E-learning培训管理系统在临床护理培训中的应用效果

[目的]探讨在线学习(E-learning)培训管理系统应用于临床护理培训的效果。[方法]以开放性Internet的"512在线培训"系统为依托,结合医院办公自动化"OA系统"、护理人员手机微信端共同构建护理继续教育系统,并将之广泛应用于临床护理培训、考核,运用护理培训效率指标(培训覆盖率、考试出题时间、阅卷时间、理论考试合格率、操作考试合格率)和培训满意度对运用E-learning培训管理系统前后的培训考核效率及效果进行评价。[结果] E-learning培训管理系统构建后培训覆盖率、考试出题时间、阅卷时间、理论考试合格率、操作考试合格率分别为(99.11±0.09)%、(2.31±0.27)h、(5.14±0.36)h、(95.53±0.21)%、(94.83±0.41)%,与构建前比较差异有统计学意义(t值分别为-421.34,1 230.56,989.54,-308.83,-179.02,P=0.000);护理人员对培训计划、培训方式、考试方式、考核设置和能力提升的满意度分别为(97.84±0.29)分、(99.12±0.11)分、(97.34±0.16)分、(95.47±0.54)分、(95.15±0.27)分,与构建前比较差异有统计学意义(t值分别为-220.97,-428.21,-359.48,-209.56,-208.48,P=0.000)。[结论] E-learning培训管理系统可优化现代护理培训工作及管理模式,确保护理培训效果,提升护理管理水平。     

责任制整体护理在全程护理模式中的应用

目的探讨责任制整体护理模式在肝胆外科围手术期患者中的应用效果。方法在肝胆外科病区实施责任制整体护理,包括改进照护模式、落实分级护理、优化工作流程、科学人力配置及完善护理质量监督体系,比较实施前后患者对专科疾病知识的了解情况、患者满意度、对责任护士知晓率、院内护理质量评分结果、护士直接护理时间及护理文件书写时间。结果实施后患者对各专科疾病知识的了解情况均高于实施前,差异有统计学意义（P〈0．05）;实施后患者满意度及对责任护士知晓率分别为98．22％,93．96％,均高于实施前的96．22％,89．67％,差异均有统计学意义（x2分别为7．16,11．84;P〈0．05）;实施后危重患者护理、急救技术、基础护理及消毒隔离的护理质量评分分别为（98．00±1．22）,（96．56±1．22）,（99．10±0．22）,（99．30±0．22）分,均高于实施前的（91．58±1．22）,（90．70±1．22）,（91．84±1．22）,（83．72±1．22）分,差异均有统计学意义（F分别为4．74,5．01,4．34,6．24;P〈0．05）;实施后护士直接护理时间为（368±12）min,高于实施前的（329±21）min,而护理文件书写时间为（20±4）min,低于实施前的（49±11）min,差异均有统计学意义（F分别为3．35,3．02;P〈0．05）。结论责任制整体护理的实施,有利于为患者提供全面、全程、专业、无缝隙的护理,促进了住院患者围手术期的专令与舒活．提高了患者及家属的满意席。     

量化考核绩效管理在优质护理中的应用

目的探讨护理绩效分配制度在优质护理中的应用,提高护理人员工作积极性,提高医院护理工作质量。方法在优质护理示范病区中应用量化考核绩效管理制度,比较实施前后患者及医生对护士工作的满意度、护理质量及护理差错发生情况。结果实施后护理质量得分分别为（96．38±0．91）,（98．26±0．90）,（97．39±0．93）,（98．69±0．96）,（97．28±0．74）,（98．57±0．98）,（99．26±0．93）分,均高于实施前的（92．36±0．72）,（90．38±0．75）,（89．26±0．76）,（91．57±0．78）,（89．93±0．76）,（91．23±0．78）,（91．38±0．79）分,差异均有统计学意义（t分别为36．647,90．990,82．833,10．910,636．529,60．461,13．177;P〈0．05）;实施后患者对护理各项工作满意度较实施前提高,差异均有统计学意义（t分别为27．750,22．733,49．430,41．483,12．926,8．980,8．517,7．806,12．920;P〈0．05）;实施后医生对护理各项工作满意度较实施前提高,差异均有统计学意义（t分别为27．336,12．975,14．344,18．237,25．745,13．100;P〈0．05）。实施后护理差错发生减少,差异有统计学意义（X2=0．845,P〈0．05）。结论将量化考核绩效管理融人护理管理中,体现优劳优酬、按劳取酬的原则,是护理管理高效科学的管理模式,确保质量改进的稳定性和持续性。     

