论临床路径在医疗管理中的应用进展

本文在阅读大量文献资料的基础上,指出常规医疗质量管理方法的漏洞较多,无法全面满足患者对医疗质量的需求。将临床路径应用其中,是解决上述问题的关键。并对临床路径在医疗管理中的应用进展进行了综合阐述,在介绍医疗管理与临床路径的基础上,分析了将临床路径应用到医疗管理中的意义,并从准备阶段、制订阶段、实施阶段、持续质量改进阶段、监测与评价等五个方面,针对其应用价值、实施方法、问题的解决与进展等问题,进行了详细阐述。明确指出临床路径在实际应用中存在的问题,在肯定其长远应用价值的同时,提出进一步研究的方向。     

临床路径在医疗质量管理中的应用

介绍了临床路径（Clinical Pathway，CP）的起源、概念、优点和实施方法，提出了在我国实施临床路径的重要意义、紧迫性、面临的困难及解决的基本思路。     

临床路径管理实践的讨论

实施临床路径(Clinical Paths;CP)管理是医疗质量持续改进、保障医疗安全的重要举措,是医院实现现代化管理的体现;实施CP还可以逐步引导医院做到"三个转变"、"三个提高". 1 我院实施临床路径管理的情况 早在2004年,鼓楼医院就在手术科室试行了"开腹胆囊炎"临床路径管理,制定了"路径流程图"、"标准医嘱"、"变异记录表"以及"胆囊炎临床路径医护版、患者版"等文件,当年有50例手术患者实施了路径管理;2009年被指定为卫生部首批临床路径管理工作的试点医院,经过3年的努力,目前临床路径管理已覆盖住院部全部临床科室,开展了93个病种的信息化路径管理.     

信息系统在口腔专科医院临床路径实施与管理中的应用

目的探索信息系统在口腔专科医院临床路径实施与管理中的应用效果,为加强临床路径的信息化管理提供参考。方法介绍口腔专科医院实施CP过程中引入信息系统管理,包括CP信息系统的建立、功能、实施效果等,分析信息系统在临床路径实施和管理中的关键环节与要点。结果信息系统对临床路径实施管理主要从路径导入、路径执行与监控、变异分析、质量效果统计等方面建立平台和实现功能,促进临床路径的持续改进和完善。结论临床路径信息管理系统作为医院信息系统的一个功能模块或功能整合系统,有助于提高管理效率,降低管理成本,准确且高效地统计质控数据,减轻临床工作人员负担,对于规范临床路径实施起到非常积极作用。     

临床路径在普外科临床带教中的应用

目的探讨临床路径(CP)教学法在普外科临床带教中应用的效果及可行性。方法将临床生产实习学生随机分为对照组和CP组,对照组采用传统带教方法,CP组采用临床路径教学法分别对两组进行考核。结果 CP组成绩优于传统教学组(P<0.05)。结论 CP教学法在临床实习中提高了教学效果。     

"临床路径"在大容量肺灌洗治疗尘肺中的应用

目的 评价临床路径(CP)应用于大容量肺灌洗治疗尘肺患者实施效果.方法 将130例大容量肺灌洗治疗尘肺患者按住院顺序随机分为CP组和对照组,对照组65例实施传统治疗和护理,CP组65例实施CP,比较两组的治疗、护理效果.结果 CP组平均每人住院费用(8803.66±812.02)元,对照组平均(10534.69±1035.43)元,两组比较,差异有统计学意义(P<0.01).CP组平均每人住院天数(9.7±1.3)d,对照组平均为(12.9±2.4)d,两组比较,差异有统计学意义(P<0.01).结论 CP应用于大容量肺灌洗治疗尘肺能提高医疗护理质量,降低住院费用,缩短住院时间,在临床实践中切实可行.     

临床路径干预对髋关节置换术预防用抗菌药物的影响

目的了解实施临床路径（CP）前后,髋关节置换术患者围手术期预防应用抗菌药物情况,为临床提供合理、有效的管理路径。方法 对某院2008年1月-2011年12月间120例髋关节手术患者围手术期预防使用抗菌药物情况进行回顾性调查。其中2008年1月-2009年12月间60例患者设为干预前组,未采取CP治疗方案;2010年1月-2011年12月间60例患者设为干预后组,执行CP治疗方案。结果实施CP后,术前0.5～2 h使用抗菌药物率（78.33%,47/60）和术后预防使用抗菌药物时间≤5 d的比率（91.67%,55/60）显著高于实施CP前（分别为31.67%,19/60;5.00%,3/60）,差异有统计学意义（均P＜0.05）;用药品种,由居前3位的头孢哌酮/舒巴坦、头孢匹胺、头孢他啶更改为头孢唑林、头孢呋辛、克林霉素;平均用药时间、平均住院时间及每日抗菌药物费用分别由（13.25±1.69）d、（17.55±1.60）d、（193.22±34.70）元降至（4.12±0.87）d、（7.83±1.36）d、（54.03±9.98）元,差异均有统计学意义（均P＜0.01）。结论 CP的实施规范了髋关节置换术围手术期的预防用药,缩短了住院时间,降低了药物费用。     

