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医疗信息化创新 两招搞定合理用血

2018-05-31 佚名 中国卫生质量杂志

临床输血信息管理平台,能为临床用血安全、合理及医师用血评价提供可靠数据,能全方位地质量管理。

临床输血信息管理平台,能为临床用血安全、合理及医师用血评价提供可靠数据,能全方位地质量管理

输血是临床不可替代的治疗手段之一。确保用血安全、合理、科学、有效,是评价输血管理的一项重要内容。陕西省人民医院根据《医疗机构临床用血管理办法》《临床输血技术规范》《三级综合医院评审标准实施细则(2012版)》等文件要求,与某软件公司合作,开发了闭环输血信息管理平台,依托此平台使医护人员、科室质控小组、输血科、输血质量管理委员会及相应职能部门共同参与临床用血质量管理工作,取得了良好效果。

1  主要做法

1.1  开展全流程环节质量管理

临床用血始于患者检查化验,终于输血后疗效评估及反馈。以临床输血过程为分界,划分为输血前、输血中、输血后3大部分。

1.1.1  输血前质量管理
  

 (1)输血前评估。临床医师选择患者信息,右键选择用血申请,选择输血类型、输血目的后进入用血申请界面。输血申请界面设置治疗性输血、术前备血、抢救特殊用血等选项,申请医生根据情况选择进入,自动链接LIS系统获取实验室检测指标及ABO、RH血型情况。根据患者症状体征及实验室检测结果评估,添加申请拟输血成分,保存输血申请单并自动打印输血知情同意书。同时,输血科审核评估用血合理性和适用性。除急救用血外,评估内容缺项者不能进行下一步操作。急救用血由用血科室电话通知输血科室,采血鉴定和/或核对信息后发血并签字,实行先用血后审核。输血质量管理委员会每月对各科急救用血情况进行通报并逐一质控,建立信息备案制度。对屡次谎报、误报急救用血的个人、科室,给予诫勉谈话、扣除绩效考核评分甚至行政处分等处罚。

(2)输血申请审核。遵循《医疗机构临床用血管理办法》要求,按照用血量,分级审核。小于800ml仅上级医生审核,800ml~1 600ml需科主任审核,1600ml以上需医务处审核并填写《大量用血申请表》。

(3)血样采集。临床护士进入血样标本采集界面,点击打印唯一的输血标本识别条码2个,1个贴在输血申请单上,1个贴在输血样本试管上,采血后将血液标本和输血申请单送至输血科。系统记录采血时间、操作人员、配送人员、输血科接收人员,保证可追溯性。

(4)血样接收。输血科人员检查血样,和送血样护士核对申请单及血样信息,扫描试管条码,再次核对信息,接收标本和申请单。

(5)血型鉴定配血。输血科人员扫描血样自动录入信息,待每次操作完毕核对结果后自动上传结果或手工核对录入。输血试验中操作人、复核人、血型鉴定配血时间会被如实记录。

(6)发血。系统按照同型输注原则从库存血液中匹配(ABO+RH(D)+抗筛)相合血袋制品信息,按照失效期先后选择血液制品,点击收费,打印发血报告单。交叉配血完成后,如需输血,护士打印取血单,到输血科与发血人员共同核对患者信息、用血信息、交叉配血信息与血袋信息,扫描血袋条码,打印用血单并双方签字。系统自动记录操作双方、发血时间。

1.1.2  输血中质量管理    

血液从输血科到临床用血科室运送配备有专用血液运送箱,箱内放置冰袋及温度计,温度保持在约4℃,离开输血科时记录箱内温度,临床科室输血前护士记录温度,执行血液运行冷链控制。血液到达病区,护士扫描血袋,系统自动记录核对时间及核对人员。输血前,护理人员执行“三查七对”,扫描患者腕带、血袋信息,核对患者配血报告,三者一致开始输血。护士记录输血开始时间、结束时间、输血情况、有无输血反应,系统自动记录操作人员姓名、输血量及输血成分等。通过输血起止时间可对各种成分血输注时间进行质量控制[1]。护士进行输血过程巡视,监测患者一般情况及体温、脉搏、呼吸、血压等生命体征。有输血不良反应者及时记录并提醒主管医师处理。输血科、质量控制部门随机抽查输血患者信息,并进行追踪抽检。

