我国护理临床实践指南的质量评价

目的:评价中国护理领域临床践指南的质量。方法:由2名研究人员检索国内外数据库,包括PubMed、CINAHL、Web of Science、中国知网(CNKI)、中国生物医学文摘数据库(CBM)、万方数据库(WanFangData)、维普中文科技期刊数据库(VIP)及相关网站,检索时间为建库至2019年7月31日,采用中国临床实践指南评价体系(AGREE-China)、RIGHT清单及指南实施性评价工具(GLIA2.0)对纳入指南进行质量评价。结果:共纳入20篇指南,AGREE-China平均得分为(71.71±13.16)分;RIGHT清单条目报告率在0和100.0%之间;实施性评价结果中单篇指南符合率最高为100.0%,最低为60.0%。结论:中国护理临床实践指南的总体质量较好,但在有效性/安全性、自主与利益冲突类型等方面的报告仍较为欠缺。     

2019年期刊公开发表的中国临床实践指南文献调查与评价——传播与实施情况

目的 分析2019年期刊公开发表的中国临床实践指南传播与实施情况,为推动我国临床实践指南的转化与落地提供建议。方法 针对2019年期刊公开发表的中国临床实践指南传播与实施相关内容报告情况,以及指南多期刊、多版本、多语种发表情况进行分析。同时,分析2019年中国临床实践指南解读类文献的发表情况,进一步了解我国指南的传播与实施现状。结果 2019年期刊公开发表的中国临床实践指南共226篇,仅5.8%(13/226)报告了传播与实施相关内容。共报告了12种传播与实施策略,其中通过学术会议及多媒体平台促进指南传播与实施被报告的次数最多,在8篇指南中均进行了报告。在传播与实施策略的应用方面,12.4%(28/226)的指南在多本期刊上公开发表,9.3%(21/226)的指南发表了不同版本,8.4%(19/226)的指南分别以中、英文语种进行发表。对2019年中国指南的解读类文献进行检索,共纳入48篇文献,分别对30篇(13.3%,30/226)指南进行了解读。指南与解读类文献发表的中位时间间隔为5.5个月。结论 2019年期刊公开发表的中国临床实践指南中传播与实施的报告率及相关策略的应用率均较低...     

2019年期刊公开发表的中国临床实践指南现状评价

调查2019年国内外期刊公开发表的中国临床实践指南现状,分别从制订人员、利益冲突、引文、证据质量和推荐强度分级、方法学质量与报告质量、研究空白、传播与实施7个方面进行分析,旨在为我国指南制订者、使用者和评价者提供参考.     

《中成药治疗优势病种临床应用指南》实施性评价

目的 分析《中成药治疗优势病种临床应用指南》的实施性现况与质量。方法 纳入2019年2月—2022年8月公开发表的中成药治疗优势病种临床应用指南。使用指南实施性评价工具对纳入指南的实施性概况进行总结及评价。结果 本研究共纳入29部指南,总体实施性质量较高,13部指南的实施性质量属于高等级(44.8%),16部属于中等级(55.2%)。结论 《中成药治疗优势病种临床应用指南》实施性质量高于国内其他中医/中西医结合指南。指南实施性评价工具适用于中医药指南的评价,但中医药指南的实施性评价方法仍需综合考量中医药本身的特殊性。     

气道湿化临床实践指南的质量评价

目的评价关于国内外气道湿化临床实践指南质量,为气道湿化相关临床工作提供参考。方法通过国内外指南网站和数据库,系统检索关于国内外气道湿化的临床实践指南,检索时限为2000年1月1日—2019年8月30日。由2名研究人员独立筛选文献,4名评价人员使用AGREE II对纳入指南独立评价,采用组内相关系数(ICC)衡量评价人员内部一致性。结果初检2 966篇文献,最终纳入12篇指南,评价人员对每个领域的总体一致性较好(ICC为0.820～0.925),各领域平均得分分别为:范围和目的87.50%、参与人员56.83%、严谨性70.93%、清晰性78.70%、应用性49.22%、编辑独立性47.05%,推荐等级均为B级。结论纳入指南质量中等,同一指南不同领域之间存在高度异质性,在应用性、编辑独立性领域仍有待提高。     

