全新发布!中国眼科日间手术管理专家共识

2021-07-08 梅斯医学整理 梅斯医学整理

3分钟get要点!

日间手术是目前发展迅速的手术医疗服务模式,眼科因其疾病诊疗特点更适合开展日间手术。近日,中华眼科杂志发布了《中国眼科日间手术管理专家共识》,系统阐释了针对眼科日间手术的设施建设、组织管理模式、手术执行的具体实施、质量与安全管理等环节,以提升眼科日间手术的规范化管理水平,保障医疗质量和患者安全。

一、眼科日间手术的设施建设

根据各医疗机构眼科医疗用房的实际情况和病房收治患者的特点,设计规划眼科日间手术区域。

1,眼科日间手术流程

眼科日间手术流程是整个设计的核心,应严格按照院内感染防控要求并满足国家相关标准规范, 充分考虑流程的合理性和便利性;兼顾患者、医师、 护士、其他工作人员的工作规范和需求。

2,眼科日间手术的器械要求

固定设备包括眼科检查基本设施和设备、眼科 护理设备、医疗办公设备、患者休息等候区域设备、 日间手术病房生活设施等。

二、眼科日间手术的组织管理

1,团队建设

日间手术团队:是开展日间手术的基础,应 由眼科医师、麻醉科医师、护理团队、日间手术管 理人员等参与,共同组成多学科团队。有条件 的医疗机构应配备临床药师,以指导围手术期用药。

管理团队:制定日间手术运行规则,关注日 间手术的运行状态,发现并及时协调处理问题。通 常由日间手术中心主任和护士长负责日常管理。

2,准入制度

准入制度是降低日间手术风险、保证患者安全 的重要举措。眼科日间手术准入制度包括手术准 入、手术医师准入、护士准入和患者准入。

1)手术准入:可以参考(但不限于)国家卫生健 康委员会的指导试点病种 ,并结合各医院的医师技术水平和服务能力,选择开展日间手术的病种 及手术种类。

2)手术医师准入:日间手术医师的准入制度是 保证日间手术安全和高效开展的基础制度。

3)护士准入:日间手术病房护士需要在短时间 内完成术前宣传教育、术前准备、手术转运、术后护 理、术后宣传教育等一系列工作,工作节奏较快,需要具备准入条件:①具备常用护理技能和急救技 能;②熟悉眼科日间手术的制度和流程,具备较全 面的专科护理知识和熟练的专科护理技能;③具备良好的沟通能力和突发事件的应对能力,且具有较好的患者宣传教育能力。

4)患者准入:须为符合手术准入病种和手术种 类的患者。合并糖尿病、高血压病、心脑血管病等 慢性疾病者,应酌情请院内(或院外)相关专科会诊,评估是否具备眼科手术条件。

3,运行模式

目前国内日间手术运行模式主要有分散收治、 分散管理,分散收治、集中管理,集中收治、集中管理。采用何种运行模式可根据医院的组织架构、病 种纳入数量等实际运营情况综合考虑。建议以集 中收治、集中管理作为主要运行和管理模式。在 开展日间手术初期,可根据医院的实际运行情况, 建立激励机制以推动日间手术开展。

4,运行流程及管理

眼科日间手术的流程化管理很重要,其运行流 程主要包括眼科门诊、术前检查、手术预约及宣传教 育、入院手术、术后观察、出院及随访等环节。 各环节的具体实施见三、眼科日间手术的具体 实施

5,信息化管理

息化管理程度可影响医疗服务能力、患者就 医感受以及医疗管理精细化程度等,因此应采用 符合眼科日间手术医疗护理特点的信息化管理系 统,实现和优化日间手术全流程信息化管理和质量 监控,提高效率和安全性。

眼科日间手术集中收治、集中管理模式运行流程

三、眼科日间手术的具体实施

眼科日间手术患者通常在术后几小时内离院, 因此应将患者的安全放在首位。为保证手术的质 量和患者的安全,眼科日间手术的具体实施建议 如下:

1,患者选择标准:根据手术准入和患者准入标 准,由手术医师、麻醉医师在门诊对需要进行手术 的患者按照全身情况、眼部病情及手术复杂程度进 行筛选,其中符合日间手术准入标准的患者可进行日间手术。

2,术前检查及麻醉评估:术前对患者的全身情 况和眼部病情进行全面评估是确保日间手术顺利完成的基础。

3,预约登记、入院及术前宣传教育:完成术前 检查及麻醉评估的患者可以进行手术预约登记,其 后患者根据预约手术的日期当日办理入院并进行术前宣传教育。

4,术前再评估:手术当日入院后对患者进行再 评估,再次判断是否符合日间手术标准,以降低 患者围手术期相关并发症的发生风险。术前向 患者及家属充分交代手术风险,完成手术同意书签 字工作。手术风险评估和交代、签字由相关专业组 主治医师负责。

5,手术及手术室管理:手术安全核查工作与传 统住院手术一致,内容包括患者身份、手术部位或 眼别、患者病史。与传统住院手术一致,须按手术 相关规范及操作流程实施手术。

6,麻醉管理:局部麻醉下手术时,常规监测患 者的心率、血压、心电图、血氧饱和度。全身麻醉下 手术时,除了局部麻醉监测指标外,还需要由麻醉 师对患者的意识状态、脑功能、气道、通气状况(吸 入氧气分数、呼气末二氧化碳浓度、呼气末麻醉气 体浓度等)进行监测。