1.1.3  输血后质量管理   

 主要涉及输血疗效评估及血袋管理两方面。

输血疗效评估主要分为术中用血评估、术后及内科治疗用血评估两类。评估等级由临床医师和/或麻醉医师认定,分为有效、无效。临床医师输血后72小时内完成输血后疗效评估,评估依据临床症状体征改善情况及血常规和血凝指标结果[2]。质控部门及输血科可随时抽查输血过程。

血袋管理主要为血袋销毁。护士按要求收回血袋,操作人员填写回收登记表,回传输血科。按医院感染管理要求,收回血袋最终统一交由医疗废物回收处。

1.2  分析与评价

1.2.1 临床用血评价    

平台可以实现临床用血统计分析功能,包括血液入库和发放、发血量、临床科室用血、单病种用血、医师用血量、医师手术用血、输血与未输血患者比例、输血不良反应、临床用血明细等。

要求科室质控员每月对输血不良反应进行上报、分析,结果记录在《科室质量安全记录本》上。输血科每月统计用血总量前10名的科室和个人,在《医务管理月报》公示。同时,通过平台可随时抽取输血患者信息,对医师输血指针把控和输血有效性评价等进行查看。

1.2.2 输血病历点评   

 输血病历点评包括输血病历首页、输血前评估单、输血知情同意书、输血申请单、配(发)血报告、输血过程记录、不良反应记录、输血疗效评估等8个方面。临床输血管理系统可进行统计评估,按科室、人员、不良反应上报、输血过程记录、输血评估等进行排名点评。

同时,科室质控员每月需质控本科室2份输血病历,结果记录在《科室质量安全记录本》上。质控科每月点评一定数量的归档输血病历。

2 效果

2.1平台使用前后流程对比

2.1.1输血前    平台使用前,临床用血提交手工申请单,存在项目填写不全、医师字迹无法辨认、提交延迟等现象,需要输血科电话核查,出错率高。平台使用后,项目填写不全即不能进行下一步操作;用血强制行输血前评估,且自动链接HIS和LIS系统,方便输血科和质量管理部门进行输血合理性评价;给各级人员赋予不同权限,在系统中完成输血审核、质量管控。

2.1.2输血中    能精准记录分析各种成分用血输注起止时间,能系统化采集全院某一起止时间段输注某种血液制品的患者信息,实现了临床用血实时监控。

2.1.3输血后    输血疗效评估更加便捷,且设置输血后检查项目提醒,和LIS系统链接。输血不良反应作为输血后评估的一部分,能随时查看,及时处理,减少用血安全隐患。输血病历可在平台中一键打印,防止关键文书缺失。

2.1.4其他方面    临床用血所有环节均有操作人与操作时间记录,便于问题追溯和质量全流程控制。平台能完成血液出入库、输血试剂及耗材、输血实验方法、输血项目收费等管理。能随时存储、提取用血统计数据,对制定计划→执行→检查→反馈提高输血质量管理水平有较大贡献。

2.2平台使用前后数据对比

2.2.1 用血量    以2016年为例:2016年1月-6月出院患者55 049人,用血总量54 395U;2016年7月-12月出院患者56 142人,用血总量50 268U。出院人数上升1.99%,但用血总量下降7.59%。

2.2.2  输血比例    在出院人数增加的情况下,出院患者输血比例由2016年1月-6月的6.40%下降为2016年7月-12月的6.07%。在手术患者增加的情况下,手术患者输血比例从2016年1月-6月的6.41%降低为2016年7月-12月的4.07%。

3 讨论

输血是患者不良预后的独立风险因素[3],涉及部门、人员、环节、要素众多,其质量直接关系到群众身体健康和生命安全。基于闭环输血信息管理平台的临床用血质量管理具有高效、全面、便捷、科学等特点,能进行输血前、中、后全过程、全方位的质量管理。系统、完善、规范、准确的临床输血信息管理平台,为临床用血安全、合理及医师用血评价提供了可靠数据,满足了用血权准入管理需求[4]。下一步将围绕平台加强质量管理,进一步拓展平台功能。

3.1 建立质量保证体系

建立质量保证体系应从实验室设置、环境、样品和试剂管控、室内质量控制和室间质量评价等着手[5],涉及人、机、料、法、环等都应逐步嵌接到平台中。例如,医护人员建立输血个人档案,将其接受培训、考核记录嵌接入平台中,纳入用血记录、输血不良反应、管理部门对输血合理性及安全性评价等。室内质量控制涉及仪器、试剂。本平台已完成对输血所用试剂的维护、查询,但需进一步扩充,如纳入输血相容性检测项目,记录现有血液标本、制备方法、操作流程等,保证检验结果的可靠、重复和安全。还可以将输血管理制度、职能分工等进行嵌入式添加,特别是制定标准操作流程,规范诊疗行为,保证评价一致性[6]。