临床路径(Clinical pathways) --一种单病种质量管理的现代新模式

临床路径 (CP)是一种单病种质量管理的现代新模式。该文较详细地阐述了 CP的定义与概念 ,CP产生的历史背景、实施 CP的目的与现实意义、选择 CP病种的原则、CP设计程序、CP实践效果的评估以及 CP在中国实施的展望     

儿外科四个单病种临床路径实施效果分析

[目的]探讨临床路径方法在儿科手术单病种的运用，为住院患者合理医疗费使用和改进医疗质量的实践提供参考。[方法]对广州市儿童医院2006年5月18日～12月31日的儿外科手术单病种（单侧腹股沟斜疝修补术、直肠病损切除术）和2006年10月1月～12月31日（唇裂修补术、鞘膜积液手术）共4个病种，分别实施了临床路径管理（CP组）作为实验组，与2005年1月1日～2005年12月30日末实施临床路径的4个相同病种用传统医疗护理管理（非CP组）对照组进行对比分析，以各组平均住院日、住院费用等作为评价指标。[结果]实施了CP组管理与非CP组管理的患者比较，4个病种在住院费用方面差异有统计学意义。有2个病种在住院时间方面差异有统计学意义。[结论]临床路径应用于儿科部份手术单病种，可以明显降低住院费用，缩短住院时间，提高病人满意度。     

某二甲医院临床路径管理的应用效果分析

目的 评价临床路径应用于8个有代表性单病种的临床效果.方法 用历史对照法选取单病种1785例实施临床路径管理(Clinical Pathway组,CP组)和同期1548例非临床路径管理组(Non-Clinical Pathway组,NCP组),对次均住院费用、平均住院日及患者满意度等指标进行综合评价后比较.结果 CP组的次均住院费用、平均住院日比NCP组低(P＜0.05),患者满意度CP组明显高于NCP组(P＜0.01).结论 临床路径管理可以降低单病种住院费用、缩短住院时间、提高患者对治疗的满意度.     

Immunopotentiation of Staphylococcus aureus type 5 capsular polysaccharide co-entrapped in liposomes with alpha-toxin

Immunopotentiation of Staphylococcus aureus type 5 capsular polysaccharide (CP5) by use of liposomes as an alternative to protein-polysaccharide conjugates was investigated. Mice were immunized twice with cationic liposomes containing CP5 alone or CP5 co-entrapped with alpha-toxin or heat-detoxified alpha-toxin. Immunogenicity of these different antigens was compared with CP5-alpha-toxin conjugates. Antibodies against CP5 were elicited in mice immunized with conjugates or liposomes containing co-entrapped CP5 and alpha-toxin. Liposomes containing CP5 alone or co-entrapped CP5 and alpha-toxoid failed to induce antibodies against CP5. All the preparations entailed an antibody response against alpha-toxin and highest antibody and neutralizing activity titers were obtained with liposomes. These results show that liposomes can be used to immunopotentiate CP5, however, a co-incorporated protein able to insert lipids bilayers is probably required.     

环磷酰胺对小鼠体重和精子影响

目的探讨不同剂量的环磷酰胺（CP）对小鼠体重和精子畸形的影响。方法将雄性昆明种小鼠随机分成阴性对照组和不同剂量环磷酰胺试验组,经口连续灌胃5 d,正常饲养到35 d解剖动物,观察各试验组小鼠体重、精子畸形和精子数量的变化。结果连续灌胃5 d后,CP各组小鼠的体重与对照组比较均减轻（F=205.06,P〈0.01）;CP剂量越大,小鼠体重减轻越多。CP剂量越大,小鼠精子数量减少越多,CP 60 mg/（kg.BW）剂量组为最少,与空白对照组比较,差异有统计学意义（F=39.71,P〈0.01）。CP 30 mg/（kg.BW）以上剂量组均可引起精子畸形数量增加,随着剂量加大,畸形精子数越多。30与40 mg/（kg.BW）组的精子畸形率与对照组差异有统计学意义（F=51.24,P〈0.01）。结论 CP 40 mg/（kg.BW）以上剂量组,可使小鼠体重明显减轻、精子数量明显减少。     

