信息化管理在腹膜透析患者门诊随访中的应用

Application of informatization management for outpatients with peritoneal dialysis

目的探索腹膜透析中心采用信息化管理在门诊随访中的应用效果。方法根据腹透中心的工作特点及护理管理需求，设计开发软件《腹膜透析管理系统》。对照组采用传统门诊随访及记录方式，改进组采用《腹膜透析管理系统》管理，分析2组患者腹膜透析管理质量和治疗效果、腹透中心护士护理文书书写所耗时间。结果在2组患者入组初期临床病情等基本信息无差异的情况下，改进组护士书写文书时间明显缩短（P〈0．05）；掉队率、失访率、并发症发生率及感染率明显降低（P〈0．05）；水肿及营养不良的改善较明显（P〈0．05）。结论采用《腹膜透析管理系统》管理，可使腹透患者透析数据更加准确、全面、动态、及时，缩短护士文书书写时间，降低失访率，减少并发症，提高中心管理效率，该软件对应用医院信息系统的医院有较好的推广使用价值。

Objective To assess the application of informatization management for outpatient follow - up in perito- neal dialysis center. Methods According to the features of peritoneal dialysis center and requirements of nursing man- agement, a software ＂Peritoneal Dialysis Management System＂ was developed. The control group chose traditional ap- proaches for outpatient follow -up and ease recording. The improvement group adopted the software ＂Peritoneal Dialysis Management System＂. Then, peritoneal dialysis management and therapeutic effects were assessed, while time duration required for writing nursing documents by nurses in our center was calculated. Results No difference was found in the clinical condition of both groups. Compared with the control, the improvement group spent obviously less time to write nursing documents （ P 〈 0.05 ） , produced significant decreases in drop - out rate, rate of loss to follow - up, incidence of complications and infection rate （P 〈 0.05 ） and presented substantially improved edema and malnutrition （ P 〈 0.05 ）. Conclusion The use of ＂Peritoneal Dialysis Management System＂ can facilitate clinical data collection in a more accu- rate, comprehensive, dynamic and timely way. It can shorten nursing document writing time, decrease dropout rate, re- duce complications and improve management efficiency. The software is more applicable for hospitals equipped with infor- matization system.