儿科重症监护室护理监测数据采集模式的构建及应用研究  

Construction and application of data collection model of nursing monitoring in pediatric intensive care unit

作　　者：傅唯佳 顾莺 张晓波[2] 胡静 沈伟杰 黄勤 FU Weijia;GU Ying;ZHANG Xiaobo;HU Jing;SHEN Weijie;HUANG Qin(Nursing Department,Children's Hospital of Fudan University,Shanghai,201102,China)

机构地区：[1]复旦大学附属儿科医院护理部,上海市201102 [2]复旦大学附属儿科医院院办,上海市201102 [3]复旦大学附属儿科医院重症监护室,上海市201102

出　　处：《中华护理杂志》2020年第11期1620-1624,共5页Chinese Journal of Nursing

基　　金：上海市卫生和计划生育委员会科研课题(201840062)。

摘　　要：目的构建儿科ICU护理监测数据采集模式,并进行临床应用,旨在提高ICU危重患儿医疗护理数据的记录质量及医护人员的工作效率.方法以临床决策支持理念为基础,构建儿科ICU抢救、输血、术后复苏数据采集模式,实施现代化、信息化、一体化的移动护理体系.统计2019年1月—2020年1月在ICU不同临床场景下护理监测数据采集模式使用情况及ICU护士对其的满意度.结果抢救模式启动328例次,输血模式启动8014例次,术后复苏模式启动1622例次;采用电子病历记录文书共4323例,其中儿科ICU 1793例、新生儿ICU 1600例、心脏ICU 930例.护士对护理监测数据采集模式的总体满意度得分为(92.47±1.62)分.结论儿科ICU不同护理监测数据采集模式的构建有效整合了急救、输血、术后复苏时各项文件的书写工作流程,通过人工及信息双重核对保障了ICU床旁数据采集的准确性,简化了护理工作程序,改善了护理文书记录质量,提高了护士的满意度.Objective To construct the nursing monitoring data collection model of pediatric intensive care units and carry out clinical application,so as to improve the recording quality of medical and nursing data of critically ill children in ICU and the working efficiency of medical staff.Methods On the basis of the clinical information system(CIS),a modern,informationalized and integrated mobile nursing system was established for the process construction of rescue mode,resuscitation mode,blood transfusion mode and special mode.Data collection patterns and nurses’satisfaction were investigated from January 1,2019 to January 1,2020 in the ICU in different clinical scenarios.Results The rescue mode was started for 328 times;blood transfusion mode was started for 8014 times;recovery mode was started for 1622 times.A total of 4323 cases were recorded by electronic medical records,including 1793 cases of PICU,1600 cases of NICU and 930 cases of CICU.The overall satisfaction score of nurses to the nursing monitoring data acquisition mode system was 92.47±1.62 scores.Conclusion The construction of different data collection modes of the PICU effectively integrates the document writing workflow for handling first aid,resuscitation and blood transfusion.The manual and informatic double-checking process ensures the scientific and effective bedside data collection in the ICU.The work procedures of nurses were simplified;the quality of nursing documents was improved;the nurse’s satisfaction with the working environment was improved.

关 键 词：数据采集 儿科重症监护室 信息化平台 儿科护理学 

分 类 号：R473.72[医药卫生—护理学]