ICU患者谵妄评估约束分级方案的设计与临床应用

目的设计ICU患者谵妄评估约束分级方案并分析其临床应用效果。方法借助德尔菲专家函询法制定ICU患者谵妄评估约束分级方案。选取2018年2月至2020年1月收治郑州大学第一附属医院ICU患者86例, 根据护理单元将其分成两组。对照组(42例)约束指导运用加拿大ICU约束决策轮和等级工具, 观察组(44例)运用ICU患者谵妄评估约束分级方案。结果对比两组患者疾病转归、总约束时间以及各级约束时间等差异有统计学意义(P<0.05)。在跌倒/坠床、非计划性拔管率、患者满意度方面的对比差异无统计学意义(P>0.05)。结论以德尔菲专家函询法制定的ICU患者谵妄评估约束分级方案, 不但能够使ICU患者的约束时间得以缩短, 身体约束率降低、约束强度减弱, 而且还能够使其预后得到有效的改善。     

基于循证构建ICU亚谵妄综合征早期识别及管理方案

目的 基于循证构建ICU亚谵妄综合征早期识别及管理方案,为临床亚谵妄综合征患者护理提供依据。方法 基于循证方法学,通过德尔菲专家函询法建立条目池并进行筛选,确立ICU亚谵妄综合征早期识别及管理方案内容,采用层次分析法确定条目权重。结果 2轮专家权威系数分别为0.817,0.820;方案整体专家肯德尔和谐系数为0.354。最终确定一级指标2项、二级指标9项、三级指标46项,包含ICU亚谵妄综合征高危因素、风险评估、认知干预、日常管理等内容。结论 基于循证构建ICU亚谵妄综合征早期识别及管理方案,具有一定科学性和可靠性,为临床亚谵妄综合征的早期识别及管理提供依据。     

ICU患者早期康复方案的构建及应用研究

目的 构建并应用ICU患者早期康复方案,以降低ICU获得性衰弱（intensive care unit acquired weakness,ICU-AW）的发生率,改善ICU患者的临床结局。方法 运用文献分析法和Delphi法构建ICU患者早期康复方案,将70例于2018年10月—2019年4月入住安徽省某三级甲等医院综合ICU的患者随机分为试验组和对照组,每组各35例,试验组按本研究制订的方案进行康复,对照组按ICU护理常规进行康复,干预后采用英国医学研究委员会（Medical Research Council,MRC）肌力评定法、Barthel指数评定表、ICU-AW的发生率、ICU住院时间评估两组的干预效果。结果 本研究构建的ICU患者早期康复方案包括早期运动、心理护理、营养支持、效果评价4个部分,32项具体康复内容。试验组转出ICU当天的肌力、Barthel指数评分均显著高于对照组（P<0.001）,ICU住院时间短于对照组（P<0.05）,ICU-AW的发生率显著低于对照组（P<0.05）。结论 本研究构建的ICU患者早期康复方案具有较强的科学性和可靠性,应用该方案能降低ICU-AW的发生率,改善患者的临床护理结局。     

ICU患者谵妄评估约束分级方案在神经外科意识障碍患者中的应用

目的讨论ICU患者谵妄评估约束分级方案在神经外科意识障碍患者约束评估管理中的应用效果观察。方法 2019年3～8月我科收治的意识障碍患者43例,按照随机数字表法分为对照组21例和试验组22例。试验组采用ICU患者谵妄评估约束分级方案,对照组采用格拉斯哥分级和RASS镇静程度评估表。比较两组患者约束强度、约束率及患者满意度。结果试验组约束例数和烦躁增加例数高于对照组(P005),两组约束部位皮损例数及患者满意度分数差异无统计学意义(P005)。结论 ICU患者谵妄评估约束分级方案能更好地为评估人员提供清晰具体的约束分级方案,可明显减少患者约束率。适合在神经外科意识障碍患者的约束评估中运用和推广。     

ICU转出患者肺部护理计划的实施及效果评价

目的 降低外科术后患者因肺部感染非计划重返ICU率。 方法 成立ICU转出患者肺部护理小组,参照多学科围手术期气道管理中国专家共识（2018版）,通过评估ICU转出患者肺部高危因素,制订和落实个体化肺部护理计划,建立实施过程风险排查机制,基于气道分级管理标准进行转出前后肺部护理效果评价及质量控制共计5个关键流程。比较改进前（对照组）、改进后（试验组）患者因肺部感染重返ICU率,以及肺部护理干预频次和患者满意度。 结果 试验组和对照组发生因肺部感染重返ICU率分别为0%和11.06%,差异具有统计学意义（P<0.01）;试验组各项肺部护理措施的干预频次多于对照组,差异均具有统计学意义（均P<0.01）;试验组满意度高于对照组,差异具有统计学意义（P<0.01）。 结论 通过ICU转出患者肺部延伸护理计划的实施,为ICU转入普通病房的过渡期患者提供持续的肺部管理,可降低重返ICU率并提高患者的就医体验。     

