住院患儿疼痛管理决策支持系统的构建与应用研究

doi:10.3761/j.issn.0254-1769.2020.08.004

摘要/Abstract

摘要：

目的构建住院患儿疼痛管理决策支持系统,并评价其应用效果。方法以疼痛管理理论与临床决策支持技术为基础,构建集护理程序各环节、医嘱处理和护理任务清单为一体的疼痛管理信息系统。于2018年9月—2019年11月在某三级甲等综合性儿科医院进行系统试运行,比较系统使用前后的护理文书书写质量、医嘱处理及时性及护士使用体验。结果住院患儿疼痛管理决策支持系统使用后,护理文书书写质量各指标均明显提高,与原疼痛管理系统比较,差异具有统计学意义（P<0.05）;医嘱处理及时性使用前后均为100%,差异无统计学意义（χ²=0.012,P=0.913）;在临床护士使用体验中,使用后“信息质量”“服务质量”“用户满意”“净收益”维度体验性均提高,与原疼痛管理系统比较,差异具有统计学意义（P<0.05）。结论住院患儿疼痛管理决策支持系统的使用提高了住院患儿疼痛管理的同质性、连续性、完整性、及时性,且护士对该系统总体体验良好。

关键词: 临床决策支持系统, 知识库, 疼痛管理, 儿童, 信息化平台, 儿科护理学

Abstract:

Objective To construct a decision support system for pain management in hospitalized children and to evaluate its effects. Methods Based on the theory of pain management and clinical decision support technology,a new pain management information system was constructed,integrating all aspects of nursing procedure,order processing and nursing task list. The system was trial-run in a tertiary comprehensive pediatric hospital from September 2018 to November 2019. The application effect of the new system was evaluated and compared through the quality of nursing document writing,the timeliness of doctor’s order processing and the experience of nurses before and after the use of the new system. Results After the application of the decision support system for pain management of hospitalized children,the quality of nursing document writing was significantly improved（P<0.05）;the timeliness of medical order processing before and after the use was 100%,and the difference was not statistically significant（χ²=0.012,P=0.913）;in the using experience of clinical nurses,the dimensions of "information quality","service quality","user satisfaction" and "net income" were improved. The differences were statistically significant（P<0.05）. Conclusion The new pain management decision support system improves the homogeneity,continuity,integrity and timeliness of pain management for hospitalized children,and nurses have good overall experience of this system.

Key words: Clinical Decision Support System, The Knowledge Base, Pain Management, Children, Informatization Platform, Pediatric Nursing

赵永信, 顾莺, 张晓波, 刘芳, 万嫣敏, 范咏. 住院患儿疼痛管理决策支持系统的构建与应用研究[J]. 中华护理杂志, 2020, 55(8): 1147-1153.

ZHAO Yongxin, GU Ying, ZHANG Xiaobo, LIU Fang, WAN Yanmin, FAN Yong. Construction and application of the decision support system for pain management in hospitalized children[J]. Chinese Journal of Nursing, 2020, 55(8): 1147-1153.

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