基于临床决策支持系统的新生儿早期诊疗护理预警模型的构建与应用  

Construction and application of early warning model of neonatal diagnosis and treatment based on clinical decision support system

作　　者：巩婷婷 金靓[1] 郑雅宁[1] 丁苗 丁颖[1] Gong Tingting;Jin Liang;Zheng Yaning;Ding Miao;Ding Ying(Gulou Hospital Affiliated to Medical College of Nanjing University,Nanjing Jiangsu,210008)

机构地区：[1]南京大学医学院附属鼓楼医院妇产科,江苏南京210008

出　　处：《护士进修杂志》2021年第7期604-609,共6页Journal of Nurses Training

摘　　要：目的构建新生儿早期诊疗护理预警模型的架构体系,保障新生儿早期诊疗护理质量安全。方法梳理出以护理程序为基础的新生儿早期诊疗护理的工作流程,构建基于临床决策支持系统(CDSS)的新生儿早期诊疗护理预警模型。于2018年6-9月构建知识库,并于2018年10月开始进行临床应用。评价基于CDSS系统的新生儿早期诊疗护理预警模型的应用效果(新生儿风险评估及时率、预防措施落实与风险评估合格率)、护士对系统满意度及早产儿家属满意度。结果护士应用新生儿早期诊疗护理预警的临床决策支持系统后,新生儿风险评估及时率(96.94%)高于系统应用前(85.18%),差异有统计学意义(P<0.001)。预防措施落实与风险评估合格率(98.13%)高于系统应用前(90.35%),差异有统计学意义(P<0.001)。护士对系统的可用性评价为(18.63±1.13)分,数据可靠性为(14.22±1.42)分,系统支持力度为(13.51±2.23)分,使用意向为(8.51±1.52)分,总体满意度为(4.42±0.51)分,净收益为(4.19±0.63)分。早产儿家属满意度处于较高水平。结论基于临床决策系统的新生儿早期诊疗护理预警模型的构建可以为临床护士在照护新生儿时对疾病早期识别和护理干预提供正确高效的决策支持,提升护士对临床常规执行的依从性和评判性思维能力,提高护士护理质量管理能力,提高医护患多角色满意度。Objective To construct the framework system of early warning model for early diagnosis and care of newborns,and to ensure the quality and safety of early diagnosis and care of newborns.Methods To sort out the workflow of early diagnosis and care for newborns based on nursing procedures,and to build an early warning model of early diagnosis and care for newborns based on clinical decision support system(CDSS).The knowledge base was constructed from June to September,2018,and clinical application began in October,2018.To evaluate the application effect(timely rate of neonatal risk assessment,implementation of preventive measures and qualified rate of risk assessment),nurses'satisfaction with the system and the satisfaction of the premature infants'families.Results After nurses applied the clinical decision support system for early diagnosis and treatment of newborns,the timely rate of neonatal risk assessment(96.94%)was higher than that before the system application(85.18%),and the difference was statistically significant(P<0.001).The qualified rate of preventive measures implementation and risk assessment(98.13%)was higher than that before system application(90.35%),and the difference was statistically significant(P<0.001).Nurses'evaluation of system usability was(18.63±1.13),data reliability was(14.22±1.42),system support was(13.51±2.23),use intention was(8.51±1.52),overall satisfaction was(4.42±0.51),and net income was(4.19±0.63).Family satisfaction of premature infants is at a hig level.Conclusion The construction of early warning model for early diagnosis and treatment of newborns based on clinical decision system can provide correct and efficient decision support for early identification of diseases and nursing intervention when nursing newborns,improve nurses'compliance with clinical routine execution and critical thinking ability,improve nurses'nursing quality management ability,and improve the multi-role satisfaction of doctors and patients.

关 键 词：智能化临床决策支持系统 新生儿 早期诊疗护理预警模型 护理质量管理 

分 类 号：R473.72[医药卫生—护理学]