院病区二级连锁式岗前培训模式在中医医院新聘护士中的应用

目的：改进新聘护士岗前培训模式,以适应中医医院护理工作的需要。方法采用便利抽样法,选取2011年入职的38名新护士为对照组,采用传统的岗前培训模式进行培训;选取2012年入职的38名新护士为研究组,采用院病区二级连锁式岗前培训模式进行培训。结果培训前,研究组中医基础理论、操作技能和综合能力评分分别为（59．68±10．23）,（70．13±7．96）,（55．91±7．74）分,对照组分别为（60．17±9．45）,（69．85±8．48）,（55．82±8．60）分,两组比较差异无统计学意义（t值分别为0．216,0．148,0．048;P＞0．05）;培训后,研究组中医基础理论、操作技能和综合能力评分分别为（86．60±6．84）,（87．10±7．25）,（70．19±9．96）分,对照组分别为（70．56±8．69）,（72．81±9．28）,（69．85±8．48）分,两组比较差异有统计学意义（t值分别为8．940,7．480,4．401;P＜0．05）。研究组新护士对培训时间、培训内容、培训方式、培训师资的满意度均高于对照组,差异有统计学意义（ t值分别为7．617,35．894,8．409,7．999;P＜0．05）。结论院病区二级连锁式岗前培训模式能全面提高新护士的临床护理能力,使其迅速适应新护理岗位需要。     

自制护理操作视频片在新入职护士岗前技能培训中的应用

目的：探讨自制护理操作视频在新入职护士岗前技能培训中的应用效果。方法将常用无菌技术、口腔护理、鼻饲、心肺复苏等一系列临床护理基本操作制成视频,作为模板应用于新入职护士岗前技能培训中。选取2012年新入职护士42名按随机数字表法分为对照组和观察组,每组21名。对照组采用传统的老师示范后自己操作训练的培训方法;观察组采用反复观看护理操作视频后再进行自己操作训练的培训方法。比较两组护士操作考核成绩及护士长、医生、患者对护士综合能力评价情况。结果观察组护士无菌技术成绩为（92．5±2．5）分、口腔护理（91．0±2．0）分、鼻饲（92．7±5．2）分、静脉输液（93．0±2．6）分、导尿（90．2±3．4）分、吸痰（91．9±5．0）分、心肺复苏（94．1±2．4）分,均高于对照组,差异有统计学意义（t值分别为2．91,3．31,2．63,2．46,3．46,2．81,2．01;P＜0．05）;两组护士、患者满意度得分比较差异均有统计学意义（P＜0．05）。结论观看自制护理操作视频,有助于提高护士岗前培训质量,优化医院的操作培训流程,使受培训人员有效地掌握护理操作技能。     

示教室培训在“优质护理示范工程”活动中的应用效果

目的探讨将示教室培训在“优质护理示范工程”活动中应用的效果。方法将8个示范病区按照床护比分为实验组和对照组,实验组人员由示教室进行集中培训,对照组由各科护士长负责组织培训,比较两组效果。结果实验组护士4月基础护理服务规范操作考核成绩为（90．41±2．128）分,6月成绩为（91．00±2．368）分,基础护理质量检查合格率2010年3季度为98％,4季度为99％,对照组分别为（86．96±2．591）,（86．25±4．508）分,88％,89％,差异均有统计学意义（t=9．927,9．001;x2=7．68,8．87;P〈0．05）;两组患者满意度比较差异有统计学意义（P〈0．05）。结论将示教室培训应用于“优质护理示范工程”活动,对提高基础护理质量和患者满意度均具有良好效果。     

