基于信息系统的三级审核模式对改善脑卒中风险表单评估准确性的研究

Study on the accuracy of three-level auditing model based on information system to improve risk assessment of stroke patients

目的探讨基于信息系统的三级审核模式对提高脑卒中患者压疮、跌倒坠床风险表单评估准确性的效果。方法采用类实验性研究的方法,共纳入358例研究对象。选择2016年3-4月我院血管神经病学二病区收治的脑卒中患者180例为对照组;2016年9-10月收治的脑卒中患者178例为观察组。对照组患者由护士采用常规评估方式对压疮、跌倒坠床风险评估表单进行评估;观察组采用三级审核模式进行评估。比较两组患者压疮、跌倒坠床风险表单评估的准确性及实施三级审核模式后护士自我成长得分。结果对两组患者进行压疮风险评估,观察组和对照组分别为712人次和716人次,进行跌倒坠床风险评估分别为542人次和546人次。实施三级审核模式前(对照组),护士在压疮风险评估表单中出现错误最多的两项为"偏瘫"和"外周血管病",在跌倒坠床风险评估表单中出现错误最多的四项依次是"行为不能自我控制""使用镇静安眠药""运动障碍""视觉听觉障碍"。实施三级审核模式后(观察组)压疮、跌倒坠床风险评估表单各条目评估错误率均低于实施前(P<0.01)。实施后,护士自我成长各项得分均高于实施前(P=0.000)。结论基于信息系统的护理三级审核模式有助于提高护士对脑卒中患者压疮、跌倒坠床风险表单评估的准确性,值得临床推广。

Objective To study the effect of three-level auditing model based on information system on improving the accuracy of risk assessment of stroke patients.Methods The experimental research method was used.A total of 180 patients with stroke enrolled in our hospital from March 2016 to April 2016 were in the control group,and 178 patients with stroke enrolled from September to October in 2016 were in the observation group.The risk assessment of the pressure ulcers and falling bed of control group was assessed using a conventional assessment method,and the observation group was assessed using the three-level audit model.The test was used to compare the accuracy of the two groups,and nurse self-development score.Results 358 subjects were included in the study,including 178 cases in the intervention group and 180 cases in the control group.The pressure ulcers risk assessment of the two groups was 712 and 716 respectively,and the falling risk assessment was 542 and 546 respectively.Before the implementation of the three-stage audit model,the two most common errors in the risk assessment of pressure ulcers were hemiplegia and peripheral vascular disease.The top four errors in the risk assessment of falling were behavior self-control,sedation,movement disorders,visual hearing impairment.After the implementation of the three-level audit model,the error rate of each item was lower than before and the difference between the two groups was statistically significant(P<0.01),nurse self-development score is higher than before(P=0.000).Conclusion The three-level review model based on information system can help to improve the accuracy of nurses's assessment of stroke patients'risk of pressure and fall,and it is worthy of clinical promotion.