基于临床实践指南决策树的设计与思考

临床实践指南可以促进临床诊疗规范化,提高医疗服务质量。但是,指南在传播与实施过程中可能存在多种障碍因素,导致其对临床实践的规范性及患者结局的有效性并未完全体现。主要障碍在于非结构化的文本指南不便于临床医生查阅和使用,阻碍了指南在临床实践中的应用。因此,本文通过介绍决策树模型,阐述将文本化的指南转化为结构化决策树的方法,提出基于临床实践指南设计决策树的优点、难点及解决策略,为推动文本化临床实践指南的转化提供参考。     

临床实践指南透明度评价工具2.0的循证构建

目的 以公信力为导向,构建临床实践指南（CPGs）透明度评价工具2.0。方法 采用德尔菲法对评价指标的重要性和可操作性进行评分和筛选,并利用层次分析法确定指标权重,通过专家共识会议确定最终评价指标体系。结果 构建了包括利益冲突和制订流程2个一级指标,制订人员、评审人员、计划书与注册、证据生产、推荐意见形成、外部评审6个二级指标,并在二级指标的基础上,从披露和管理的角度出发构建了21个三级指标,其逻辑结构严谨、和谐。结论 本研究构建的CPGs透明度评价工具2.0,为CPGs的透明度评价提供了新的衡量标准和评估体系。     

临床实践指南综合评价的思考与探索

临床实践指南的综合评价是衡量指南质量的重要方法。本文介绍了指南评价的作用和意义,系统梳理了指南评价工具的现状与发展;在此基础上,阐述了指南综合评价工具STAR的内容和特点,以期为指南综合评价体系的完善以及高质量指南的制订提供参考。     

中西医结合临床实践指南实施框架构建的思考

中西医结合临床实践指南作为医学实践的重要指导性文件,是发挥中西医各自优势,促进中西医结合的重要抓手。然而目前中西医结合指南的研究存在“重研制”而“轻实施”的问题,依据实施科学的理论框架,构建中西医结合临床实践指南实施框架和方法,有利于促进中西医结合指南的实施和中西医临床的融合与发展。本文通过梳理和分析知识-行动框架,对中西医结合指南实施框架的研发思路展开讨论和思考,以期为未来相关研究奠定基础。     

制订指南临床适用性评价工具

目的建立由指南目标使用者担任评价者的指南临床适用性评价工具。方法课题组组建了多学科团队,通过系统评价现有指南临床适用性评价工具、两轮德尔菲法专家咨询及外审,循证建立指南临床适用性评价工具。结果指南临床适用性评价工具包括:①评价者基本信息12个条目;②指南临床适用性评价内容,包括可获得性、可读性、可接受性、可行性4个领域和总体评价共12个条目;③评分方案。结论本研究建立了由指南使用者任评价者的指南临床适用性评价工具,为循证评价指南临床适用性提供标准和方法。     

Clinical practice guideline dissemination and a new approach using Haddon matrix as a conceptual framework of evidence-based implementation strategies

To err is human. Clinical practice guidelines (CPGs) are often not followed and lead to adverse outcomes. The issue on implementation of CPG is complex. A review of CPG implementation is done to identify the barriers and enablers. For the first time, a fishbone diagram is used to delineate the root-causes. And Haddon matrix is applied to help understand the complexity of evidence-based implementation (EBI) strategies.KEY WORDS: Clinical practice guideline, Implementation, Barriers, Enablers     