尿铜蓝蛋白与糖尿病肾病关系的研究

目的 研究尿铜蓝蛋白(CP)与糖尿病肾病(DN)的关系.方法 将236例2型糖尿病患者分为正常白蛋白(Alb)尿组(DMN组)129例,微量Alb尿组(DMMA组)107例,另选择81例健康体检者作为对照组(C组).检测尿CP、Alb、肌酐(Cr)和血清CP等.结果 (1)尿CP/Cr中位数在DMMA组为2.55 ng/mmol,在DMN组为1.18 ng/mmol,均显著高于C组0.92 ng/mmol,P<0.01;血清CP在各组间比较差异均无统计学意义(P>0.05).(2)2型糖尿病患者尿Alb/Cr与尿CP/Cr呈显著正相关(r=0.188,P<0.01),糖尿病病程为尿CP/Cr和Alb/Cr升高的危险因素.结论 2型糖尿病患者尿CP与尿Alb排泄量有一致性升高的趋势.2型糖尿病患者尿CP升高,其与DN的发生和严重程度有较好的相关性,尿CP可以用来监测DN的发生、病情进展和治疗效果.     

新疆维吾尔族儿童脑性瘫痪发生的危险因素分析

目的 分析新疆维吾尔族儿童脑瘫发生的危险因素,为脑瘫的预防和治疗提供临床依据。方法 收集2013年1月-2015年6月新疆自治区人民医院收治的0~6岁维吾尔族脑瘫患儿286例,与相同年龄段的维吾尔族健康儿童572名作比较,应用单因素和多因素Logistic回归分析脑瘫发生的危险因素。结果 单因素Logistic分析显示:影响脑瘫发生涉及遗传因素、产前、产时和产后的多种因素。多因素Logistic回归分析得出该种族儿童脑瘫的危险因素主要有近亲结婚、脑病家族史、母孕期感染、母不良孕产史、胎龄<32周、宫内窘迫、低出生体重、新生儿窒息、新生儿重度黄疸、新生儿缺氧缺血性脑病。结论 新疆维吾尔族儿童脑瘫的发生涉及多种危险因素,应积极加强对各危险因素的预防和干预工作,以降低儿童脑瘫的发生率。     

基于文献计量方法的我国临床路径政策问题论证

目的:分析我国临床路径不同发展阶段及特点,论证现阶段我国临床路径面临的主要问题并提出对策建议。方法:采用文献计量方法分析国内临床路径文献总体趋势,采用内容分析法分析我国临床路径政策及阶段特点,采用关键词共现法分析现阶段我国临床路径面临的主要问题。结果:我国临床路径发展可划分为理论探索、试点探索和综合发展3个阶段。临床路径已进入常态化管理,但尚面临管理水平、标准化、信息化和医保支付等多方面问题。结论:在政策推动下,临床路径已成为医院科学化管理的重要工具,但仍需通过提升临床路径管理水平、规范临床路径实施流程、完善医保支付方式、加强信息化建设等方式,促进我国临床路径的发展。     

The effect of varying crude protein level and the proportions of fibre in diets containing a mixture of meat-and-bone meal and wheat bran as the only protein source on nitrogen balance indices and energy digestibility in the rat

1. The experiment was designed to investigate the effect of protein level in diets on apparent protein digestibility (AD), true protein digestibility (TD), biological value (BV), net protein utilization (NPU) and energy digestibility (DE) in rats. The design involved fourteen dietary treatments in which a combination of wheat bran and meat-and-bone meal (1:1, w/w dry matter (DM) basis) was the only nitrogen source. Crude protein (N x 6.25; CP) level ranged from 60 to 329 g/kg DM in approximately even increments. All diets contained a constant level of minerals and vitamins. The balance of the diet consisted of a N-free mixture. 2. AD increased from 0.602 at 60 g CP/kg DM to 0.702 at 120 g CP/kg DM, with little change at the higher levels of dietary protein. The fitting of a curve indicated an asymptote of 0.721. 3. TD did not vary significantly between 60 and 225 g CP/kg DM (mean 0.781). At the higher protein levels there was a slight but significant reduction in the mean value (0.758). 4. BV increased from 0.475 at 60 g CP/kg DM to 0.498 at 80 g CP/kg DM where it plateaued, and then from 160 g CP/kg DM it decreased at an increasing rate to 0.216 at 329 g CP/kg DM. 5. The response in NPU closely reflected that obtained with BV, rising from 0.370 to 0.384, then declining to 0.162 at the highest CP concentration. 6. DE decreased linearly from 0.851 at 60 g CP/kg DM to 0.617 at 329 g CP/kg DM. 7. The results confirmed that AD values should only be compared at a defined protein level. TD was essentially independent of dietary CP level, except for a small reduction above 250 g CP/kg, whereas BV and NPU were stable only within the range 80-140 g CP/kg DM. DE was negatively related to dietary CP and fibre level.     

