构建导航护士在ERAS 腹腔镜肝切除术中的管理路径:护患沟通我有一套

2019-05-16 杨艳英 健康界

构建导航护士在ERAS腹腔镜肝叶切除术中的管理路径一、项目背景近年,加速康复外科(Enhanced Recovery After Surgery )的安全性和有效性被越来越多的研究证实,目前该理念被运用于多个学科。外科医生、护理、麻醉、营养、康复科、心理等多学科组成的ERAS-MDT团队是加速康复外科运行的组要模式,得到国内专家的普遍认同。尽管如此,在工作开展过程中仍暴露出诸多问题,其中最为突

构建导航护士在ERAS腹腔镜肝叶切除术中的管理路径

一、项目背景

近年,加速康复外科(Enhanced Recovery After Surgery )的安全性和有效性被越来越多的研究证实,目前该理念被运用于多个学科。外科医生、护理、麻醉、营养、康复科、心理等多学科组成的ERAS-MDT团队是加速康复外科运行的组要模式,得到国内专家的普遍认同。尽管如此,在工作开展过程中仍暴露出诸多问题,其中最为突出的是ERAS围手术期各项措施不能按时按质落实,这就导致ERAS的效果大打折扣。

通过分析现状,查阅文献,访谈专家,找到导致以上问题的两大共性原因1.各专业之间碎片化的医疗服务不能将ERAS围手术期各阶段进行无缝隙的连接。2.ERAS工作无完整的执行和评价体系。因此如何整合多学科碎片化的医疗服务以及如何监督和评价ERAS各项措施的落实就成为了亟待解决的问题?

我们再次通过查阅文献借鉴美国肿瘤护理协会对肿瘤导航护士角色的定义,借鉴梅奥诊所提出的首诊医生成为患者就医的全程导医的理念,我们决定预设一名导航护士,在MDT团队成员之间承担学科间的衔接、措施实施的评估和反馈,治疗效果的监控和数据的全程收集。

二、项目内容

1.构建新的立体化MDT团队

导航护士的定义:由国外兴起,是指为患者全程医疗服务提供导航作用,包括治疗措施,做好医患、部门之间的沟通,为患者提供优质、及时的医疗服务。

导航护士的准入条件:英语四级;主管护师,有五年以上肝胆外科临床工作经验;担任责任组长,临床经验丰富,有较强的沟通能力和团队协作能力。

在我科室ERAS腹腔镜肝叶切除术MDT团队中加入导航护士及患者支持系统,建立MDT工作微信群。构建新的立体化的MDT团队。

2.明确导航护士的四大工作职责

(1)团队协调: 在MDT团队成员之间,进行沟通以及问题反馈,组织召开协调会议不断优化MDT团队的合作形式。

(2)全程监控:全程监控患者治疗的各个环节是否按需、按质量落实ERAS的各项措施,并协调处理突发事件

(3)延续照护:制定家庭康复计划,监控患者出院后的恢复指标,及时协调介入伤口、营养、康复等专科医务工作者,预防并发症的发生。

(4)数据收集:全程进行数据的收集,以及数据的整理,为团队科研提供数据支持。

3.梳理导航护士在ERAS肝叶切除术预康复阶段(预约入院到正式入院,在家等床的阶段)、住院阶段(术前一天入院到出院)、延续照护阶段(出院延续护理阶段)的工作流程图。

4.为导航护士在三大阶段的工作中匹配相应的评估表、路径表、宣教单、数据收集表等。《腹腔镜肝叶切除术ERAS临床路径》;预康复阶段:NRS202、SAS、SDS、Caprini血栓风险评估量表、疼痛评估尺、肺康复筛查量表、《腹腔镜肝叶切除术ERAS预康复期病员指导表(病员一本通)》;住院阶段:《腹腔镜肝叶切除术ERAS导航表》、《腹腔镜肝叶切除术ERAS健康教育》;延续照护阶段《腹腔镜肝叶切除术ERAS延续性护理表》。

5.亮点工作

预康复阶段亮点工作:

(1) 导航护士协助收集资料,识别异常指标,及时协调多学科会诊;

(2) 导航护士全面评估患者情况,联合多学科制定个性化的预康复锻炼措施,为患者发放《病员一本通》定期复评锻炼效果。包括评估与关注营养、血栓、肺康复、心理与营养门诊,阳光医院项目工作合作等;

(3)全程使用小米手表检测患者睡眠、活动等。

(4)根据《患者评价手册》阶段性的评价患者预康复期的情况。

住院阶段亮点工作:

(1) 导航护士通过《导航表》全程监控围手术期ERAS各项措施的落实情况,导航表随病例交接;

(2) 通过查询手术台次,确定术前口服12.5%碳水化合物的具体时间,并用患者手机设置提醒功能,保证服液到口;

(3) 制定早期进食评估流程和术后患者营养菜单,减少早期进食风险;

(4) 在首次下床前评估患者的活动痛和跌倒发生的高风险点,制定评估流程并干预,如下床前半小时口服止痛药,减少早期下床风险;

(5) 推广使用团队发明的移动式引流袋固定装置,减少非计划拔管;

(6) 参与多学科查房,定期召开MDT会议,收集问题反馈问题,PDCA持续改进质量,打造紧密型MDT团队。

(7) 导航护士全程数据收集整理,为团队科研提供数据支持。

(8)导航护士根据术后并发症发生的风控点,督导床边责任护士根据专科要点及时观察病情并处理。

延续照护阶段亮点工作:

(1) 改变传统问候式的出院回访,判断并发症发生的高峰点及风控点,制定个性化的回访时间、内容,从而及时发现并发症;

(2) 针对出院回访异常问题,建立回访异常问题处理机制,及时联系多学科介入患者的治疗,保障患者安全。

三、项目成果及推广

1.提高ERAS围手术期各项措施的落实率:16项ERAS围手术期措施落实率为100%,2项96.6%,1项93.3%。

2.ERAS肝叶切除术平均住院日下降4.6天、平均费用下降8684元,但未增加各类安全事件,甚至肺部感染和血栓呈下降趋势,证明导航护士的全程安全管控有效;

3.导航护士的工作得到多方的认可,拓宽了护理的职业生涯;

4.院外多家医院参观学习,该模式在省级继续教育学习班进行推广;

5.申请专利两项:移动式引流袋固定装置201820110196.3已取得证书,该专利自制产品正在临床使用,准备转化;胆汁回输型双腔T型管201711335762.7 已经受理,该专利在全国专利比赛中获三等奖 ;

6.1项科研正在申报中:《导肮护士在ERAS腹腔镜肝切除术中的应用》;

7、制定了导航护士在ERAS工作中的流程图、路径表、宣教单,如《导航表》。

四、下一步展望

1.探索并制定导航护士的准入条件、职业规范、岗位核心胜任能力;

2.将导航护士的管理模式推向更多的学科;

3.通过制作延续性照护回访APP,协助异常情况的提醒和识别,并及时自动化反馈导航护士;

4.与HIS系统对接,实现数据收集和处理的自动化。

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    2019-08-29 changfy
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    2019-11-08 rgjl
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