以护士为主导的早期活动方案在机械通气患者中的应用研究

目的 分析以护士为主导的早期活动方案在神经系统重症疾病机械通气患者中应用的安全性、依从性及效果。 方法 选取2019年1月—3月某三级甲等医院ICU收治的158例患者作为试验组,实施以护士为主导的早期活动方案;选取2018年10月—12月收治的神经系统重症疾病机械通气患者147例作为对照组,给予机械通气常规护理。观察试验组的安全性及依从性,比较两组恢复情况及并发症发生率。 结果 试验组运动前（5 min、10 min）,运动中（5 min、10 min）以及运动后（5 min、10 min）颅内压、心率、血氧饱和度变化差异无统计学意义（P>0.05）,平均动脉压变化差异有统计学意义（P<0.05）。试验组依从性为98.1%,对照组的依从性为74.8%,两组比较,差异具有统计学意义（P<0.05）。试验组机械通气时间、ICU住院时间、整体住院时间明显低于对照组（P<0.05）,出院日常生活能力评分明显高于对照组（P<0.05）。试验组呼吸机相关性肺炎、下肢深静脉血栓发生率明显低于对照组（P<0.05）;两组ICU谵妄发生率差异无统计学意义（P>0.05）。 结论 对神经系统重症疾病机械通气患者实施以护士为主导的早期活动方案具有较高的安全性及依从性,能够改善患者的恢复状况,减少并发症的发生,促进患者早期康复。     

ICU患者谵妄严重程度分级的研究进展

目的 梳理ICU患者谵妄严重程度的国内外研究现状,为临床护理工作提供借鉴。方法 检索国内外相关文献,从ICU患者谵妄严重程度的相关概念、国内外研究现状、ICU谵妄严重程度常用的评估工具及重症患者谵妄治疗理念的转变等方面进行综述。结果 谵妄的严重程度与ICU患者较高的死亡率增加、长期认知功能下降相关;谵妄严重程度的判定不仅关注不同症状表现强度的总和,而且需要谵妄症状持续的时间;医务人员在运用谵妄严重程度评估工具时应掌握谵妄的核心症状群,明确工具应用的优缺点。结论 ICU患者谵妄严重程度的评估,促使量化分级评价谵妄,有助于科学的制定与实施谵妄管理方案,实时监测治疗效果与并发症,促进患者康复。     

心脏外科手术患者ICU过渡期护理清单的设计及应用

目的 提高心脏外科手术患者ICU过渡期护理质量。方法 设计ICU过渡期护理清单。便利选取2017年1月—2018年12月在盐城市某三级甲等医院心脏外科收治的需要行心脏手术的患者156例,其中2018年1月—12月的81例患者为试验组,2017年1月—12月的75例患者为对照组。试验组在接受常规护理基础上,采用ICU过渡期护理清单;对照组接受常规护理。比较两组转科交接时间,术后48 h、ICU转出前、ICU转出后1周3个时间点的静息状态疼痛程度,术后常见并发症发生率,术后早期下床活动时间,住院费用,住院时间及满意度,访谈医护人员对清单的看法。结果 与对照组相比,试验组转科交接时间明显缩短（t=2.16,P<0.05）,3个时间点静息状态疼痛程度明显降低（均P<0.01）;试验组术后常见并发症发生率、ICU转出后初次下床活动时间明显下降,两组差异有统计学意义（P<0.05）;两组住院时间、住院费用比较,差异无统计学意义（P>0.05）;试验组患者满意度高于对照组,差异有统计学意义（P<0.05）;护士和医生对应用该清单的满意度均>96%;访谈医护人员,对该清单的使用给予了肯定。 结论 使用ICU过渡期护理清单能够缩短心脏术后患者ICU转运时间,减少心脏围手术期患者的术后应激与并发症,提高医、护、患的满意度。     

