持续质量评审对阴道分娩严重产后出血规范化诊治及其并发症影响研究  

Effect of continual quality audit in severe postpartum hemorrhage on its standardized diagnosis and treatment and the complications

作　　者：周燕 顾宁[1] 徐晓峰[1] 周航[1] 卢先艳[1] 王志群[1] 胡娅莉[1] 戴毅敏[1] ZHOU Yan;GU Ning;XU Xiao-feng;ZHOU Hang;LU Xian-yan;WANG Zhi-qun;HU Ya-li;DAI Yi-min(Department of Obstetrics and Gynecology,Nanjing Drum Tower Hospital,Nanjing University Medical School,Nanjing 210008,China)

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：《中国实用妇科与产科杂志》2021年第10期1039-1043,共5页Chinese Journal of Practical Gynecology and Obstetrics

基　　金：江苏省产科临床医学中心(创新平台)建设单位(苏卫科教[2016]17号);江苏省妇幼健康科研项目(F201742)。

摘　　要：目的探讨阴道分娩严重产后出血(severe postpartum hemorrhage,S-PPH)的持续质量评审对其规范化诊治及并发症的影响。方法根据中华医学会发布的《产后出血预防与处理指南(2014)》制定评审表单,从南京大学医学院附属鼓楼医院2016年1月至2019年12月阴道分娩孕产妇中抽取514例S-PPH产妇的资料,围绕救治过程中预防性宫缩剂应用及时性、产后出血诊断和处理及时性、出血量计算是否准确、二线止血措施是否及时合理、输血指征是否恰当、医疗和护理记录是否及时等6项诊疗质量问题进行评审(2017年1月始)并反馈,比较评审开展前后的变化。结果阴道分娩总数为19338例,S-PPH 514例(2.7%)。其中,24h出血量1000~1500 mL为368例(1.9%),>1500~<2000 mL为105例(0.5%),≥2000 mL为41例(0.2%)。(1)2016年尚未开展评审,以此为对照,评审开展后,S-PPH病因诊断的及时正确率从87.2%逐年上升至97.3%(χ_(趋势)^(2)=11.378,P=0.001)。(2)氨甲环酸使用率从16.7%逐年上升至99.3%(χ趋势2=211.81,P<0.001),产时人工剥离胎盘从46.2%下降至30.6%(χ_(趋势)^(2)=4.974,P<0.05),二线处理中宫腔止血囊填塞时机提前,出血量尚未达到1000 mL开始填塞率,从34.1%上升至66.1%(χ_(趋势)^(2)=10.661,P=0.001)。(3)产后需要清宫者从16.7%下降至0.7%(χ_(趋势)^(2)=33.519,P=0.000);介入性盆腔血管栓塞率从3.8%降至0.7%(χ_(趋势)^(2)=4.201,P<0.05),近期总严重并发症发生率由5.4%下降至1.4%(χ_(趋势)^(2)=4.890,P<0.05)。(4)输血率从46.2%逐年下降至12.9%(χ_(趋势)^(2)=30.124,P=0.000),其中产后24h出血量<1500 mL者中,输血率从23.1%逐年下降至3.8%(χ_(趋势)^(2)=13.165,P=0.000),合理输血率由79.5%逐年上升至93.2%(χ_(趋势)^(2)=7.280,P=0.007)。结论通过对S-PPH病例的评审反馈,可持续改进S-PPH的环节管理,提高产科全体医护人员对指南的执行力,使S-PPH相关的输血率和近期严重并发症发生率降低。Objective To assess the effect of continual quality audit in severe postpartum hemorrhage(S-PPH)following vaginal delivery on its standardized diagnosis and treatment and the complications.Methods A checklist was developed based on Chinese Medical Association’s guideline on PPH(2014).A criteria-based audit was conducted on 514 PPH patients in Nanjing Drum Tower Hospital between January 2016 and December 2019.Clinical audit in the management of S-PPH was evaluated based on six aspects(since January 2017):the timeliness of the prophylactic use of oxytocin,the timeliness of diagnosis and treatment,the accuracy of estimated blood loss,prompt and appropriate use of the secondline hemostasis measures,appropriate use of blood transfusion,and timeliness of medical and nursing records.The changes before and after the audit were compared.Results From 2016 to 2019,the number of vaginal deliveries was 19338,514 cases being audited.According to the 24h bleeding volume,368 cases(1.9%)were 1000-1500 mL,105 cases(0.5%)were>1500-<2000 mL,and 41 cases(0.2%)were≥2000 mL.(1)Compared with that of 2016,when no audit was conducted,the rate of timely and accurate diagnosis of the cause of S-PPH increased from 87.2%to 97.3%(χ_(Trend)^(2)=11.378,P=0.001)year by year.(2)Tranexamic acid use increased year by year from 16.7% to 99.3%(χ_(Trend)^(2)=211.81,P<0.001);the rate of manually removing placental decreased from 46.2% to 30.6%(χ_(Trend)^(2)=4.974,P<0.05).The proportion of cases with an early intrauterine balloon tamponade(blood loss<1000 mL at the time of tamponade)increased from 34.1% to 66.1%(χ_(Trend)^(2)=10.661,P=0.001).(3)The rate of uterine curettage after delivery decreased from 16.7% to 0.7%(χ_(Trend)^(2)=33.519,P=0.000)The rate of interventional pelvic vascular embolism decreased from 3.8% to 0.7%(χ_(Trend)^(2)=4.201,P<0.05),while overall short-term severe maternal morbidity decreased from 5.4% to 1.4%(χ_(Trend)^(2)=4.890,P<0.05).(4)Blood transfusion rate was gradually decreased from 46.2% to 12.9%(χ_(Trend)^(2)=30.

关 键 词：严重产后出血 临床评审 质量改进 宫腔填塞 输血治疗 

分 类 号：R714.7[医药卫生—妇产科学]