SBAR表格式手术护理交接单在口腔颌面外科中的应用

Design and application of surgical care delivery sheet under situation background assessment recommendation in oral and maxillofacial surgery

目的 探讨标准化沟通方式(situation backgroud assessment recommendation,SBAR)表格式手术护理交接记录单在口腔颌面外科手术患者交接中的应用.方法 回顾分析2016年10-12月北京大学口腔医院的旧版手术护理交接单存在的问题,于2017年1-6月根据SBAR设计新版手术护理交接单,2017年6-9月试运行3个月,于2017年10月完善修订后在口腔颌面外科进行全科培训推广使用.以2017年1-6月使用旧版交接单的118例手术患者作为对照组,以2018年1-6月使用新版交接单的118例手术患者作为观察组.比较SBAR表格式手术护理交接单使用前后两组患者转出交接消耗时间、使用安全性,以及护士对两版交接单的满意度总评分及满意率.结果SBAR表格式手术护理交接单推广使用后,转出交接消耗时间由(10.20±3.01)min减少至(9.06±3.08)min,差异有统计学意义(P<0.05).SBAR表格式手术护理交接单使用后未发生交接安全问题.护士对手术护理交接单的满意度总评分由(17.67±3.27)分提高至(22.34±2.61)分,差异有统计学意义(P<0.05);护士对交接单格式设置的满意率由52.45%提升至94.29%,交接内容完整性满意率由56.30%提升至96.82%,交接内容顺序满意率由51.15%提升至96.77%,交接条目设置内容满意率由47.31%提升至92.89%,填写便捷满意率由49.92%提升至96.67%;差异均有统计学意义(χ2值分别为34.795、33.298、39.727、36.657、41.409;P<0.05).结论SBAR表格式手术护理交接单的使用更能体现交接的连续性、整体性,简单清晰实用,能够有效减少转出交接消耗时间,提高交接效率、安全性以及护士满意度,值得推广.

Objective To explore the application of surgical care delivery sheet under situation background assessment recommendation (SBAR) in patients undergoing oral and maxillofacial surgery. Methods The problems in the old version of surgical care delivery sheet used in Peking University Hospital of Stomatology from October to December were retrospectively analyzed. The new version of surgical care delivery sheet was designed according to SBAR from January to June 2017. A pilot run was tried for 3 months from June to September 2017 before it was revised in October 2017 and used in the whole Department of Oral and Maxillofacial Surgery. Totally 118 surgical patients who were treated with the old version of surgical care delivery sheet from January to June 2017 were selected as a control group, while 118 surgical patients who were treated with the new version of surgical care delivery sheet from January to June 2018 were selected as an observation group. The time consumed for transfer and delivery, safety of use as well as nurses' total satisfaction score and satisfaction rate in terms of the two version of surgical care delivery sheet were compared between the two groups before and after the SBAR-based surgical care delivery sheet was applied. Results After the SBAR-based surgical care delivery sheet was applied, the time consumed for transfer and delivery was reduced from (10.20±3.01) min to (9.06±3.08) min, and there was statistically significant difference (P< 0.05). No delivery safety problems occurred since the SBAR-based surgical care delivery sheet was applied. Nurses' total satisfaction score for surgical care delivery sheet was increased from (17.67±3.27) to (22.34±2.61), and there was statistically significant difference (P< 0.05). Nurses' satisfaction rates were increased from 52.45% to 94.29% in terms of the format, from 56.30% to 96.82% in terms of content integrity, from 51.15% to 96.77% in terms of delivery content order, from 47.31% to 92.89% in terms of content and from 49.92% to 96.67% in terms of convenience, and there was statistically significant difference (χ2=34.795, 3.298, 39.727, 36.657, 41.409;P<0.05). Conclusions The use of SBAR-based surgical care delivery sheet, which is clear and practical, can embody the continuity and integrity of delivery, effectively reduce the time consumed for transfer and delivery, improve delivery efficiency and safety, and enhance nurses' satisfaction,which is worthy promoting in clinical practice.