7,术后护理:术后由医护人员密切观察病情变 化并给予有效处理。对于手术中存在特殊情况的 患者,手术医师应在术后即刻向日间手术病房医师说明术中情况及术后处理注意事项。

8,转出机制:日间手术中或手术后出现意外 情况,如眼部和(或)全身出现严重并发症,应根据 医院的管理和社会医疗保险的要求,建立转入住 院病房治疗的流程或请相关医师会诊的制度,并 健全术后 24 h 急诊绿色通道,以及时处理术后并发症。

9,出院标准及出院前评估:满足下列条件的患 者可安排出院后继续随访:生命体征平稳;意识清 醒;无明显或仅有轻度术后恶心呕吐症状;伤口敷 料清洁,无明显渗血、渗液;可充分控制术后疼痛; 已完成出院指导和术后宣传教育工作;家属和本人 具备术后独立护理能力;全身麻醉者符合全身麻醉 出院评分标准;有成年人陪同回家,并保证在出院 24 h 内有成年人陪护;出院证明、门诊复诊预约等手续完善。

10,出院康复指导和随访:出院时进行康复指 导,提高自我护理能力,促进术后康复。

四、眼科日间手术质量和安全管理

(一)确定医疗质量和安全评估指标是进行质量和 安全管理的有效手段。

1,手术取消率:手术当日由于各种原因导致手 术取消的患者数量占当日日间手术病房患者总数 的比例。该指标反映术前筛查的效率

2,患者失约率:由于各种自身原因未能按照约定时间前往医院接受手术的患者数量占当日日间 手术病房患者总数的比例。该指标反映日间手术病房的术前管理水平。

324 h 延迟出院率:入院时间超过 24 h 的日间手术患者数量占日间手术总人数的百分比。

4,非计划再入院及再手术率:日间手术后30 d 内因直接或间接并发症而入院的患者数量或再次 手术患者数量占日间手术患者总数的比例。

5,术后 30 d 内眼部与手术相关的不可逆严重视功能损伤并发症的发生率:如视网膜中央动脉阻 塞、术后感染性眼内炎、驱逐性脉络膜上腔出血、眶蜂窝织炎、大量球后出血致眶尖综合征、药物控制不良的继发性青光眼等的发生率。

6,术后30 d内死亡率和严重并发症发生率: 30 d内的死亡率以及包括循环系统障碍(血压异 常、严重的心律不齐)、呼吸系统障碍(吸入性肺炎、 肺栓塞)、中枢或周围神经系统障碍、过敏反应、高 热、感染及麻醉药品毒性作用等在内的严重并发症发生率。

7,患者满意度:日间手术患者出院后对日间手 术就医过程的满意程度。在患者出院 7 d 内进行调查,满分为 100 分。

(二)建立眼科日间手术医疗质量控制和改进体系

相关科室应严格按照各类医疗管理制度开展 工作,尤其准入制度中的相关要求。可以对眼科日 间手术医疗质量和安全评估的主要指标进行持续 监测和分析评估,对发现的问题采用计划执行 处理的循环管理方法进行持续改进。

五、传染病流行期间的眼科日间手术管理

国内临床经验表明,新型冠状病毒肺炎疫情防 控期间严格筛查患者,严格按照疫情防控工作不同 时期相应流程要求开展工作,严格落实眼科诊疗防 控措施,可有效保障眼科手术顺利完成以及围手术期医护人员和患者的安全。

1,术前就诊管理:1)医院入口处落实一级预 检分诊,对进入医院的患者进行筛查,严格把关; 2)病区入口由分诊护士进行二级预检分诊,核查 健康码、询问流行病学史、测量体温等;(3)拟进行 眼科日间手术的患者提前完善新型冠状病毒核酸 及相关血常规项目等检测,并按照当日手术量分时 段安排入院时间,避免人员聚集;(4)候诊时患者隔 座候诊,并由工作人员做好引导和解释工作,及时 疏解患者,减少人员聚集。

2,日间手术病房管理:1)患者进入日间手 术病房当日再次审核新型冠状病毒核酸检测报 告、血常规项目检查结果以及必要的胸部 CT 影像学检查结果,并检测体温,询问流行病学史, 检查患者佩戴口罩等情况;(2)医护人员做好一 级防护,避免感染及交叉感染;(3)若患者出现发 热、咳嗽、咽痛等症状,应就地隔离,暂停患者当 日手术,医务人员升级防护措施,同时上报相关 科室,进行标本采集,明确诊断后再行后续诊治 或转治工作。

3,加强培训:组织日间手术病房医护人员定期 学习疫情防控相关知识,关注相关部门发布的全国 中高风险地区通知,及时调整流行病学筛查内容。

4,加强环境管理:应按照疫情防控要求严格落 实相关措施,依据相关管理部门提出的标准对手术 环境、器械及空气进行及时的清洁消毒并做好记录。

原始出处

中国医药教育协会眼科委员会,解放军医学科学技术委员会眼科学分会,中国老年 医学学会眼科分会.中国眼科日间手术管理专家共识(2021)中华眼科杂志 2021 6 月第 57 卷第 6 Chin J Ophthalmol, June 2021, Vol. 57, No. 6

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    学习了,感谢分享

    0

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    2022-03-03 spiritnsy

    学习了

    0

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    2022-01-29 moon-386

    学习了

    0

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    2021-11-04 ccy0755

    学习了

    0

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    2021-10-25 眼科芳

    学习了

    0

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    2021-10-13 ms3000000687039028

    多次学习

    0

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    2021-09-30 小琳子123abc

    学习了

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