基于医疗失效模式与效应分析优化体外循环术后患者应激性高血糖管理流程的效果评价

Effect evaluation of optimized management process of stress-induced hyperglycemia in patients after cardiopulmonary bypass based on health failure mode and effect analysis

目的探讨医疗失效模式与效应分析(health failure mode and effect analysis,HFMEA)在优化体外循环术后应激性高血糖(stress-induced hyperglycemia,SHG)管理流程中的效果。方法对心胸外科重症监护室SHG管理流程应用HFMEA进行分析,绘制流程图,分析潜在的风险因素,制定并落实更为细化的SHG管理流程、SHG管理流程核查图等改进措施,比较HFMEA实施前(2019年10月—2020年12月)和实施后(2021年1月—2022年3月)SHG管理风险值、血糖管理情况及患者预后情况。结果HFMEA实施后未落实分层培训、护士未充分认知监测血糖必要性、未判断患者术前血糖基数及有无高血糖病史、管理方案制定不合理、目标血糖值设置不合理、肠内及静脉营养患者SHG管理方案未制定、胰岛素冲配过程不规范、胰岛素使用后,血糖监测不及时、给药护理措施不到位、管理评价不及时等10项失效模式的风险值均比实施前下降,差异有统计学意义(P<0.05);实施HFMEA后血糖管理情况明显好转、患者预后情况明显好转,且各项监测指标比较差异均有统计学意义(P<0.05)。结论运用HFMEA优化体外循环术后SHG管理流程,可降低SHG管理风险,改善血糖管理效果,促进患者临床转归。

Objective To investigate the effect of health failure mode and effect analysis(HFMEA)on optimizing management process of stress-induced hyperglycemia(SHG)in patients after cardiopulmonary bypass(CPB).Methods HFMEA was performed in the SHG management process in the cardiothoracic surgery intensive care unit.After the flowchart was drawn,and potential risk factors were analyzed,improvement measures such as refined SHG management process,SHG management process verification chart and other measures were developed and implemented.SHG management risk values,glycemic management,and patient prognosis before(October 2019 to December 2020)and after(January 2021 to March 2022)the implementation of HFMEA was compared.Results After the implementation of HFMEA,the risk of training without tier,inadequate cognition on necessity of blood glucose monitoring,being unaware of patients’preoperative blood glucose base and history of hyperglycemia,unreasonable management protocols and target blood glucose value,without SHG management protocols for enteral and intravenous nutrition,no standardized insulin preparation,and without timely blood glucose monitoring,medication nursing and management evaluation after insulin administration was decreased,indicating statistical significance(P<0.05);the blood glucose management and patient prognosis were significantly better after the implementation,and the differences between the monitoring indexes before and after implementation were statistically significant(P<0.05).Conclusion Optimized postoperative SHG management process after CPB by HFMEA can reduce SHG management risk,improve the effect of blood glucose management,and promote the clinical outcomes of the patients.