ICU临床路径建设与HIS融合是构筑数字化医院的核心:2016至2018年柳州市工人医院ICU临床路径建设经验

Integration of clinical pathway construction and hospital information system in intensive care unit is the core of digitalized hospital:experience of clinical pathway construction in Liuzhou Worker's Hospital from 2016 to 2018

目的探讨重症医学科(ICU)开展临床路径建设的有效策略。方法2016年1月至2018年7月广西壮族自治区柳州市工人医院ICU出院患者共1488例次。先选择路径较单纯、变异较小的"心脏病术后监护治疗"推行试点,成功后推进至"术后监护"等。按时间分3个阶段实施临床路径:第一阶段是试点阶段,2016年1月至2017年5月,87例次患者试行进入临床路径;第二阶段,2017年6月至12月,"心脏病术后监护治疗"进入路径111例次;第三阶段,2018年1月至7月,"心脏病术后监护治疗"进入路径116例次,"术后监护"进入路径96例次。结合试点阶段的失败经验,利用互联网+医疗(2017年柳州市工人医院成为腾讯公司在互联网+医疗领域的第5家深度合作伙伴,进行了"微信智慧医院3.0"的规划与实践),在连接、支付、安全保障、生态合作四大方面进行升级,加速电子病历(EMR)6级建设。通过疾病诊断相关分组(DRGs),以循证医学、质量管理、持续改进理念为主导,结合医院信息系统(HIS)、EMR系统的建设现状,制定分阶段实施推进步骤,设计临床路径信息化管理平台。以临床路径完成率、平均住院日、平均费用、治愈率、好转率作为主要观察指标。结果试点阶段无一例完成临床路径。外科ICU2017年6月至12月"心脏病术后监护治疗"临床路径完成率从33.33%逐月增长至94.44%,2017年10月完成率达100%;2018年1月至7月平均临床路径完成率为94.00%。综合ICU2018年1月至7月"术后监护"临床路径完成率从81.82%逐月增长至92.86%。2016至2018年各年度整体临床路径完成率比较差异有统计学意义(χ^2=204.300,P=0.000)。2017年6月临床路径有效实施后,患者总住院时间较实施前明显缩短(d:2.96±0.43比6.66±0.75,P<0.01),日均费用明显减少(元:3550.92±755.51比6171.48±377.29,P<0.01)。外科ICU"心脏病术后监护治疗"有效实施临床路径后患者住院时间较实施前缩短了3.84d(P<0.01),日均费用减少了2108.39元(P<0.01);综合ICU"术后监护"有效实施临床路径后患者住院时间缩短了2.98d(P<0.01),日均费用减少了5094.13元(P<0.01)。外科ICU有效实施临床路径后,患者治愈率从1.16%(7/603)提高至42.26%(105/227),好转率从94.36%(569/603)下降至52.86%(120/227,均P<0.01);而综合ICU有效实施前后治愈率、好转率差异无统计学意义〔2.77%(33/1193)比2.22%(2/90),79.21%(945/1193)比97.78%(88/90),均P>0.05〕。结论应用临床路径对ICU进行质控,并引导诊疗,完成包括临床指南、平均住院时间、平均住院费用、成本效率比等更精细化诊疗方案,证实临床路径管理策略的改进源自临床需求。临床路径信息化、智能化、标准化、规范化、有效控制医疗成本,可提高医疗品质和精准管理。ICU临床路径建设与HIS融合可促进数字化医院的发展。

Objective To explore the effective strategies of clinical pathway construction in intensive care unit (ICU). Methods From January 2016 to July 2018, 1488 patients were discharged from ICU of Liuzhou Worker's Hospital of Guangxi Zhuang Autonomous Region. The pilot project of "postoperative monitoring of heart disease" with simpler route and less variation was selected first, and then the pilot project was promoted to "post-operative monitoring" after its success. The implementation of the clinical pathway was divided into three stages: the first stage, January 2016 to May 2017, for the pilot phase, a total of 87 patients were enrolled in the clinical pathway trial;the second stage, June 2017 to December 2017, surgical ICU "postoperative monitoring of heart disease" was put into the pathway 111 times;the third stage, January 2018 to July 2018, surgical ICU "postoperative monitoring of heart disease" was entered in the path 116 times;comprehensive ICU "postoperative care" was put into the path 96 times. After carefully analyzed the reasons and sum up the experience, internet+medical treatment (Liuzhou Worker's Hospital became the fifth deep partner of Tencent Inc in the internet+medical field, and carried out the plan and practice of "WeChat wisdom hospital 3.0" in 2017) was used, four aspects of connection, payment, security and ecological cooperation were upgraded, and the construction of 6 level of electronic medical record (EMR) was accelerated. At the same time, through diagnosis related groups system (DRGs), the concept of evidence-based medicine, quality management and continuous improvement as the leading factor, and combined with the construction status of hospital information system (HIS) and EMR system, step by step implementation and design of information management platform for clinical pathway were formulated. The completion rate of clinical pathway, average length of hospital stay, average cost, cure rate and improvement rate were the main observation parameters. Results In the first stage, none of the 87 patients who entered the clinical pathway completed the clinical pathway. In the second stage, the completion rate of surgical ICU clinical pathway was increased from 33.33% in June 2017 to 94.44% in December 2017, and up to 100% in October 2017, and the average completion rate from January to July 2018 was 94.00%. The completion rate of ICU clinical pathway was increased from 81.82% in January 2008 to 92.86% in July 2008. There was a significant difference in the overall clinical pathway completion rate from 2016 to 2018 (χ^2 = 204.300, P = 0.000). After the effective implementation of clinical pathway in June 2017, the length of hospital stay of patients was significantly shortened as compared with that before implementation (days: 2.96±0.43 vs. 6.66±0.75, P < 0.01), and the daily cost was significantly reduced (Yuan: 3550.92±755.51 vs. 6171.48±377.29, P < 0.01). The average length of hospital stay was shortened by about 3.84 days (P < 0.01), and the average daily cost was reduced by about 2108.39 Yuan (P < 0.01) after the implementation of clinical pathway by surgical ICU "postoperative monitoring of heart disease" as compared with those before implementation. The average length of hospital stay was shortened by about 2.98 days (P < 0.01) and the average daily cost was reduced by 5094.13 Yuan (P < 0.01) after the implementation of clinical pathway by comprehensive ICU "post-operative monitoring" as compared with those before implementation. At the same time, the cure rate was increased from 1.16% (7/603) to 42.26% (105/227), and the improvement rate was decreased from 94.36% (569/603) to 52.86% (120/227, both P < 0.01) after the implementation of surgical ICU clinical pathway, but there was no significant difference in the cure rate or the improvement rate after the implementation of comprehensive ICU [2.77% (33/1193) vs. 2.22% (2/90), 79.21% (945/1193) vs. 97.78% (88/90), both P > 0.05]. Conclusions Application of clinical pathway to control ICU quality and guide diagnosis and treatment, more refined diagnosis and treatment schemes including clinical guidelines, average length of stay, average cost of hospitalization, cost-efficiency ratio and so on were completed, which confirmed that the improvement of clinical pathway management strategy originated from clinical were needed. Informatization, intellectualization, standardization and effective control of medical cost of clinical pathway could improve medical quality and accurate management. The integration of ICU clinical pathway construction and HIS could promote the development of digital hospitals.