专病一体化管理模式对提高腹膜透析质量的重要作用

Impact of continuous quality improvement initiatives on clinical outcomes in peritoneal dialysis

目的腹膜透析(peritoneal dialysis,PD)患者的居家管理是影响其远期预后的重要因素之一。文中通过总结实施专病团队化管理前后透析质量的变化,证明对PD患者实施专病团队化管理模式的临床价值。方法运用持续质量改进(continuous quality improvement,CQI)理念创立了PD专病一体化管理模式,即由专职医师、护士组成专业团队,对PD患者实施一体化管理,并对PD的各个环节采取了CQI管理,以达到PD质量的不断提高。专病管理组:选取2008年7月至2011年6月行PD置管并有专业团队管理的370例患者;非专病管理组:为2005年7月至2008年6月期间行PD的249例患者,此阶段仅由一名专职护士负责专业培训,2组患者持续随访3年。以心血管合并症、腹膜炎发生率、患者生存率及技术存活率作为主要观察指标,回顾性分析对比2组上述指标的变化。结果非专病管理组2006至2008年腹膜炎发生率分别为1/22.2、1/22.2、1/22.6次/患者月,专病管理组2009至2011年腹膜炎发生率分别为1/30.1、1/77.1、1/77.3次/患者月,专病管理组腹膜炎发生率整体趋势较非专病管理组降低(P<0.001)。专病管理组患者血压控制达标率明显高于非专病管理组(67.6%vs 47.4%,P<0.05)。3年随访期间专病管理组心脏体积变化不明显,而非专病管理组患者PD心胸比、室间隔厚度较基线水平[(0.55±0.08)vs(0.50±0.05),(11.07±1.66)mm vs(10.26±1.40)mm]显著增加(P<0.05)。透析2年、3年后专病管理组左心室内径与非专病管理组比较,差异均有统计学意义(P<0.05)。专病管理组患者1、2、3年的存活率均明显高于非专病管理组患者存活率(97.3%vs 92.6%、96.3%vs 82.4%、96.3%vs 67.3%,P=0.001)。专病管理组技术存活率亦明显高于非专病管理组(95.6%vs 89.6%、92.6%vs 79.2%、92.6%vs 76.8%,P=0.001)。结论以专业医护人员组成专职团队对PD患者实施一体化管理可以大大提高PD治疗质量及患者的预后。

Objective We evaluated the role of a quality improvement initiative in improving clinical outcomes in peritoneal di-alysis （ PD） . Methods In a retrospective analysis of 6 years of data from a hospital registry, the period between 1 July 2005 and 30 June 2008 （ control group） provided baseline data from before implementation of systemic outcomes monitoring, and the period between 1 July 2008 and 30 June 2011 [continuous quality improvement （CQI） group] represented the time when a CQI program was in place.Per-itonitis incidence, patient and technique survival, cardiovascular status, causes of death, and drop-out were compared between the groups. Results In the 370 patients of the CQI group and the 249 patients of the control group, the predominant underlying kidney diseases were chronic glomerulonephritis and diabetic nephropathy.After implementation of the CQI initiative, the peritonitis rate de-clined to 1 episode in 77.3 patient-months from 1 episode in 22.6 patient-months.In the CQI group, the complicance of blood pressure was more significantly improved than the control group （ 67.8% vs 47.4%,P〈0.05）.During the 3 years of follow-up,cardiothoracic ratio and IVST were significantly increased in the control group [0.55 ± 0.08 vs 0.51 ±0.05,P〈0.05,11.07 ±1.66 mm vs 10.25 ±1.38 mm, P〈0.05〗.The difference of LVID between the two groups was signifi-cant at the 2nd and 3rd year of follow-up（P〈0.05）.Patient survival at 1, 2, and 3 years was significantly higher in the CQI group （97.3%, 96.3%, and 96.3%respectively） than in the control group （92.6%, 82.4%, and 67.3%respectively, P〈0.001）.Imple-mentation of the CQI initiative also appeared to significantly improve technique survival rates：95.6%, 92.6%, and 92.6%in the CQI group compared with 89.6%, 79.2%, and 76.8%in the control group （P〈0.001） after 1, 2, and 3 years respectively. Conclusion Integration of a CQI process into a PD program can significantly improve the quality of therapy and its outcomes.