(Summary)
This study was conducted to analyze the use of surgical preventive antibiotics, to establish the critical pathways and check list for it, to develop the electronic medical record-based program, and to apply that program to the clinical setting, thereby expediting the efficiency of the ...
(Summary)
This study was conducted to analyze the use of surgical preventive antibiotics, to establish the critical pathways and check list for it, to develop the electronic medical record-based program, and to apply that program to the clinical setting, thereby expediting the efficiency of the related clinical management and administrative work and contributing to the improvement of patient safety and quality of medical service.
The study included the patients who underwent three major surgeries (gallbladder, gastric, and colorectal surgeries) which account for over 50% among 15 surgeries. For this study, the healthcare benefit quality assessment data for surgical preventive antibiotics use from the Health Insurance Review and Assessment Service was extracted based on the Korea Uniform Hospital Discharge Data Set (KUHDDS). The study was approved by the institutional review board (IRB No, KYUH 2016-04-023).
The collected data were re-classified and analyzed for the characteristics per surgery. The clinical pathway and the check list for surgical preventive antibiotics use were designed and linked electronically to the clinical application program which was developed for this study.
The results of analysis are as follows:
First, the total number of surgery was 289 and numbers of patients for each type of surgery were : 185(64%) for the gallbladder surgery, 63(21.8%) for colorectal surgery and 41(14.2%) for gastric surgery.
Second, we thoroughly reviewed the medical records of the patients who were enrolled for this study regarding the details (the patient’s medical history related to infection and allergy, activity, diet, procedure, medications, work up, and patient’s education) based the pre-existing guidelines and revised after gathering the opinion from the medical professionals.
Third, the medical records were faithfully filled in, according to the template items which were provided on there revised guidelines. The template items included admission and discharge summary, admission notes, progress notes, preoperative records, postoperative records, anesthesia records, and operation records.
Fourth, all the items included in the check list for the evaluation of appropriateness of surgical preventive antibiotics use were automatically linked to the check list for surgical preventive antibiotics use. The missing items were filled out ex post manually after obtaining the confirmation by the medical professionals.
Fifth, the electronic medical record program for clinical application was developed by the construction of critical pathway for surgical preventive antibiotics use through the processes above.
When should be applied to the clinical setting, the electronic medical record program which was developed through the processes of linking the clinical data automatically to the revised critical pathway for the surgical preventive antibiotics use is expected to have positive impacts on the followings: the standardization of treatment-related process, the facilitation of insurance review, the improvement of quality of medical care, and the acquisition of incentives from the government. Further research which can analyze the quantitative changes in the reduction of time spent for the related administrative work including the minimization of errors while filling out the check list and the augmentation of the completeness of medical records is required. This study needs to be expanded to other diseases and medical fields beyond the surgical preventive antibiotics use.
(Summary)
This study was conducted to analyze the use of surgical preventive antibiotics, to establish the critical pathways and check list for it, to develop the electronic medical record-based program, and to apply that program to the clinical setting, thereby expediting the efficiency of the related clinical management and administrative work and contributing to the improvement of patient safety and quality of medical service.
The study included the patients who underwent three major surgeries (gallbladder, gastric, and colorectal surgeries) which account for over 50% among 15 surgeries. For this study, the healthcare benefit quality assessment data for surgical preventive antibiotics use from the Health Insurance Review and Assessment Service was extracted based on the Korea Uniform Hospital Discharge Data Set (KUHDDS). The study was approved by the institutional review board (IRB No, KYUH 2016-04-023).
The collected data were re-classified and analyzed for the characteristics per surgery. The clinical pathway and the check list for surgical preventive antibiotics use were designed and linked electronically to the clinical application program which was developed for this study.
The results of analysis are as follows:
First, the total number of surgery was 289 and numbers of patients for each type of surgery were : 185(64%) for the gallbladder surgery, 63(21.8%) for colorectal surgery and 41(14.2%) for gastric surgery.
Second, we thoroughly reviewed the medical records of the patients who were enrolled for this study regarding the details (the patient’s medical history related to infection and allergy, activity, diet, procedure, medications, work up, and patient’s education) based the pre-existing guidelines and revised after gathering the opinion from the medical professionals.
Third, the medical records were faithfully filled in, according to the template items which were provided on there revised guidelines. The template items included admission and discharge summary, admission notes, progress notes, preoperative records, postoperative records, anesthesia records, and operation records.
Fourth, all the items included in the check list for the evaluation of appropriateness of surgical preventive antibiotics use were automatically linked to the check list for surgical preventive antibiotics use. The missing items were filled out ex post manually after obtaining the confirmation by the medical professionals.
Fifth, the electronic medical record program for clinical application was developed by the construction of critical pathway for surgical preventive antibiotics use through the processes above.
When should be applied to the clinical setting, the electronic medical record program which was developed through the processes of linking the clinical data automatically to the revised critical pathway for the surgical preventive antibiotics use is expected to have positive impacts on the followings: the standardization of treatment-related process, the facilitation of insurance review, the improvement of quality of medical care, and the acquisition of incentives from the government. Further research which can analyze the quantitative changes in the reduction of time spent for the related administrative work including the minimization of errors while filling out the check list and the augmentation of the completeness of medical records is required. This study needs to be expanded to other diseases and medical fields beyond the surgical preventive antibiotics use.
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