Relationship between exposure to chlorpyrifos and concentration of urinary alkylphosphates in termite control workers

Chlorpyrifos (O, O-diethyl-3,5,6-trichloro-2-pyridinyl phosphorothioate; CP) has been used for insecticide to prevent infestation of termites. A study was made on occupational exposure to CP of termite control workers engaged in spraying this organophosphorus insecticide. Workers were engaged in two types of spraying; that is spraying CP under floor and spraying CP around house. All the under-floor sprayers wore respirators during spraying. CP levels in air near the breathing zone, contact amounts of CP with skin, and urinary alkylphosphates levels were higher in the under-floor sprayers than in the around-house sprayers. The personal ambient CP levels of the under-floor sprayers were 0.012 to 0.145 (8 h-TWA, mg/m3) lower than the threshold limit value (0.2 mg/m3) proposed by ACGIH. A maximum diethylphosphate (DEP) excretion was observed in the first urine collected the next day, while the highest diethylthiophosphate (DETP) was excreted in the last urine in the working day. In the excretion amount, DEP was higher than DETP. Amounts of CP collected in respirators used by the under-floor spraymen averaged 0.76 mg/respiratory comparable to their estimated theoretical value of 0.69 mg/m3. The urinary total alkylphosphate (DEP + DETP) level was more closely correlated with the contact amount of CP with skin (r = 0.86) than with the personal ambient CP level (r = 0.05). These results indicate that 1) respiratory absorption of CP was prevented by the use of respirator; 2) the urinary alkylphosphates were mainly derived from the dermal absorption of CP; and 3) biological monitoring using urinary alkylphosphates levels is an useful index for CP exposure.     

A preliminary study into the economic burden of cerebral palsy in China

OBJECTIVES: To measure the economic burden of cerebral palsy (CP) in China is to provide information on CP's societal impacts to policy-makers. METHODS: The economic burden of CP includes direct healthcare costs, direct non-healthcare costs, developmental costs and indirect costs such as productivity loss. The incidence approach is employed to estimate the lifetime economic burden of a new CP birth and that of all new cases in China in 2003. Caregivers of 319 CP patients were interviewed in specialty hospitals in five cities in 2004. Average expenditure and utilization rates for different services by age groups from this sample were obtained to estimate the economic burden of CP. Chinese CP patients' life expectancy and survival rate were simulated with reference to Australian data with Human Development Index adjustment. RESULTS: From the societal perspective, the average lifetime economic burden of a new CP case in China was US$ 67,044 in 2003, and the life-span total economic loss due to all new CP cases in 2003 amounted to US$ 2-4 billion. Indirect (productivity) costs are responsible for 93% of total economic loss, and direct healthcare and developmental costs make up 3% each. There are several factors which contribute to the extraordinarily high economic burden of CP, including productivity loss, reduced life expectancy, dependency, progressive deterioration of motor physical function, and recurrent use of rehabilitation services. CONCLUSION: The economic burden of CP in China is substantial for the family of a CP patient, as well as to society. Public provision and financing of necessary preventive and rehabilitative services is urgently needed to mitigate this heavy burden for patients and their families.     

60例脑性瘫痪儿童视频脑电图的特征分析

目的 分析视频脑电图在脑瘫患儿中的应用价值。方法 采用国际10/20系统电极放置法,对60例脑瘫患儿进行清醒、睡眠等状态的视频脑电图检查,分析脑电图异常特征与患儿脑瘫类型的相关性。结果 60例脑瘫患儿的脑电图异常率为76.67%(46/60),其中痉挛型脑电图异常率最高85.37%(35/41),痉挛型脑瘫中并发癫痫的比例为46.34%(19/41)。结论 脑瘫患儿脑电图异常率高,脑电图异常特征能帮助判断脑损伤部位、是否并发癫痫及明确发作类型,有助于反映患儿神经系统的功能状况。