基于数据直采的非计划性拔管质量指标管理系统的设计和应用  

Design and application of unplanned extubation quality index management system based on direct data acquisition

作　　者：朱双爱 潘红英[1] 徐玉兰[1] 程丽丽[1] 徐虹霞[2] 陈钧[2] 黄晨[1] Zhu Shuang′ai;Pan Hongying;Xu Yulan;Cheng Lili;Xu Hongxia;Chen Jun;Huang Chen(Department of Nursing,Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine,Hangzhou 310006,China;Department of General Surgery,Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine,Hangzhou 310006,China)

机构地区：[1]浙江大学医学院附属邵逸夫医院护理部,杭州310006 [2]浙江大学医学院附属邵逸夫医院普外科,杭州310006

出　　处：《中国实用护理杂志》2022年第6期438-442,共5页Chinese Journal of Practical Nursing

基　　金：浙江省医药卫生平台计划(2019ZD006)。

摘　　要：目的运用信息化技术对非计划性拔管(UEX)质量指标数据从护理病历系统直接采取, 达到UEX质量管理数据更科学、精准和高效。方法 2019年6—8月于浙江大学医学院附属邵逸夫医院建立管路管理包括管路名称、管路评估、管路护理措施、管路UEX原因的知识库;通过对管路各个节点的分析, 建立管路管理系统, 并将UEX相关的数据集直接采集至护理质量管理系统中进行统计和分析, 对直采数据进行验证。结果 2019年9月至2020年9月临床应用期间, UEX质量指标数据直采全院每月节约护理人力成本约496 h, 数据直采的精准性由试运行的95.8%(161/168)提升到100.0%(494/494);不良事件漏报率降为0;UEX质量指标管理系统的使用满意度得分为(4.35 ± 0.73)分。结论 UEX质量指标数据直采提高了数据的精准性, 护士无需再呈报UEX不良事件, 临床护理信息系统与护理管理系统互联互通, 提高UEX管理效能, 值得临床应用推广。Objective To acquire more scientific,accurate and efficient unplanned extubation(UEX)quality management data by using information technology to directly take the quality index data of unplanned extubation from the nursing medical record system.Methods From June 2019 to August 2019,a knowledge base of pipeline management including the name of pipeline,pipeline evaluation,pipeline care measures,and reasons for unplanned extubation of pipeline was established in Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine.Through the analysis of each node of pipeline management,pipeline management system was established.And the non-planned pipeline management data set was directly collected to the nursing quality management system for statistics and analysis,which was verified.Results In clinical application from September 2019 to september 2020,the direct collection of unplanned extubation quality index data saved 496 hours of nursing labor costs per month,and the accuracy of direct data collection increased from 95.8%(161/168)in trial operation to 100.0%(494/494).The underreporting rate of adverse events decreased to 0.Satisfaction with the application of the quality index management system for unplanned extubation was(4.35±0.73)points.Conclusions The direct collection of quality index data for unplanned extubation improves the accuracy of the data.Nurses no longer need to report unplanned extubation incidents.The clinical nursing information system and the nursing management system are interconnected to improve the management efficiency of unplanned extubation.It is worthy of application and promotion in clinic.

关 键 词：临床护理 信息系统 质量管理 非计划性拔管 节点管理 

分 类 号：R472[医药卫生—护理学]