医院VTE防控管理体系的信息化构建与实现

Research on Information System of VTE Prevention and Control Management in Hospital

目的通过信息化手段,实现江苏省南京鼓楼医院静脉血栓栓塞症(venous thromboembolism,VTE)防控管理的信息化和自动化,整合有效的管理方法,形成一套有效的VTE防控管理体系。方法基于一体化电子病历和临床数据中心(CDR),完善血栓风险评估Caprini评分表,实现数据自动化抓取,以及不良事件上报的自动触发,自动生成每月住院患者VTE防治信息总表,并进行全院推广。结果形成了标准化、规范化并具有本院特色的VTE防治管理体系,提高了临床VTE防治工作的效率,避免了手工评估及上报带来的错报、漏报弊端。结论南京鼓楼医院VTE防控管理体系的建立,结合信息化的实现,能够有效提升管理效率,促进医护合作,进一步保证患者的医疗质量,同时为临床医疗提供了必要的决策支持。

Objective To realize the informationization and automation of VTE(Venous Thromboembolism)prevention and control management of Nanjing Drum Tower Hospital,integrate effective management methods,and form an effective VTE prevention and control management system by information technology.Methods Based on the integrated electronic medical record and CDR,the Caprini score scale of thrombus risk assessment is improved,the data is automatically captured,and the adverse event reporting is automatically trigged,and at last,the VTE prevention and treatment information table for inpatients monthly is automatically generated and promoted by the whole hospital.Results A standardized VTE prevention and management system with the characteristics of the hospital is formed,which improved the efficiency of clinical VTE prevention and treatment,and avoid the drawbacks of misreporting and underreporting caused by manual evaluation and reporting.Conclusion The establishment of VTE prevention and control management system of Nanjing Drum Tower Hospital,combined with the realization of informatization,can effectively improve the management efficiency,promote medical and nursing cooperation,further ensure the quality of medical care,and provide necessary support for clinical decisions.