社区糖尿病高危足管理最佳证据应用的审查指标制定及应用

Development and application of review indicators for best evidence application in the management of high-risk diabetic foot in community

目的开展社区糖尿病高危足足部管理的证据转化, 构建审查指标评估社区应用的现状, 分析证据转化中的促进及障碍因素, 制订变革策略及优化措施。方法以加拿大KTA知识转化模型为理论框架, 在确定临床护理问题、汇总证据、引入社区情景的基础上, 制定审查指标及审查方法;根据基线审查结果进行障碍因素分析, 制定对策。结果本研究共纳入31条最佳证据, 制定25条审查指标, 第2、4~7、16、20、21、23条审查指标执行率分别为8%、6%、8%、8%、8%、16%、17%、4%、4%, 其余指标执行率均为0;通过焦点访谈分析主要障碍因素:社区糖尿病高危足足部管理模式尚在摸索, 护理多学科门诊平台搭建需要强大领导力及资源支撑, 护理多学科团队岗位设置待完善, 糖尿病高危足足部管理缺乏合理就诊流程, 门诊缺乏糖尿病高危足足部管理多样化宣教材料, 社区护士循证准备度不足。促进因素包括:院部及护理部管理层重视程度高, 专科护士重视糖尿病高危足管理的意义, 患者预期良好的结局是专科护士工作的动力。变革策略:搭建门诊护理平台, 明确门诊护理岗位职责, 优化门诊就诊流程, 配置硬件设施(各项筛查、检查仪器、宣教运动室)完成高危足健康教育支撑材料(包括课件、实践手册、视频、海报、卡片), 开展社区糖尿病高危足管理。院内外培训后, 指标1~17、20~23执行率为100.00%, 指标18执行率为61.11%, 指标19执行率为79.63%, 指标24执行率为66.67%, 指标25执行率为82.41%。结论糖尿病高危足足部管理与社区实践尚存在极大差距, 充分全面地分析社区实践存在的障碍与促进因素, 实施相应的变革策略, 可以促进证据有效运用于社区情景。

ObjectiveeTo carry out evidence transformation for the management of high-risk diabetic foot in communities,construct review indicators to evaluate the status quo of community application,analyze the promoting and obstacle factors in evidence transformation and formulate reform strategies and optimization measures.Methods Based on the Canadian Knowledge to Action Framework as the theoretical framework,the review indicators and review methods were developed on the basis of identifying clinical nursing problems,summarizing evidence and introducing community scenarios.Based on the results of baseline review,obstacle factors were analyzed and countermeasures were developed.Results A total of 31 best evidences were included in this study,and 25 review indicators were developed.The implementation rates of the 2,4 to 7,16,20,21 and 23 review indicators were 8%,6%,8%,8%,8%,16%,17%,4%and 4%,respectively,and the implementation rates of the remaining indicators were O.Through focus interview analysis,the main obstacle factors included that the management mode of diabetic high-risk foot in the community was still exploring,the construction of multidisciplinary nursing outpatient platform needed strong leadership and resource support,the post setting of multidisciplinary nursing team needed to be improved,the management of diabetic high-risk foot lacked reasonable medical procedures,the outpatient department lacked diversified publicity and education materials for diabetic high-risk foot management and community nurses lacked evidence-based preparation.The promotion factors included the high level of attention paid by the management of the hospital and nursing department,the significance of the management of high-risk diabetic foot paid by specialist nurses and patient expectations of good outcomes as motivation for specialist nurses to work.The reform strategy included building an outpatient nursing platform,clarifying the responsibilities of outpatient nursing posts,optimizing the outpatient treatment process,configuring hardware facilities(various screening and examination instruments and propaganda and education sports room),completing the supporting materials for high-risk foot health education(including courseware,practice manual,videos,posters and cards),and carrying out the management of diabetic high-risk foot in the community.After in-hospital and out-of-hospital training,the implementation rate of indicators 1 to 17,20 to 23 was 100.00%,the implementation rate of indicator 18 was 61.11%,the implementation rate of indicator 19 was 79.63%,the implementation rate of indicator 24 was 66.67%and the implementation rate of indicator 25 was 82.41%.Conclusions There is still a great gap between the foot management of high-risk diabetic foot and community practice.A full and comprehensive analysis of the obstacles and promoting factors in community practice and the implementation of corresponding reform strategies can promote the effective application of evidence in community situations.