基于角色转变冲击模型ICU新护士培训课程体系的构建

目的 构建基于角色转变冲击模型的ICU新护士培训课程体系,用于指导护理实践,科学评价ICU新护士的培训质量。 方法 以角色转变冲击模型为理论依据,采用文献检索法、专家小组讨论、德尔菲专家函询、半结构访谈等方法,建立ICU新护士培训课程体系。结果 2轮专家函询的问卷有效回收率分别为100%和94.44%,专家权威程度系数为0.890,专家意见的协调系数为0.412。最终确定的培训课程体系包括一级指标4个、二级指标17个、三级指标126个。结论 基于角色转变冲击模型构建的ICU新护士培训课程体系的科学性和实用性较好,为ICU新护士的培训提供了参考。     

床上功能椅的设计及应用

目的 探讨自行设计的床上功能椅在ICU心脏直视术后患者床边坐起中的应用效果。方法 自行设计床上功能椅,选取某院ICU入住的心脏直视术后患者60例,采用随机数字表法分为试验组和对照组,每组各30例。试验组用床上功能椅进行床边坐起,对照组利用床边椅子进行床边坐起。比较两组体位改变耗时、住ICU时间、不良事件发生率、患者满意度和护士的满意度。结果 试验组疼痛感觉和体位改变耗时优于对照组,护士满意度高于对照组,差异有统计学意义（P<0.05）。结论 床上功能椅可以减轻患者的疼痛,减少患者活动风险,提高护士的工作效率。     

The Effect of CMS's Comprehensive Care for Joint Replacement Bundled Payment Model on Trajectories of Post-acute Rehabilitation Care After Total Hip Arthroplasty

ObjectiveTo evaluate the effect of the Comprehensive Care for Joint Replacement (CJR) policy on the 90-day trajectory of post-acute care after a total hip arthroplasty (THA).DesignMultivariable difference-in-difference models applied to Medicare beneficiaries undergoing a THA prior to (2014-2015) and post-CJR implementation (2017) in areas subjected to or exempt from the policy.SettingHospitals in standard metropolitan statistical areas.Participants357,844 elderly Medicare patients nationwide undergoing THA (N=357,844).InterventionsNone.Main Outcome MeasuresEscalation in care to institutionalization (ie, admission to an inpatient rehabilitation or skilled nursing facility during 90-days postdischarge for those initially discharged to the community and return to the community at the end of the episode of care among those initially discharged to an institutional setting).ResultsOf the 357,844 elderly Medicare patients nationwide undergoing THA during the study period, 47.6% were discharged directly to the community and 52.4% received post-acute care in an institution. Patients discharged to an institution post-policy in a CJR area were about 10% less likely to return to the community (odds ratio=0.91; 95% confidence interval, 0.84-0.98; P=.02) at the end of the 90-day episode of care than those treated in policy-exempt areas. Despite the large magnitude, estimates of escalation in care among patients treated in bundling areas post-CJR implementation were not statistically significant.ConclusionsOur findings support further exploration of unanticipated effects of mandatory bundled payment policies on outcomes, as well as further examination of outcomes among policy-relevant subgroups of patients undergoing hip replacement in the United States.     

The meanings of culture in health and social care: a case study of the combined Trust in Somerset

On the 1st of April 1999 Somerset Health Authority and Somerset County Council established a Joint Commissioning Board (JCB) to commission mental health services. Simultaneously, the Somerset Partnerships Health and Social Care NHS Trust was set-up as a combined health and social care services provider; for the first time in England, the majority of social services mental health staff transferred their employment to this Trust. The JCB commissioned an evaluation of the impact of these innovations on users and carers, staff and senior officers and members in the organisations concerned. In the course of the research, one concept frequently recurred as a source of both optimism and concern: 'culture'. However, the meanings attributed to this term varied significantly between stakeholders. After summarising the methodology and the results to date of the evaluation, this paper briefly reviews the conceptions of culture in the literature on organisations, and introduces a taxonomy for discussing culture. That taxonomy is then deployed to explore the ways in which the notion of 'culture' is being applied to and within the combined Trust in Somerset, and the implications of those applications for local practice and national policy around partnership.     

Is general practice effective? A systematic literature review

Objective - To find evidence of the effectiveness of physicians working in primary care. Design - Systematic literature search in the Medline and Cochrane databases. Material - Out of 7223 titles found in the search, 45 studies, comparing, from different aspects, primary care with specialist care, were extracted. Main outcome measures - Health indicators, health care costs, quality of health care. Results - Primary care contributed to improved public health, as expressed through different health parameters, and a lower utilisation of medical care leading to lower costs. Physicians working in primary care, in comparison with other specialists, took care of many diseases without loss of quality and often at lower cost. The organisation of primary care was important in respect of reimbursement by capita tion, more group practices, higher personal continuity, and having generalists as primary care physicians. Conclusions - To compare the effectiveness of primary care and specialist care is a complex task and there are limitations in all studies. However, we have found evidence that increased accessibility to physicians working in primary care contributes to better health and lower total costs in the health care system. It is also clear that studies with evaluation of how to most effectively organise primary care are far too few. There is an extensive need for future research in this area, a suitable task for collaborative research between the Nordic countries.     

