多学科分级协作管理在慢性阻塞性肺疾病患者吞咽筛查及干预中的效果评价

The effectiveness of multidisciplinary graded collaborative management on swallowing screening and intervention in patients with chronic obstructive pulmonary disease

目的:探讨多学科分级协作管理对慢性阻塞性肺疾病患者吞咽筛查及干预的效果。方法:成立慢性阻塞性肺疾病患者吞咽项目多学科管理小组,制订慢性阻塞性肺疾病患者吞咽功能筛查、干预流程,以及制定多学科分级协作管理流程、进食管理常规、培训方案和质量控制方案,开展培训并完成考核。于2022年5—10月在中山大学附属第三医院呼吸与危重症医学科实施吞咽筛查及干预并持续质量控制。结果:共筛查慢性阻塞性肺疾病患者186例,其中,并发吞咽障碍43例,发生率为23.12%(43/186)。实施多学科分级协作管理后,患者吞咽筛查率为100.00%(186/186),吞咽障碍患者根据容积-黏度吞咽测试结果进行干预率为100.00%(43/43),营养吞咽专科护士会诊率为24.19%(45/186),营养医生会诊率为19.89%(37/186),吞咽康复治疗师会诊率为5.91%(11/186)。43例吞咽障碍患者干预后体质量[(61.21±10.99)kg]、血红蛋白[(132.44±11.27)g/L]、血清白蛋白[(37.63±3.51)g/L]、血清前白蛋白水平[(199.77±40.15)mg/L]均高于干预前[分别为(59.99±10.96)kg、(124.67±10.86)g/L、(35.01±2.82)g/L、(177.12±40.09)mg/L](t=-9.871、-8.634、-7.708、-11.703,P值均<0.001);干预后营养风险NRS 2002评分[(2.47±0.74)分]、显性误吸发生率[16.28%(7/43)]、吸入性肺炎发生率[2.33%(1/43)]均低于干预前[分别为(3.53±0.91)分、89.74%(35/39)、35.90%(14/39)](t=10.488,χ^(2)=44.177、0.245,P值均<0.001);干预后专科护理团队临床营养及吞咽理论得分[(86.43±3.80)分]、技能得分[(87.29±2.51)分]均高于干预前[分别为(76.00±6.04)分、(76.76±4.95)分](t=-10.890、-8.584,P值均<0.001)。结论:对慢性阻塞性肺疾病患者常规进行吞咽功能筛查,及早识别并发吞咽障碍患者,进行多学科分级协作管理,可降低患者的营养风险,提升患者进食的安全性,促进专科护理的精细化发展。

Objective:To explore the effectiveness of multi-disciplinary graded collaborative management on swallowing screening and intervention in patients with chronic obstructive pulmonary disease(COPD).Methods:Data were collected on COPD participants who received swallowing screening and intervention from May to October 2022 in The Third Affiliated Hospital,Sun Yat-sen University.Intervention was composed of the followings:(1)A multidisciplinary management team was established.(2)A swallowing function screening and intervention process for patients with COPD was developed.(3)A multidisciplinary graded collaborative management process and feeding management routine were formulated,training program and quality control program were developed.(4)Nurses were trained and assessed.Results:A total of 186 patients with COPD were screened,of whom 43 had swallowing disorders,with a positive rate of 23.12%(43/186).After the implementation of multidisciplinary graded collaborative management,the swallowing screening rate of patients was 100.00%(186/186),the intervention rate of positive patients based on the volumetric viscosity swallowing test results was 100.00%(43/43),the consultation rate of nutrition swallowing specialist nurses was 24.19%(45/186),the consultation rate of nutrition doctors was 19.89%(37/186),and the consultation rate of swallowing rehabilitation therapists was 5.91%(11/186).After intervention,the average body weight((61.21±10.99)kg),hemoglobin((132.44±11.27)g/L),serum albumin((37.63±3.51)g/L)and serum prealbumin((199.77±40.15)mg/L)of the 43 positive patients were all increased than those before intervention(respectively(59.99±10.96)kg,(124.67±10.86)g/L,(35.01±2.82)g/L,(177.12±40.09)mg/L,(t=-9.871,-8.634,-7.708,-11.703,all P<0.001));After intervention,the average nutritional risk NRS 2002 score(2.47±0.74),the incidence of dominant aspiration(16.28%(7/43))and aspiration pneumonia(2.33%(1/43))were lower than before intervention(respectively(3.53±0.91),89.74%(35/39),35.90%(14/39),(t=10.488,χ^(2)=44.177,0.245,all P<0.001));After intervention,the average clinical nutrition and swallowing theory scores(86.43±3.80)and skill scores(87.29±2.51)of the specialist nursing team were increased than those before intervention((76.00±6.04)and(76.76±4.95),respectively,t=-10.890,-8.584,P<0.001).Conclusion:Routine screening of swallowing function in patients with COPD and multi-disciplinary graded collaborative management can reduce the nutritional risk of patients,improve the safety of patients’feeding and promote the refined development of specialized nursing care.