基于GRADE系统的临床护理路径应用于髋关节置换病人手术前后功能锻炼的系统评价

System evaluation on clinical nursing pathway based on GRADE system applied in functional exercise of patients with hip replacement before and after operation

[目的]系统评价将临床护理路径用于髋关节置换病人手术前后功能锻炼的效果。[方法]计算机检索中国期刊全文数据库(CNKI)、数字化期刊全文数据库(WanFang Data)、中文科技期刊数据库(VIP)、PubMed、Web of science、EMbase、CBM和The Cochrane Library(2015年第5期)查找2010年1月—2015年6月将临床护理路径用于髋关节置换病人手术前后功能锻炼的随机对照试验(RCT),并对纳入文献的参考文献进行检索。对于符合标准的文献,由2位评价员严格按照纳入标准独立筛选、提取资料,并进行偏倚风险评估后,使用RevMan5.3软件进行Meta分析,采用GRADE profiler3.6软件评价证据质量,进行等级推荐的分级。[结果]共纳入15个RCT,总计1 248例病人。Meta分析结果显示:临床护理路径组在髋关节功能Harris评分[SMD=3.35,95%CI(2.53,4.16),P<0.000 01],降低血栓栓塞[RR=0.28,95%CI(0.15,0.53),P<0.000 1]、肺部感染[RR=0.33,95%CI(0.14,0.82),P=0.02]、尿潴留[RR=0.22,95%CI(0.09,0.52),P=0.000 5]、便秘[RR=0.20,95%CI(0.10,0.40),P<0.000 01]的发生率,提高病人对于护理工作满意度[RR=1.26,95%CI(1.17,1.36),P<0.000 01]和缩短病人住院时间[SMD=-1.91,95%CI(-2.39,-1.43),P<0.000 1]等方面均优于对照组,其差异均有统计学意义;但在降低关节脱位[RR=0.25,95%CI(0.05,1.15),P=0.08],压疮[RR=0.25,95%CI(0.03,2.19),P=0.21]及并发症总发生率[RR=0.42,95%CI(0.15,1.12),P=0.08]等方面,两组差异无统计学意义。平均住院时间的漏斗图分析显示,纳入研究的文献可能存在一定的发表偏倚。GRADE系统评价结果显示,证据质量水平髋关节功能Harris评分为中级,血栓栓塞发生率、尿潴留发生率和病人对护理工作满意度为低级,其余均为极低级。[结论]将临床护理路径用于髋关节置换病人手术前后功能锻炼的效果显著优于常规护理。但受研究结果评价的等级及纳入研究规范性、统一性等方面的限制,上述研究结果的推广还有待更多高质量的随机对照试验加以验证。

Objective:To evaluate effect of clinical nursing pathway applied in functional exercise of patients with hip replacement before and after operation.Methods:China journal full text database(CNKI),digital periodical full text database,Wanfang Data,Chinese science and technology journals database(VIP),PubMed,web of science,EMBASE,CBM and the Cochrane Library(2015 5)were retrievaled,randomized controlled trial(RCT)of the clinical nursing pathway on functional exercise in patients with hip replacement before and after operation were founded from June 2015 to January 2010,and the references included in the literature were retrieved.For the literature met standard,2 reviewers independently selected and extracted data according to inclusion and standard strictly,and assessed risks of bias,and RevMan5.3software was used for meta analysis.The quality of evidence was evaluated by using grade profiler3.6software,the level recommended for grading.Results:A total of 15 RCT,1 248 patients were included.Meta analysis showed that:Harris score of clinical nursing path group in the hip function[SMD=3.35,95%CI(2.53,4.16),P<0.000 01],and reduced the incidence of thrombosis embolism[RR=0.28,95%CI(0.15,0.53),P<0.000 1],pulmonary infection,[RR=0.33,95%CI(0.14,0.82),P=0.02],urinary retention[RR=0.22,95%CI(0.09,0.52),P=0.000 5],incidence of constipation[RR=0.20,95%CI(0.10,0.40),P<0.000 01],and improved patients’ satisfaction for nursing care[RR=1.26,95%CI(1.17,1.36),P<0.000 01]and shorten the hospitalization time[SMD=-1.91,95%CI(-2.39,-1.43),P<0.000 1],and the above aspects were better than that in control group,the difference had statistically significant;but in reducing joint dislocation[RR=0.25,95%CI(0.05,1.15),P=0.08],pressure ulcer[RR=0.25,95%CI(0.03,2.19),P=0.21],and the incidence of complications[RR=0.42,95%CI(0.15,1.12),P=0.08]and so on,there was no statistically significant difference between both groups.The funnel plot analysis of the average length of stay showed that there may be some publication bias in the literature.GRADE system evaluation results showed that the level of Harris score of hip function was intermediate,the incidence of thrombosis,the incidence of urinary retention and the satisfaction of patients to nursing work were low,and the rest were very low.Conclusion:The effect of clinical nursing pathway for the functional exercise of hip replacement patients before and after operation was significantly better than that of routine nursing.However,it was restricted by the grade of the evaluation of research results and the standardization and uniformity of the research,the results of the above study have yet to be verified by more high-quality randomized controlled trials.