保护性约束信息化管理系统的构建及应用

The construction and clinical application of information management system for protective restraint

目的构建保护性约束信息化管理系统,指导临床护士科学决策并合理使用约束用具。方法 2017年5月—11月,通过文献回顾、专家咨询、小组讨论等方法构建保护性约束信息化管理系统的内容主体,并与计算机中心合作形成规范化的住院患者身体约束评估、上报、监控管理体系,研发信息化管理系统模块,形成保护性约束信息化管理系统,通过试运行逐步完善后投入临床应用。结果保护性约束信息化管理应用前后,护理人员约束实施与决策轮的一致率由78.102%上升至97.321%,患者的约束率由0.906%下降至0.799%,差异均有统计学意义(P<0.05);应用保护性约束信息化管理系统后,约束评估指征准确率、约束行为规范率、约束动态观察落实率、约束交接班落实率稳步提升,差异有统计学意义(P<0.05)。结论保护性约束信息化管理系统可替代经验管理帮助护士科学、客观地评估和决策约束使用的指征和时机,规范身体约束流程,指导护士及时上报、动态监控、准确反馈对患者的身体约束。

Objective To construct an information management system for protective restraint,for guiding clinical nurses to make scientific decisions and use constrained appliances reasonably.Methods Through literature review,expert consultation,group discussion and other methods,main contents of the management system were established.By collaborating with the computer center,a standardized system for assessment,reporting,monitoring for inpatients was built,and put into clinical application after trial operation and clinical debugging.Results The concordance rates for using protective constraint before and after the implementation of information system were 78.102% and 97.321%,respectively,and the rates of protective constraint were 0.906% and 0.799%,respectively,the differences were statistically significant(P<0.05).After the implementation of information system,the accuracy rate of assessment,the execution rate of standardized measures,the rate of dynamic observation,and the rate of shift turnover were getting improved,and the differences were statistically significant(P<0.05).Conclusion The information management system for protective constraint can replace experience management to help nurses scientifically,objectively evaluate and decide on the constraints and timing,regulate body constraint process,and guide nurses to timely report,dynamically monitor and accurately feedback.