北京市血液透析护士血管通路穿刺现况及影响因素分析

A cross-sectional investigation on vascular access cannulation among hemodialysis nurses in Beijing

目的:调查北京市血液透析护士血管通路穿刺现状,分析临床现状与最佳证据之间的差距,为临床实践改进提供依据。方法:于2021年8月采用便利抽样法选取北京市临床医院血液透析室或血液透析中心护士,使用基于循证证据设计的问卷调查其血管通路穿刺现况并分析影响因素。结果:542名护士规范操作得分中位数(四分位数间距)是4.64(0.62)分,操作规范性与护士职称、职务、穿刺培训、超声应用有关;穿刺并发症处理得分比穿刺前评估、穿刺过程得分低(P<0.001);评估自体动静脉内瘘(AVF)/人工动静脉内瘘(AVG)成熟及能穿刺的时间点与最佳证据相符的护士占46.4%/12.3%;AVF/AVG穿刺采用绳梯穿刺、扣眼穿刺、局部区域穿刺的护士占比分别是96.5%/93.9%、27.3%/13.5%、26.9%/19.9%。结论:护士穿刺规范性水平有待提升,特别是对穿刺并发症的处理亟待引起护士的重视,对内瘘成熟及穿刺时机的评估时间尚不统一,穿刺方法有待改进,血管通路的穿刺规范性与护理管理相关。

Objective:To describe the characteristics of vascular access cannulation among clinical nurses in hemodialysis centers in Beijing based on the best evidence,therefore to identify the gap between clinical practice and the best practice of vascular access cannulation,and provide evidence for future improvement.Methods:Following convenient sampling,eligible nurses from the hemodialysis centers of study hospitals were included in the current study.Using questionnaire which was designed based on the evidence-based practice,clinical guidelines and expert consensus,the characteristics and influencing factors of vascular access cannulation among clinical nurses were examined.Results:A total of 542 valid questionnaires were collected and analyzed.Among these nurses,the average score for the standardized operation was 4.64(0.62),which was related to the nurse’s professional title,position,received training on puncture and ultrasound application.Meanwhile,the score on handling puncture complications was significantly lower than the scores on both assessment before puncture and the puncture process(P<0.001).The proportion of nurses who assessed the maturity of AVF and AVG at the time of puncture according to the best evidence was 46.3%and 12.3%,and the proportion of nurses who adopted"rope-ladder cannulation","buttonhole cannulation"and"area cannulation"in AVF/AVG were 96.5%/93.9%,27.3%/13.5%and 26.9%/19.9%,respectively.Conclusion:There are potential needs to standardize nurses’cannulation process,especially those related to the handling of puncture complications.The time assessing maturity and cannulation of the initial arteriovenous fistula is not consistent,the cannulation methods needs to be improved.The overall nursing management of vascular access is significantly related to the standardization of nurses’cannulation in hemodialysis centers.