Abstract:

Objective To evaluate the clinical application effect of a coagulation management system for patients undergoing extracorporeal membrane oxygenation（ECMO） based on the Swiss Cheese Model，aiming to provide a reference for clinical coagulation management in ECMO therapy. Methods The research team summarized and synthesized evidence on coagulation management for ICU patients receiving ECMO. Through group discussions，expert consultations，and preliminary trials，a coagulation management system based on the Swiss Cheese Model was developed for ICU patients on ECMO. A before-after study design was adopted，enrolling patients admitted to the ICU of a tertiary hospital in Beijing between January 2019 and January 2024. An experimental group（n=29） was managed using the coagulation management system，while a control group（n=15） received conventional care. The incidence of deep vein thrombosis（DVT），cannulation site bleeding，ECMO duration，weaning outcomes，and survival rates were compared between the 2 groups. Results The coagulation management system based on the Swiss Cheese Model comprised 4 key aspects：standardizing organizational protocols（organizational influences），constructing a four-tier defense system（unsafe supervision），identifying environmental factors（preconditions for unsafe acts），and refining and standardizing individual practices（unsafe acts）. After clinical implementation，the experimental group showed significantly lower incidences of DVT and cannulation site bleeding compared to the control group（P<0.05）. Additionally，the ECMO duration was significantly longer in the experimental group（P<0.05）. Conclusion The implementation of the Swiss Cheese Model-based coagulation management system for ECMO patients reduces the incidence of DVT and cannulation site bleeding，prolongs ECMO duration，and demonstrates significant clinical nursing application value.

Key words: Extracorporeal Membrane Oxygenation, The Swiss Cheese Model, Anticoagulation, Bleeding, Thrombus, Nursing Care

摘要：

目的 探讨基于瑞士奶酪模型的体外膜肺氧合（extracorporeal membrane oxygenation，ECMO）患者出凝血管理体系的临床应用效果，旨在为临床做好ECMO患者的出凝血管理提供借鉴。方法 研究小组对ICU患者ECMO出凝血管理证据进行归纳、总结，通过小组讨论、专家咨询和预试验，构建基于瑞士奶酪模型的ECMO患者出凝血管理体系。采用历史前后对照研究，选取2019年1月至2024年1月北京市某三级甲等医院ICU收治的患者作为研究对象，试验组29例，对照组15例。试验组应用ECMO患者出凝血管理体系进行管理，对照组采用常规护理。比较两组深静脉血栓发生率、穿刺点出血发生率、ECMO运行时长、撤机情况及存活情况的差异。结果 形成的基于瑞士奶酪模型的ECMO患者出凝血管理体系包括规范组织制度（组织影响）；构建四层防御体系（不安全的监督）；识别环境因素（不安全行为前兆）；完善和规范个人行为（不安全的行为）4个方面。该体系应用于临床后，试验组深静脉血栓发生率、穿刺点出血发生率低于对照组，差异具有统计学意义（P<0.05），试验组ECMO运行时长高于对照组，差异具有统计学意义（P<0.05）。结论 实施基于瑞士奶酪模型的ECMO患者出凝血管理体系可降低深静脉血栓发生率和穿刺点出血发生率，延长ECMO运行时长，具有较好的临床应用价值。

关键词: 体外膜肺氧合, 瑞士奶酪模型, 抗凝, 出血, 血栓, 护理