根因分析法联合流程优化降低外出检查早产儿低体温的研究

目的 探讨根因分析法联合流程优化对新生儿重症监护室早产儿外出检查体温的影响.方法 成立根因分析小组,应用根因分析法对2020年1～7月67例新生儿重症监护室外出检查早产儿进行追踪,调查导致外出检查低体温发生的原因,寻找近端原因、剖析根本原因,制订改进措施,包括对早产儿外出检查流程进行重排、合并、优化等.并于2020年8月至2021年2月在58例外出检查早产儿中实施,比较改善措施实施前后低体温发生率.结果 改善措施实施后,早产儿腹部B超、全腹B超及听诱发检查时体温显著改善(均P＜0.01);早产儿外出检查低体温发生率由实施前的37.31％下降至实施后的10.34％,差异有统计学意义(P＜0.01).结论 根因分析法联合优化早产儿外出检查流程,可有效降低早产儿外出检查低体温发生率.

Root cause analysis combined with procedure optimization reduces hypothermia in preterm infants going out for diagnostic tests

Objective To explore the effect of root cause analysis (RCA) combined with procedure optimization on temperature in NICU preterm infants going out for diagnostic tests. Methods A RCA group was established, and 67 NICU preterm infants going out for diagnostic tests from January to July 2020 were tracked using RCA to investigate the causes of hypothermia, the proximal causes were found and the root causes were analyzed, then the improvement measures were developed, including resetting, merging and optimizing the procedure of going out for diagnostic tests. In August 2020 to February 2021, totally 58 preterm infants received the improved measures during going out for diagnostic tests, and the incidence of hypothermia before and after the improvement were compared. Results After implementation of the improved measures, the temperatures of the preterm infants during going out for B-mode ultrasound imaging of part of, or full abdomen, and auditory evoked potentials test were significantly improved (P<0.01 for all), and the incidence of hypothermia decreased from 37.31% before to 10.34% (P<0.01) after the implementation. Conclusion RCA combined with procedure optimization in preterm infants going out for diagnostic tests, could effectively reduce the incidence of hypothermia during going out for diagnostic tests.