Honoring Veterans' Preferences: The Association Between Comfort Care Goals and Care Received at the End of Life

ContextAs part of its Life-Sustaining Treatment (LST) Decisions Initiative, the Veterans Health Administration (VA) in January 2017 began requiring electronic documentation of goals of care and preferences for Veterans with serious illness and at high risk for life-threatening events.ObjectivesTo evaluate whether goals of “to be comfortable” were associated with greater palliative care (PC) use and lesser acute care use.MethodsWe identified Veterans with VA inpatient or nursing home stays overlapping July 2018–January 2019, with LST templates documented by January 31, 2019, and who died by April 30, 2019 (N = 18,163). From template documentation, we identified a “to be comfortable” goal. Using VA and Medicare data, we determined PC use (consultations and hospice) and hospital, intensive care unit, and emergency department use 7 and 30 days before death. Multivariate logistic regression examined the associations of interest.ResultsSixty-four percent of the 18,163 Veterans had comfort-care goals; 80% with comfort care goals received hospice and 57% PC consultations (versus 57% and 46%, respectively, for decedents without comfort-care goals). In adjusted analyses, comfort care documented on the LST template prior to death was associated with significantly lower odds of hospital, intensive care unit, and emergency department use near the end of life. In the last 30 days of life, Veterans with a comfort care goal had 44% lower odds (adjusted odds ratio 0.57; 95% CI: 0.51, 0.63) of being hospitalized.ConclusionFindings support the VA's commitment to honoring of Veterans' preferences post introduction of its Life Sustaining Treatment Decisions Initiative.     

慢性心力衰竭患者姑息照护的研究进展

综述了国内外对慢性心力衰竭患者实施姑息照护的现状,总结对慢性心力衰竭患者实施姑息照护的必要性,发现影响慢性心力衰竭患者实施姑息照护的因素主要包括慢性心力衰竭疾病轨迹特点、心理社会因素、医护人员姑息照护知识缺乏、伦理因素等,明确慢性心力衰竭患者接受姑息照护实施模式的研究现状,以期为我国开展慢性心力衰竭姑息照护实践提供指引。     

ICU后综合征患者症状特征的潜在类别分析

目的 探讨ICU后综合征（post-intensive care syndrome,PICS）患者症状特征的潜在类别并分析各类别患者在人口学特征和疾病特征上的差异。 方法 采用便利抽样法,于2019年8月16日—2020年1月16日、2020年6月8日—2020年10月30日选取贵州省某三级甲等医院综合ICU的患者作为调查对象。患者转出ICU 1个月时,采用PICS相关症状评估量表对其进行电话随访。对PICS患者的症状特征进行潜在类别分析,并通过单因素分析和多项分类Logistic回归识别其潜在类别的影响因素。 结果 共纳入299例ICU患者,其中165例（55.18%）出现PICS症状。PICS患者的症状特征分为3个潜在类别,分别为“疲劳-睡眠障碍组”（44.24%）、“焦虑组”（16.97%）、“症状高发组”（38.79%）。“症状高发组”与“疲劳-睡眠障碍组”比较,PICS患者的急性生理与慢性健康状况评分Ⅱ（Acute Physiology and Chronic Health Evaluation Ⅱ,APACHE Ⅱ）越高归于“疲劳-睡眠障碍组”的概率越小（OR=0.882,P=0.001）,无呼吸系统疾病史和无气管切开归于“疲劳-睡眠障碍组”的概率较大（OR=5.443,P=0.048;OR=4.015,P=0.006）;“症状高发组”与“焦虑组”比较,PICS患者的APACHE Ⅱ越高归于“焦虑组”的概率越小（OR=0.903,P=0.027）,年龄<50岁归于“焦虑组”的概率较大（OR=3.392,P=0.025）;“疲劳-睡眠障碍组”与“焦虑组”比较,年龄<50岁的PICS患者归于“焦虑组”的概率较大（OR=4.422,P=0.005）。结论 PICS患者的症状特征存在异质性,可分为3个潜在类别。高APACHE Ⅱ、有呼吸系统疾病史和气管切开的PICS患者归为“症状高发组”的概率较大,年龄<50岁的PICS患者归为“焦虑组”的概率较大。临床医护人员应关注PICS患者症状特征的异质性,对不同类别的患者给予针对性的干预措施。     

Who should provide care for patients receiving palliative chemotherapy? A qualitative study among Dutch general practitioners and oncologists

Abstract

Introduction: While close collaboration between general practitioners (GPs) and hospital specialists is considered important, the sharing of care responsibilities between GPs and oncologists during palliative chemotherapy has not been clearly defined.

