基于SBAR沟通模式的产房与新生儿科交接班记录单的设计及临床应用

The design and application of the handover record based on SBAR communication mode in delivery room and neonatal department

目的探讨SBAR沟通模式在产房与新生儿科之间新生儿交接过程中的应用效果。方法方便选取2016年3-6月由产房转人新生儿重症监护室（NICU）的新生儿100例作为对照组，以传统口头交接模式交接；2016年7-9月从产房转入NICU的新生儿106例为观察组，采用SBAR（现状、背景、评估、建议）结构框架设计的产儿科交接单进行产儿科间的新生儿疴情交接。比较2组病情交接的完整性、正确率、不良事件杜绝的比例、转运交接耗时及医护人员满意度的差异。结果观察组病情交接的完整率、正确率、不良事件杜绝的比例，医护人员对交接内容的完整性、病情描述准确性、实用性、可操作性的满意度分别为99．06％（105／106）、99．06％（105／106）、15．09％（16／106）、93．33％（28／30）、90．00％（27／30）、96．67％（29／30）、93．33％（28／30），对照组分别为89．00％（89／100）、94．00％（94／100）、2．00％（2／100）、63．33％（19／30）、60．00％（18／30）、73．33％（22／30）、26．67％（8／30），2组比较差异有统计学意义（χ^2=4．008—27．778，P〈0．05或0．01）；2组在转运交接耗时上差异无统计学意义（P〉0．05）。结论基于SBAR沟通模式的产儿科交接班记录单在产房与新生儿科之间的应用，提高疴隋交接的完蛰性、正确率，能及时发现不良事件，及时杜绝。交接内容更加全面、疴l青描述更加准确规范，此表格简单实用、可操作性强，受到临床医护人员的信赖，值得在产房与新生儿科之间推广使用。

Objective To explore the effect of SBAR communication mode in handover between delivery room and neonatal department. Methods A total of 100 cases of neonates transferred from neonatal intensive care unit from March to June 2016 were selected as the control group. The traditional oral transfer mode was used. From June to September 2016, 106 cases of newborn infants who were transferred to neonatal intensive care unit were observed in the observation group. The newborns were transferred with SBAR structural framework. The differences of the integrity, the correct rate, the proportion of adverse events, the transfer time and the satisfaction of the medical staff in the 2 groups were compared. Results The integrity, the correct rate, the proportion of adverse events, the satisfaction of the medical and nursing staff on the integrity of the handover, the accuracy of the description of the disease, the practicality, and the operability were 99.06%（105/106）, 99.06%（105/106）, 15.09%（16/106）, 93.33% （28/30）, 90.00% （27/30）, 96.67% （29/30）, 93.33%（28/30） in the observation group, 89.00%（89/100）, 94.00% （94/100）, 2.00%（2/100）, 63.33%（19/30）, 60.00% （18/30）, 73.33%（22/30）, 26.67%（8/30） in the control group, the differences were significant （χ^2=4.008-27.778, P〈0.05 or 0.01）. There was no significant difference in the transit time （P〉 0.05）. Conclusions The design and application of the handover record based on SBAR communication mode in the delivery room and neonatal department improve the integrity of the patient＇s condition, the correct rate, can detect adverse events in time. The st＇aft were more comprehensive, more accurate description of the disease description, this form is simple and practical, operable, by the clinical staff of the trust, it is worth in the delivery room and the promotion of the use of newborns.