胆总管结石临床路径变异与退出原因分析

Analysis of Causes on Variation and Exit of Clinical Pathway of Choledocholithiasis

目的分析胆总管结石临床路径变异与退出的原因和影响因素,为进一步完善临床路径的管理提供理论依据。方法选取2015年1月-2017年3月纳入胆总管结石临床路径的患者,收集发生变异和退出路径患者的病例信息,找出退出的主要原因。结果 848例患者中,有598例患者发生变异。其中254例(42.48%)患者发生负性变异,与患者相关的变异占30.10%,与医务人员相关的变异占4.01%,与医院系统相关的变异占8.36%。可控变异占15.45%,不可控变异占84.55%。有414例患者退出路径,原因主要为:240例(58%)患者病情稳定,符合出院指征提前出院;36例(8.6%)出现并发症;30例(7.8%)未见胆总管结石。年龄、并发症、抗生素使用情况、患者依从性、住院天数对临床路径的退出有统计学意义(P<0.05)。结论进一步优化现有的胆总管结石临床路径,严格按照入径标准纳入,关注患者的病情变化,制定相关的应对措施,推动临床路径管理体系不断完善。

ObjectiveTo analyze the reasons and risk factors on variation and exit of clinical pathway of choledocholithiasis to provide evidence for management improvement of clinical pathway. MethodsPatients with choledocholithiasis clinical pathway from January 2015 to March 2017 were included for information collection on variation and exit of clinical pathway for main reasons analysis.ResultsAmong all 848 patients, 598 patients had variation, of which 254 （42.48%） patients had negative variation, patients accounted for 30.10% of variation, medical personnel accounted for 4.01% of variation, and hospital system accounted for 8.36% of variation. The uncontrollable variation accounted for 84.55%, and controllable variation accounted for 14.54%. 414 patients exit the pathway with 240 （58%） patients in a stable condition which accorded with discharge indications, 36 cases （8.6%） quit the clinical pathway due to the complications, and 30 cases （7.8%） without choledocholithiasis. Age, complications, the use of antibiotics, patient compliance, and the length of stay were the significant factors on quitting clinical pathway （P〈 0.05）.Conclusion The current clinical pathway of choledocholithiasis should be optimized with strictly following the entry criteria, focusing on the patient＇s condition changes and formulating relevant countermeasures to constantly improve the management of clinical pathway.