微信平台在临床护理培训考试中的应用效果

目的探讨微信平台在临床护理培训考试中的应用效果。方法选取本院入职1～25年的380名临床护士作为研究对象,随机分为对照组及观察组各190名,观察组护士运用微信轻发布平台对培训考试的试卷进行试卷编辑,通过发布微信二维码、组织考试、阅卷管理、培训签到的方法进行护理培训考试,与传统纸质考试方式进行护理培训考试,比较2种考试在试卷编辑/印刷、签到/发卷、考试及阅卷所耗时间,比较2组护士对护理培训的满意度情况。结果微信平台考试方式在试卷编辑/印刷、签到/发卷及考试时间、阅卷/统计分析上所耗时间短于传统纸质考试(P 0. 05);实验组护士对护理培训考试的满意度由于对照组(P 0. 05)。结论微信轻发布平台培训考试具有避免纸张浪费,节约物资资源,节约人力成本,提高工作效率,通过随机组题防止舞弊发生,节省资料保存的空间和成本等优点。在很大程度上节省了人力、物力、财力,能切实提高护理培训管理者的工作效率,值得在护理培训中推广应用。     

责任护士参与医生查房对临床护理质量的影响

目的探讨责任护士参与医生查房对临床护理质量的影响。方法每名责任护士分管2～4张病床,要求责任护士在班时,必须参与医生早晚查房。结果责任护士参与医生早晚查房前后基础护理检查评分由（94．63±0．48）分上升为（98．43±0．56）分,健康教育评分由（95．00±0．58）分上升为（98．57±0．79）分,专科护理评分由平均（95．29±0．49）分上升为（99．14±0．90）分,患者满意度由82．65％上升为93．93％,两组比较差异有统计学意义（t分别为11．148,17．678,14．789;X。=14．830;P〈0．01或P〈0．05）。结论责任护士参与医生早晚查房有利于临床护理质量的提高。     

应用微技能培训法提高急诊年轻护士应急能力效果分析

目的：探讨微技能培训法对提高急诊年轻护士应急能力的作用效果。方法对31名急诊年轻护士使用微技能培训法进行专科培训,比较其培训前后应急能力考核成绩、急诊专科疾病知识得分、急诊抢救技能得分及急救护理过程的执行时间。结果培训前护士应急能力考核评分如监护理论、抢救技术、个案护理得分分别为（85．93±4．30）,（86．17±3．68）,（83．14±4．70）分;培训后相应得分分别为（90．74±4．72）,（92．55±4．21）,（90．25±4．58）分,差异有统计学意义（t 值分别为-2．484,-2．665,-2．956;P＜0．05）。培训后护士急诊专科疾病知识得分与培训前比较差异有统计学意义（t值为-2．848～-2．472;P ＜0．05）。培训后护士急诊抢救技能总分为（88．05±4．66）分,培训前为（74．50±4．74）分,差异有统计学意义（t＝-4．824,P＜0．05）。培训后护士在急救护理过程执行时间与培训前比较差异有统计学意义（ t值为2．470～2．662;P＜0．05）。结论微技能培训法运用积少成多的策略,实行每日限时教学、反复强化记忆的方法,有效提高了护士急诊理论知识及专科性操作技能,提高了年轻护士的应急反应能力。     

护理路径表在尿毒症腹膜透析置管术后患者中的应用

目的：探讨护理路径表在尿毒症患者腹膜透析（ PD）置管术后自我管理中的应用效果。方法将PD置管患者140例按照置管顺序分为观察组（62例）和对照组（78例）,对照组采用传统的置管术后常规护理结合PD护士7 d培训的方法进行护理,观察组采用责任护士与PD护士实施全程护理路径表的方法进行护理,比较两组患者住院时间、住院费用、术后1个月腹膜炎发生率及患者健康教育知晓度和满意度。结果观察组患者平均住院时间为（13．53±2．52）d,住院费用为（1．83±0．49）万元,均明显低于对照组的（16．97±3．99）d,（2．367±0．51）万元,两组比较差异有统计学意义（t值分别为4．630,4．579;P＜0．05）。观察组患者满意度得分为（97．44±1．31）分,健康教育合格率为91．0％,均明显高于对照组（96．19±1．71）分及77．4％,两组比较差异有统计学意义（ t/χ2值分别为-3．654,5．016;P＜0．05）。结论采用PD置管术全程护理路径表对尿毒症患者进行护理管理可明显减少患者住院费用及术后1个月的腹膜炎发生率,提高患者满意度及健康教育合格率。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.