全球指南临床适用性评价工具现状的系统评价

目的了解全球指南临床适用性评价工具现状,为循证建立指南临床适用性评价指标体系提供依据。方法计算机检索7个生物医学文献数据库、6个指南数据库及16个学术机构与卫生行政部门网站,搜集有关指南临床适用性评价工具的文献,检索时限均为建库至2019年4月。由2名研究者独立筛选文献、提取资料后,采用主题综合法初拟出指南临床适用性的评价指标。结果共纳入19篇文献,其中专门针对指南临床适用性的评价工具4个,涉及指南临床适用性评价条目的评价工具15个。通过梳理比较,发现这些工具在评价者、评价领域、评价条目等方面均存在差异。结论全球现有指南临床适用性评价工具的目标针对性不强、指标完整性欠佳、对评价者的指南方法学知识要求较高,尚缺乏从指南目标用户视角出发的指南临床适用性评价工具。     

基于渥太华研究应用模式的妊娠期糖尿病临床护理实践指南应用方案的构建

目的构建妊娠期糖尿病临床护理实践指南应用方案。方法以渥太华研究应用模式为指导,建立指南应用方案构建小组和咨询小组,采用专家咨询法,根据前期确定的障碍因素,从证据、采纳者及实践环境三面面构建指南应用方案。结果在证据方面,制定了针对护理人员的“妊娠期糖尿病护理管理最佳实践手册”;在实践者方面,构建了护理人员培训方案;在患者方面,构建了“妊娠期糖尿病孕妇自我管理手册”、体验门诊、基于微信平台的健康教育;在实践环境方面,构建了护理操作规范和管理流程、患者血糖管理档案、以妊娠期糖尿病专科护士为主导、病区责任护士参与的专科护理团队、多途径、多形式的妊娠期糖尿病健康教育方案、GDM专科护士与医生的双向转诊流程。结论在渥太华研究应用模式的指导下,本研究构建了基于指南的可操作性强的综合干预策略,获取领导力支持、推动干预策略的实施,是下一步研究的重点。     

The implementation of a nursing student clinical assessment tool onto an online platform: An evaluation by clinical facilitators and academic staff

BackgroundFormative and summative assessment plays an integral role in the learning process for undergraduate nursing students on clinical placement.AimEvaluate the integration and implementation of the Australian Nursing standards assessment tool to the online SONIA database.MethodsThe study was designed to evaluate the experiences of clinical facilitators and academic staff using the online platform, which included an online survey and focus group sessions.FindingsWhilst there are benefits gained from using the online system, results highlighted limitations in using technological devices on clinical placement and a lack of education in using the online platform.DiscussionImplementation of a student clinical assessment tool onto an online platform was introduced to counteract the inherent challenges of managing hard-copy assessment data and meet sustainable teaching practices. Participants noted an ease of accessibility to assessment, although issues identified were access to internet in healthcare organisations and lack of education prior to the implementation of the online tool would have supported their experience.ConclusionIntegration of the Australian Nursing Standards Assessment Tool (ANSAT) onto the planet software database brought significant improvements to the access and management of clinical placement assessment information.     

指南临床适用性评价的问题与需求

临床实践指南是缩小当前最佳证据与临床实践差距的决策工具。指南临床适用性是指临床指南推荐意见能够应用于临床实践的程度。已有研究显示:现有临床指南存在临床适用性差的问题,且仅提高指南质量可能无法解决此问题。国家卫生健康委医疗管理服务指导中心立项开展临床实践指南临床评价体系建设,拟基于循证方法制订由临床指南目标使用者进行评价的指南临床适用性评价体系,旨在:(1)甄别出临床适用性高的指南;(2)推广临床适用性佳的指南在临床的应用;(3)为指南制/修订者反馈指南的临床适用性结果,以帮助优化指南制订和更新,持续提升指南适用性,真正使临床实现指南可用、好用。     

