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題 名 | 臨床資訊系統於外科加護中心之運用:三年經驗與成效=Implementation of a Clinical Information System in Surgical Intensive Care Unit: Three Years Experience and Outcome |
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作 者 | 廖文進; 張秉宜; 廖如文; 吳清平; 林作舟; 汪志雄; 何善台; | 書刊名 | 中華民國重症醫學雜誌 |
卷 期 | 6:2 民93 |
頁 次 | 頁101-111 |
分類號 | 419.21 |
關鍵詞 | 臨床資訊系統; 加護中心; 電子病歷; Clinical information system; CIS; Intensive care; Electronic medical record; |
語 文 | 中文(Chinese) |
中文摘要 | 重症加護病房擁有臨床上最複雜且變動最頻繁之臨床資訊。很明顯地,處理這些繁雜的資訊必須仰賴一套整合性電子病歷記錄系統,即臨床資訊系統(Clinical In formation System,簡稱CIS)。CIS讓護理人員花較少時間在病歷文件寫作,可以有較多時間照顧病患。因此,使用CIS可以減少不利的事件發生(例如呼吸器事件)與降低醫療錯誤,增進病患安全。因此,本院在外科加護中心率先導入運用全中文化之CIS。 此系統之設計,以整合其他週邊設備,例如生理監視器、血液氣體分析儀及呼吸器等機器運作資料為目標。此外,希望醫院資訊室相關病患資料亦可依設定載入,並自動儲存於系統資料庫作為日後研究分析使用。其結果必須是全中文化操作及中文化表單輸出。在導入CIS之前由我們成立行動小組,協力廠商也組成專案工作團隊,每週定時開會、研究與討論,並隨時協調醫院資訊中心專責人員配合相關事宜。 此系統並於90年年1月1日在外科加護中心全面上線使用。目前除了已經可以自動提供醫學評鑑加護病房各項常規統計項目,尚可提供其他醫學統計項目,以供管理者研究分析。因為全中文操作及全中文輸出使其操作容易、讀取更方便,此系統已為全球首套全中文化操作之臨床資訊整合系統。上線後,使用者對CIS大多給予正向評價。就成效評估而由,在導入使用CIS以後,統計結果發現每月新病人數與佔床率有逐年增加之趨勢。死亡率分別在90年與92年有顯著的下降。而且,血流與泌尿道感染之發生率比導入CIS之前每年都有顯著下降之趨勢;呼吸器相關肺炎則從第二年起亦有顯著下降,而年度總感染則有逐年顯著下降之趨勢。 此套CIS已為國內現代重症醫學豎立了一個嶄新的里程碑。本文希望藉由本院外科加護中心運用CIS之經驗,提供醫界同仁參考,盼能有助於國內發展中文化CIS,以提升全國整體醫療品質。 |
英文摘要 | The most complex and changeable clinical information are in the intensive care unit. Obviously, managing this complex information needs an integrated electronic medical recording system, that is, clinical information system (CIS). Thus, nurse spends less time on the medical record and gets more time to take care of the patients. Hence, CIS can decrease the adverse events (e.g. ventilator events) and reduce the incidence of medical error, consequently improve patient safety. So, we intended to implement the first Chinese version of clinical information system in our hospital. The designs of this system were able to integrate the information from the peripheral devices, such as monitor, arterial blood gas analyzer and ventilator et al. In addition, the patient’s information in the HIS would be downloaded and automatically saved in the databank to provide statistical analysis thereafter. Finally, the recording sheets should be inputted and printed out in Chinese. An action team was organized before the implementation of CIS, including our staffs and vendor programmer. Meeting was held every week to discuss and study the designs of working documents and look for help from the hospital engineer. The system was completely implemented in January, 2001. It not only can provide regular statistic for hospital evaluation, but also can provide other medical statistic functions for study analysis of the administrator. Since this system is inputted and printed out in Chinese it is easier to operate and read, and thus it has been the first Chinese version of in the world. Most of the staff users’ opinion is positive after using the system. In evaluation , the new patient numbers per month and the rate of bed occupancy increases after the implementation of CIS. Mortality rate decreased in 2001 in 2002, respectively. Additionally, blood stream and genitourinary tract infections decreased gradually per year. Ventilator-associated pneumonia also decreased since the second year of CIS implementation. This system has established a milestone in Taiwan critical care medicine. We hope to help the development of CIS and upgraded the whole quality of critical care in Taiwan by sharing the experience of our implementation of CIS in surgical intensive care unit. |
本系統中英文摘要資訊取自各篇刊載內容。