ICU患者谵妄管理临床决策支持系统的构建与应用研究

doi:10.3761/j.issn.0254-1769.2023.09.002

摘要/Abstract

摘要：

目的构建ICU患者谵妄管理临床决策支持系统，并评价其应用效果。方法构建包括风险评估与风险识别、智能决策、效果评价等功能的ICU谵妄管理临床决策支持系统，2022年6月—8月在江苏省某三级甲等医院ICU病房中正式使用，比较系统应用前后患者的谵妄发生率、首次接受谵妄预防措施的时间、护理记录书写耗时及护理记录缺陷率，收集护士对系统的满意度。结果 ICU患者谵妄管理临床决策支持系统应用后，患者的谵妄发生率、首次接受谵妄预防措施的时间、护理记录书写耗时及护理记录缺陷率均较应用前降低，差异均具有统计学意义（P<0.05）；护士对该系统的总体满意度评分为（100.88±4.06）分。结论 ICU患者谵妄管理临床决策支持系统能够为护士提供科学的决策依据，提高ICU患者谵妄预防管理的质量，护士对系统的满意度处于较高水平。

关键词: 决策支持系统, 临床, 谵妄, 重症监护病房, 信息系统, 护理

Abstract:

Objective To construct a clinical decision support system for delirium risk in ICU patients，and to provide a reference for its application in ICU patients. Methods A clinical decision support system for delirium management in ICU was constructed，including risk assessment and identification，intelligent decision making，effect evaluation，and other functions，which will be officially used in the ICU ward of a tertiary A hospital in Jiangsu Province from June 2022 to August 2022. The incidence of delirium，the first time for patients to receive delirium prevention measures，the time for writing nursing records，and the defect rate of nursing records before and after the system application were compared，and the satisfaction rate of nurses to the system was collected. Results After the application of the clinical decision support system for delirium management in ICU patients，the incidence of delirium，the first time to receive delirium prevention measures，the time to write nursing record sheets，and the nursing record defect rate of patients were all reduced，with statistical significance（P<0.05）. The overall satisfaction score of nursing staff with the system was（100.88±4.06）. Conclusion The clinical decision support system for delirium management in ICU patients can provide a scientific decision basis for nurses and improve the quality of delirium prevention and management in ICU patients.

Key words: Decision Support System, Clinical, Delirium, Intensive Care Units, Information System, Nursing Care

薛瑾, 王清, 蒋玲, 程念开, 黄琴, 倪兴梅, 顾肖, 陈怡雷, 夏莲子. ICU患者谵妄管理临床决策支持系统的构建与应用研究[J]. 中华护理杂志, 2023, 58(9): 1037-1042.

XUE Jin, WANG Qing, JIANG Ling, CHENG Niankai, HUANG Qin, NI Xingmei, GU Xiao, CHEN Yilei, XIA Lianzi. Construction and application of a clinical decision support system for delirium management in ICU patients[J]. Chinese Journal of Nursing, 2023, 58(9): 1037-1042.

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