外科重症监护室病人治疗性干预时每日诊疗目标表格用于诊疗管理的效果  

Usefulness of a list of daily targets for different therapeutic interventions in surgical intensive care unit

作　　者：罗哲[1] 薛张纲[1] 诸杜明[1] 程立宏[1] 何义舟[1] 

机构地区：[1]复旦大学附属中山医院麻醉科外科重症监护室,上海市200032

出　　处：《中华麻醉学杂志》2010年第2期192-193,共2页Chinese Journal of Anesthesiology

摘　　要：自2008年1月起，本课题组将每日诊疗目标表格用于外科重症监护室（SICU）中每例病人的不同治疗性干预。首先评估住院医生和护士对病人情况的知晓度2周，第1周未应用该表格，第2周应用该表格。每天随机选2例病人，向主管住院医生和护士询问病情。评估标准：完全知晓为5分；大部分知晓为4分；部分知晓为3分；了解一点为2分；不知晓为1分，其中5分和4分判定为对病人病情知晓。应用表格前，住院医生和护士对病人诊疗知晓度评分分别为（3．21±0．71）分和（2．29±0．49）分，应用表格后，评分分别为（4．79±0．27）分和（4．07±0．61）分，应用表格后住院医生和护士对病人诊疗知晓度评分明显高于应用表格前（P〈0．05）。2008年病人SICU住院时间短于2007年（P〈0．05）。提示每日诊疗目标表格是科学管理SICU的措施之一，对医护人员达成有效的共识和改善病人的预后具有积极地作用。Since January 2008 we have been using a list of daily targets for different therapeutic interventions in each patient in surgical intensive care unit （SICU）. The degree of understanding of patient＇s condition by residents and nurses was evaluated and scored （5 = fully understand, 1 = no understanding）. The scores obtained before and after the application of the list were compared. The length of patient＇s stay in SICU in 2008 and 2007 was also compared. The use of the list significantly improved the understanding of patient＇ s condition by residents and nurses 3.21 ± 0.71 （residents） and 2.29 ± 0.49 （nurses） before the application of the list; 4.79 ± 0.27 （residents） and 4.07 ±0.61 （nurses） after the application of the list. Implementing the list of daily targets results in a significant improvement in the effectiveness of communication of the medical staff and a reduction in the length of patient＇s stay in SICU.

关 键 词：表格和记录管理 重症监护 

分 类 号：R473.6[医药卫生—护理学]