基于战伤编码和循证医学证据等级的战伤套餐医嘱构建——以四肢战伤为例

Structure of a clinical order set for combat-related injuries based on combat injury code and evidence level in evidence-based medicine-with injuries of limbs as an example

目的 构建战伤套餐医嘱,提高战伤救治标准化程度,提高救治效率,同时便于指导精准化卫勤保障,支撑卫勤决策。方法 以前期战伤编码研究成果为基础,根据PRISMA标准构建循证策略,利用牛津循证医学中心临床证据水平分级建立证据等级结构,遵循我军现行医疗后送体制和救治能级,构建套餐医嘱。结果 基于86种四肢伤战伤编码,设计了每种伤情的在不同救治机构和救治能级中的套餐医嘱,涵盖分类、伤势定级、急救措施、手术、用药、检查、后送以及信息填写不同技术类别,共974条。结论 套餐医嘱及编码的构建能够实现战伤信息与药品器材信息的耦合,为卫勤保障数据资源的有效利用奠定了标准化的基础。

Objective To construct a clinical order set of combat-related injuries, so as to enhance the standardization in combat casualty care, improve treatment efficacy, and direct accurate medical service and render support for medical decision-making.Method A clinical order set for combat-related injuries was constructed, based on previous research results of injury codes, and in accordance with the PRISMA and Oxford Evidence-based Medicine Center’s clinical evidence classification, and the current medical evacuation system and treatment capability levels shoud be closely adhered to.Results Based on 86 injury codes of limbs, a standard clinical order set for different military treatment facilities were designed and constructed, covering classification, injury severity, first aid measures, surgery, medication, examination, evacuation and filling in of basic information, with a total of 974 itemst.Conclusion The construction of a standard clinical order set could facilitate realization of coupling between injury data and medical supply data, which will lay a good foundation for effective use of medical service data resources.