Prioritizing guideline topics: development and evaluation of a practical tool

RATIONALE, AIMS AND OBJECTIVES: A clear process for selecting and adopting clinical practice guidelines in the new topic areas is needed. The aim of this study is to design and develop a practical tool to assess guideline topics that have been suggested to the organization responsible for producing guidelines. METHODS: We carried out an iterative development, feasibility and validation study of a guideline topic prioritization tool. The setting included the guideline producer organization and the tax-funded health care system. In the first stage of the tool development, participants were researchers, members of the Current Care Board and experts from health care organizations. In the second stage, the evaluation was done internally within the project by three independent reviewers. The main outcome measures were responses to an evaluation questionnaire, qualitative process feedback and analysis of the performance of the instrument on a random set of guidelines. RESULTS: Evaluations by three independent reviewers revealed good agreement and face validity with respect to its feasibility as a planning tool at the guideline board level. Feedback from board members suggested that the instrument is useful in prioritizing guideline topics. CONCLUSION: This instrument was accepted for use by the Board. Further developments are needed to ensure feedback and acceptability of the instrument by those proposing topics.     

The fracture and osteoporosis outpatient clinic: an effective strategy for improving implementation of an osteoporosis guideline

BACKGROUND: Clinical screening for osteoporosis in women aged over 50 years following a fracture is advocated by all guidelines on osteoporosis, but such attitude is widely reported to be inadequate. The aim of this study was to evaluate the effect of a strategy comparing referral for a dual-energy X-ray absorptiometry (DXA) scan as part of the osteoporosis guideline by a dedicated osteoporosis nurse with referral in hospitals without the presence of an osteoporosis nurse. METHODS: We retrospectively compared one reference hospital with five surrounding hospitals in the Netherlands. During a 2-week period, all female patients aged over 50 years who presented with a fracture at the emergency department of the six hospitals were included. Follow-up was minimal 11 weeks. The primary outcome was the referral for DXA measurement. RESULTS: In total, 135 patients were included, of whom 33 were seen in the reference hospital and 102 in the surrounding hospitals. In both groups, mean age and fracture location were similar. In the reference hospital, 14 patients qualified for DXA measurement, of whom 10 patients effectively underwent a DXA scan (71%). In the surrounding hospitals, 78 patients qualified for DXA measurement, of whom only three effectively underwent a DXA scan (4%). Taking into account a refusal percentage for DXA of 33% as was found in the reference centre, 47 patients in the surrounding hospitals should have been qualified for DXA measurement. Thus, successful referral in the surrounding hospitals was three out of 47 (6%) patients. The presence of an osteoporosis nurse did have a significant influence on the amount of DXA scans after fractures [RR 11 (95% CI: 3.6-35.1)]. CONCLUSIONS: This study indicates that referral for DXA is low in surrounding hospitals, and suggests that the presence of an osteoporosis nurse in the reference hospital significantly increased the number of patients receiving adequate osteoporosis screening with DXA measurement after a recent fracture. With this strategy patients who are at risk of osteoporosis are identified effectively, after which treatment can be started, in order to reduce the risk of future fractures.     

The effect of an algorithm-based sedation guideline on the duration of mechanical ventilation in an Australian intensive care unit

Objective To examine the effect of an algorithm-based sedation guideline developed in a North American intensive care unit (ICU) on the duration of mechanical ventilation of patients in an Australian ICU.Design and setting The intervention was tested in a pre-intervention, post-intervention comparative investigation in a 14-bed adult intensive care unit.Patients Adult mechanically ventilated patients were selected consecutively (n = 322). The pre-intervention and post-intervention groups were similar except for a higher number of patients with a neurological diagnosis in the pre-intervention group.Intervention An algorithm-based sedation guideline including a sedation scale was introduced using a multifaceted implementation strategy.Measurements and results The median duration of ventilation was 5.6 days in the post-intervention group, compared with 4.8 days for the pre-intervention group (P = 0.99). The length of stay was 8.2 days in the post-intervention group versus 7.1 days in the pre-intervention group (P = 0.04). There were no statistically significant differences for the other secondary outcomes, including the score on the Experience of Treatment in ICU 7 item questionnaire, number of tracheostomies and number of self-extubations. Records of compliance to recording the sedation score during both phases revealed that patients were slightly more deeply sedated when the guideline was used.Conclusions The use of the algorithm-based sedation guideline did not reduce duration of mechanical ventilation in the setting of this study.