全院联动静脉血栓形成防治信息化体系的建立与实践  

Establishment and practice of a hospital information system of prevention and treatment for venous thromboembolism

作　　者：余红梅[1] 潘红英[2] 占玉芬[3] 黄晨[4] 程丽丽[2] 李迪琼 丁珊妮 吴觅之 YU Hongmei;PAN Hongying;ZHAN Yufen;HUANG Chen;CHENG Lili;LI Diqiong;DING Shanni;WU Mizhi

机构地区：[1]浙江大学医学院附属邵逸夫医院普外科,杭州市310016 [2]浙江大学医学院附属邵逸夫医院护理部,杭州市310016 [3]浙江大学医学院附属邵逸夫医院医务科,杭州市310016 [4]浙江大学医学院附属邵逸夫医院护理教育部,杭州市310016 [5]湖州师范学院护理学院

出　　处：《中华护理杂志》2020年第3期373-378,共6页Chinese Journal of Nursing

基　　金：浙江省医药卫生科技计划平台计划(2019ZD006);浙江省医院可持续发展正大天晴研究项目(2018ZHA-ZDTQ101)。

摘　　要：目的构建基于信息化的全院联动静脉血栓形成(venous thromboembolism,VTE)防治体系,提升医护人员对VTE的防治能力,改善VTE患者疾病管理现状。方法成立VTE防治管理团队,建立以信息化为基础的VTE防治流程,实行强制性节点管理控制,如术前强制性风险评估、快速反应智能预警系统、护理智能决策系统及结构化随访等,实现全院联动的VTE防治体系,2018年9月-12月在全院范围内实施该体系,与2017年9月-12月对比,分析该防治体系实施前后医院VTE风险的评估率、出血评估率、VTE相关措施落实率、深静脉血栓形成(deep vein thrombosis,DVT)及肺血栓栓塞症(pulmonary thromboembolism,PTE)的发生率、VTE相关病死率等的变化。结果防治体系实施前后,VTE的评估率从0.5%上升到75.5%,出血评估率从1.4%上升至75.8%;防治体系实施后VTE相关措施落实率中基础预防落实率达100%,中高危患者中使用物理预防落实率达15.7%,药物预防落实率达25.9%;全院患者的PTE的发生率从2.87‰上升至4.35‰,DVT的发生率从2.89‰上升至6.28‰,医院VTE相关的病死率从14.03‰下降至1.78‰,差异均有统计学意义(P<0.05)。结论信息化全院联动VTE防治体系的建立与实践能够提高医护人员对VTE的防治意识,提高临床VTE防治措施的落实率,降低患者VTE相关的病死率。Objective To establish a prevention and treatment system of venous thromboembolism(VTE) based on hospital informationization,and to improve the cognition and the management of VTE. Methods A team of VTE prevention and treatment management was established;the working process of informationized VTE prevention and treatment was built;key management measures were taken such as mandatory pre-operation risk assessment,intelligent early warning system of rapid response intellegent,nursing decision-making system and structural follow-up. The system was officially in application from September to December,2018,which was used to compare the data from September to December,2017,comparing VTE risk assessment rate,bleeding assessment rate,implementation rate of VTE related measures,incidence of deep vein thrombosis(DVT) and pulmonary thromboembolism(PTE),and VTE related mortality. Results After the application,VTE risk assessment rate was increased from 0.5% to 75.5%,and bleeding assessment rate was increased from 1.4% to 75.8%. The implementation rate of VTE related measures reached 100% for basic prevention,15.7% for moderate/high-risk patients and 25.9% for drug prevention. The incidence of PTE in the hospital was increased from 2.8‰ to 4.35‰;the incidence of DVT was increased from 2.8‰to 6.28‰;the VTE-related mortality was decreased from 14.03‰ to 1.78‰,and the differences were statistically significant(P<0.05). Conclusion The establishment and practice of the hospital information system of venous thromboembolism prevention and treatment can improve the cognition of medical staff towards prevention and treatment of VTE,improve implementation of clinical VTE prevention and treatment,and decrease VTE-related mortality.

关 键 词：信息化 静脉血栓形成 防治体系 节点管理 护理管理研究 

分 类 号：R473[医药卫生—护理学]