稽核，以落實交接班完整性，同時為了讓所有內科系及外科系的醫師能夠再次深入了解ISBAR及臨床病人警示評分的精神及意義，進行多次內部教育訓練活動，交接班完整率由2007年12月的47.18％提升至2013年10月97.30％。完整及持續性的交接班有助於病人後續照護品質的提升，透過結構化的溝通模式及團隊訓練加強醫護人員溝通協助能力，不僅縮短醫護團隊成員不必要的時間浪費，同時也可以增加對於治療病況的掌握，進而提升病人臨床照護的水平，未來個案醫院將持續推動以ISBAR結構化的方法進行交接班，並運用臨床警示系統發展快速反應團隊，並及早介入照護，以提升整體醫療品質及病人安全。

The Joint Commission for the Accreditation of Health Care Organization (JACHO) of United States reported 3,548 sentinel events from year 1995 to 2005, to find 65% may have stemmed from poor commimication. The current handover style is far from physicians' expectation. The lack of structured handover has become a real threat to the continuity of patient care. Michael Leonard (2002) developed a structured SBAR (Situation, Background, Assessment, Recommendation) handover module, claiming this, either done orally or hand-written, would help physicians to monitor the patients' condition longitudinally, and to improve patient safety. Study also has shown that handover through information system, together with the SBAR module, can greatly improve the completeness, quality, and safety of patient care. The research hospital has worked with the emergency care and ward chief committees to introduce the on-line, non-simultaneous resident handover system, with aims to help the message transmission by improving its timeliness, correctness, completeness, and convenience. Aside from the SBAR handover module, the system embedded clinical alert system (Gardner-Thorpe) to generate early warning scores, including systolic pressure (mmHg), pulse rate (bpm), respiration rate, temperature, consciousness, urine output, oxygen saturation, seizure, arrhythmia, chest pain, and clinical recommendations fro handover personnel. Attending physicians are in charge of supervision to ensure the handover completeness. Series of education sessions were delivered. The handover completeness rate has improved from 47.18% (December 2007) to 97.30% (October 2013). Complete and thorough handover is the keystone to good care quality. The structured handover module and team training not only improve the cross-function communication, work efficiency, but also secure the patient condition monitoring and ensure the clinical care quality. We will continue to use the SBAR handover module. In the future we will organize rapid response team to early intervene unstable patients.