压力性损伤临床决策支持系统的研发与应用  

Development and application of clinical decision support system for pressure injury

作　　者：夏冬云[1] 史婷奇[1] 陆巍[1] 陆瑶[1] 程建平[1] 傅巧美[1] 吴玲[1] XIA Dongyun;SHITingqi;LU Wei;LU Yao;CHENG Jianping;FU Qiaomei;WU Ling

机构地区：[1]南京大学医学院附属鼓楼医院门诊伤口护理室,南京市210008

出　　处：《中华护理杂志》2020年第1期50-54,共5页Chinese Journal of Nursing

基　　金：2018年度南京市卫生科技发展专项资金项目计划(YKK18070)。

摘　　要：目的研发压力性损伤(pressure injury,PI)临床决策支持系统,探讨其在临床PI管理中的应用效果。方法成立研发小组,构建PI领域知识库和护理文书数据库,设计人机交互规则,以实现动态评估预警、智能判读推荐、实时监测分析等功能。比较该系统应用前后PI入院风险评估及时率、预防措施落实与风险评估合格率、护理记录缺陷率、医院获得性PI发生率和高风险患者医院获得性PI发生率等指标。结果应用PI临床决策支持系统后,PI入院风险评估及时率从84.78%提高至95.94%,PI预防措施落实与风险评估合格率从90.15%提高至99.13%,PI护理记录缺陷率从16.42%下降至8.70%,与应用前比较,差异均有显著统计学意义(P<0.001)。系统应用后,医院获得性PI发生率和高风险患者医院获得性PI发生率均下降。结论 PI临床决策支持系统为护士提供准确、客观的决策依据,提高了护理质量及管理效率。Objective This research is to develop a clinical decision support system for pressure injury(PI)and explore its application effect in clinical PI management. Methods A Research & Development team was set up to build a PI knowledge base and a database of nursing documents,and to design human-computer interaction rules,in order to realize functions such as dynamic assessment and early warning,intelligent interpretation and recommendation,real-time monitoring and analysis,etc. Indicators before and after the application,including the ratios of timely risk assessment upon hospital admission,the rates of qualified implementation of risk assessment-based preventive measures,the rates of defect in nursing records,the occurrences of hospital acquired PI,and the occurrence of hospital acquired PI in high-risk patients. Results After applying the clinical decision support system for PI,the ratio of timely risk assessment upon hospital admission increased from 84.78% to 95.94%;the rate of qualified implementation of risk assessment-based preventive measures increased from 90.15% to 99.13%;the rate of defect in nursing records decreased from 16.42% to 8.70%;and the differences were statistically significant(P<0.001). The occurrence of hospital acquired PI and the occurrence of hospital acquired PI in high-risk patients were both lower.Conclusion The clinical decision support system for PI provides nurses with accurate and objective decision-making basis,thus effectively improves the quality of PI care and upgrades management efficiency.

关 键 词：临床决策支持 医院信息系统 压力性损伤 护理管理研究 

分 类 号：TP311.52[自动化与计算机技术—计算机软件与理论] R47[自动化与计算机技术—计算机科学与技术]