Objective: Evaluate the opinions of GPs and oncologists about who should provide different aspects of care for patients receiving palliative chemotherapy.

Design: We conducted semi-structured interviews using six hypothetical scenarios with purposively sampled GPs (n?=?12) and oncologists (n?=?10) in the Netherlands. Each represented an example of a clinical problem requiring different aspects of care: problems likely, or not, related to cancer or chemotherapy, need for decision support, and end-of-life care.

Results: GPs and oncologists agreed that GPs should provide end-of-life care and that they should be involved in decisions about palliative chemotherapy; however, for the other scenarios most participants considered themselves the most appropriate provider of care. Themes that emerged regarding who would provide the best care for the patients in the different scenarios were expertise, continuity of care, accessibility of care, doctor–patient relationship, and communication. Most participants mentioned improved communication between the GP and oncologist as being essential for a better coordination and quality of care.

Conclusion: GPs and oncologists have different opinions about who should ideally provide different aspects of care during palliative chemotherapy. Findings raise awareness of the differences in reasoning and approaches and in current communication deficits between the two groups of health professionals. These findings could be used to improve coordination and collaboration and, ultimately, better patient care as results demonstrated that both disciplines can add value to the care for patients with advanced cancer.

• Key points

• This study identified contrasting opinions of GPs and oncologists about who should provide different aspects of care for patients receiving palliative chemotherapy.

• Important themes that emerged were expertise, continuity of care, doctor-patient relations, accessibility of care, and communication.

• Although frequently using the same arguments, GPs and oncologists often considered themselves to be the most appropriate providers of palliative care.

     

The Oxford Group and Alcoholics Anonymous

Since the early 1980s in Britain, specialist reports and government policy documents have encouraged the involvement of general practitioners (GPs) in the treatment of problem drug users. More recent guidelines on the clinical management of drug misuse further emphasise a central role for primary care staff, and the principle of 'shared care' is advocated as the mechanism by which this role may be fulfilled. To date, and in spite of these policy initiatives, the involvement of GPs has been described as 'patchy and slow'. This paper examines the historical peculiarities of British drug policy to help understand the challenges of contemporary care. It is proposed that specialist-led models of 'shared care' may militate against GP involvement and alternative approaches to the primary care management of drug misuse are examined. 'Primary care facilitation' is presented as one such alternative and its critical features are elaborated.     

How is the communication of bad news being performed in Neonatal Intensive Care Units and how to improve it: A Scoping Review

ObjectiveTo identify how the communication of bad news has been treated in the care of newborns admitted to Neonatal Intensive Care Units.MethodThis is a Scoping Review conducted according to the proposal of the Joanna Briggs Institute (JBI), using the databases LILACS, Scopus, PubMed, Web of Science, Embase and ScholarGoogle.ResultsDifferences were found in the view of parents and the health team regarding what is considered bad news and the way it is communicated - what would be ideal and what actually occurs -, in this context, highlighting the death imminent or potential risk of the newborn.ConclusionsDespite the knowledge about the particularities of the context, the professionals only make a situational diagnosis, requiring the use of tools or protocols that seek to facilitate understanding and reduce any trauma. In addition, points of change and investigation are brought into the daily practice of professionals, as well as key concepts for understanding the phenomenon.     

General practitioners’ views on radiology reports of plain radiography for back pain

Scand J Prim Health Care 2003;21:15-20. ISSN 0218-3432 Objective -?To analyse the influence of rates of general practitioner visits on rates of hospitalisations. Design?-?Ecological cross-sectional study of factors influencing hospitalisation rates. Aggregated data on primary care centre area level. Setting?-?The county of ÖstergÖtland, Sweden, with 3 hospital districts and 41 primary health care centres, and the hospital district of JÖnkÖping in the county of JÖnkÖping, Sweden, with 11 primary health care centres. Outcome measure?-?Hospitalisation rates. Results?-?Age and rates of outpatient hospital visits were the most important factors explaining the variation in rates of hospitalisations between the primary health care centre areas. Hospital districts, socioeconomic factors and rates of GP visits also influenced the rates of hospitalisations. Conclusion?-?When evaluating the influence of primary health care on the rates of hospitalisations, both socioeconomic factors and health care structure must be taken into consideration. Doing this, the rates of GP visits correlated negatively with the rates of hospitalisations.