县级重症医护人员对慢性阻塞性肺疾病患者营养认知的状况

The situation about cognitive performance of critical care staffs in nutrition therapy for mechanical ventilated COPD patients in county hospitals

目的了解浙江省杭州地区县级医院ICU医务人员对慢性阻塞性肺疾病（ chronicobstructive pulmonary disease, COPD）机械通气患者营养认知的情况，为改善县级医院COPD患者的营养治疗策略提供依据。方法参照国内外权威指南制定一份调查表，并选取浙江省杭州地区12家县级医院危重症医护人员为研究对象。描述医护人员对营养治疗的认知状况，并通过Logistic回归分析影响认知状况的相应因素。结果一共137份调查问卷。几乎所有医护人员认可营养治疗在COPD机械通气患者救治中的作用。90％的医护人员没听过或很少使用NRS2002（ nutritional riskscreening 2002营养风险筛查评分）对COPD患者进行营养风险筛查和评估，工作年限越高，使用相对较多（OR=1．08，95％CI：1．01-1．16，P=0．04）。绝大多处医护人员会使用血生化和系统的营养评估方法，但医生相对护士更加根据临床经验和感觉。大部分医护人员首选肠内营养治疗且医生相对护士认为更加需要（OR=3．10，95％CI：1．27～7．55，P=0．01），工作年限更高的人员认为更加需要（OR=1．13，95％CI：1．03-1．23，P=0．01）。对于营养状况较好的患者，高级职称的医护人员认为早期肠外营养需要不强烈（OR=0．14，95％CI：0．04-0．57，P=0．01）。对于血流动力学不稳定的患者，工作年限越高的医护人员倾向于不使用肠内营养（OR=1．10，95％C／：1．03～1．16，P=0．002）。绝大多处医护人员认为肠内营养时需要床头抬高和胃残余量监测，但医生相对护士（OR=0．39，95％CI：0．18-0．83，P=0．01）执行较差。绝大多处人员认为需要营养治疗的核查表，但仅20％的单位使用类似的表单。医生相对护士对营养治疗知识更加熟悉且更加迫切需求（OR=3．13和5．33，95％CI：1．45～6．75和1．13-25．02，P=0．004和0．03）。结论浙江杭州地区县区级危重症专业的医护人员对营养治疗在COPD机械通气患者中的作用非常认可，但对相关规范的熟悉程度还不够，且认知状况受人员类型及工作年限等因素的影响。

Objective To investigate the situation about cognitive performance of critical care staffs in nutrition therapy for mechanical ventilated chronic obstructive pulmonary disease （COPD） patients in county hospitals. Methods A chart of questionnaire about nutrition therapy was formulated according to the current guidelines. Critical care staffs from 12 hospitals of county-level of Hang Zhoa city were enrolled. The role of staffs in management of nutritional therapy for patients was observed to assess their cognitive performance and influence factors were analyzed according logistic analysis. Results A total of 137 staffs were enrolled. Almost all of the staffs thought that nutrition therapy for ventilated COPD patients was very important. About 90% of the staffs never heard about the use of NRS2002 （nutritional risk screening 2002）to evaluation COPD patients but the rate of using it was higher among senior staffs （ OR = 1.08, 95% CI： 1.01-1.16, P =0. 04）. Most of staffs assess the nutritional status of patients according to biomarkers and other methods. However, doctors might assess nutritional status more often according to their experience. The majority of staffs did choose enteral nutrition for patients especially seen in doctors and senior staffs （ OR = 3. 10 andl. 13, 95% CI： 1.27-7. 55 and 1, 03-1.23, both P = 0.01 ）. For those without malnutrition, senior staffs did not choose parenteral nutrition （ OR =0. 14, 95% CI： 0. 04-0. 57, P = 0. 01 ）. Besides, senior staffs did not continue the enteral nutrition in patients with unstable haemodynamics （ OR = 1.10, 95% CI： 1.03-1.16, P =0. 002）. Most of staffs considered that the head piece of bed was raised up to 30- 45 degree and gastric residual volume monitoring was very important. However, compared with nurses, the cognitive performance of doctors was poorer （ OR =0. 39, 95% CI： 0. 18-0. 83, P = 0. 01 ）. Most of staffs thought that the nutrition therapy implementation checklist was necessary but it was used in only 20% institutions. The understanding and demand for nutritional knowledge was more urgent among doctors than nurses （ OR -= 3. 13 and 5.33, 95% CI： 1.45-6. 75 and 1.13-25.02, P = 0. 004 and 0. 03 ）. Conclusions Nutrition therapy was important for ventilated COPD patients, but the staffs were not very familiar with nutritional knowledge. The cognitive performance of medical staffs was influenced by their profession and experience of practice.