3.2 加强培训

临床医护人员对输血适应症、禁忌症、输血不良反应等的掌握程度参差不齐,对输血新概念了解较少。以输血不良反应记录评估为例,多局限在发热、皮疹、过敏反应描述,对非溶血性发热反应、变态反应、过敏反应、溶血反应、细菌污染、循环超负荷、出血倾向、酸碱平衡失调、输血相关性急性肺损伤、静脉炎、传播感染性疾病等了解不够[7]。加强培训,可提高医护人员对输血不良事件的早发现、早识别、早处理水平。质量管理核心是交互式反馈下的不断改进,可利用平台,开发对接手机APP服务,实现输血者、输血执行医护人员、输血管理者的实时信息交互。

3.3 加强对重点科室、病种、手术的输血管理

从平台反馈数据来看,该院用血前几位科室是血液内科、重症医学科、消化内科,排名前几位病种是急性白血病、上消化道出血、慢性肾衰竭(用血浆)、再生障碍性贫血、重度贫血,手术用血总量排名依次是剖宫产术、肺叶切除术、升主动脉替换加主动脉瓣替换、冠状动脉搭桥、颅内血肿清除术。输血管理部门通过对重点科室、病种、手术的管理,使输血总量、手术用血量在业务增长的情况下降低,提高了输血安全性和合理性。

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    2018-06-02 飘飘爱

    很好

    0

  2. 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  3. 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topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Fri Jun 01 07:03:31 CST 2018, time=2018-06-01, status=1, ipAttribution=)]
  4. 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topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Fri Jun 01 07:03:31 CST 2018, time=2018-06-01, status=1, ipAttribution=)]
  5. 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topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Fri Jun 01 07:03:31 CST 2018, time=2018-06-01, status=1, ipAttribution=)]
  6. [GetPortalCommentsPageByObjectIdResponse(id=320916, encodeId=eaf132091616, content=很好, beContent=null, objectType=article, channel=null, level=null, likeNumber=107, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib2emBzjO0FtqTJ05AqrEEdRmp6tmlsLXqpzfxWdtgbbgPGWRHagoK9fLTd3IayRPgkJVIVBWtdlmnkBhOIR4cFM/0, createdBy=e8d51649330, createdName=飘飘爱, createdTime=Sat Jun 02 20:32:27 CST 2018, time=2018-06-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1285582, encodeId=167712855827c, content=<a href='/topic/show?id=77903209422' target=_blank style='color:#2F92EE;'>#创新#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=32094, encryptionId=77903209422, topicName=创新)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=512a199, createdName=lilianxiang, 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topicName=医疗信息化)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=e07514702355, createdName=ay2005fy, createdTime=Sat Jun 02 14:07:00 CST 2018, time=2018-06-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1619970, encodeId=13a416199e06b, content=<a href='/topic/show?id=13f13482639' target=_blank style='color:#2F92EE;'>#医疗信息#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=34826, encryptionId=13f13482639, topicName=医疗信息)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=docwu2019, createdTime=Sat Jun 02 14:07:00 CST 2018, time=2018-06-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=320737, encodeId=8386320e3771, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Sat Jun 02 07:00:07 CST 2018, time=2018-06-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=320514, encodeId=b37a32051491, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Fri Jun 01 08:05:51 CST 2018, time=2018-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=320504, encodeId=50733205044e, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=130, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Jun 01 07:44:27 CST 2018, time=2018-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=320477, encodeId=cf643204e789, content=coolway, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLCclExeQ6LOGMD4dTsia4Ty4HtZCxRmG5vO5XIKfKX3a3vusfhHSej4Iib517vmhFW7RQgh7bpDp1yw/0, createdBy=50951609779, createdName=baihao215, createdTime=Fri Jun 01 07:24:15 CST 2018, time=2018-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=320462, encodeId=9718320462ea, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Fri Jun 01 07:03:31 CST 2018, time=2018-06-01, status=1, ipAttribution=)]
    2018-06-02 yfjms

    学习

    0

  7. 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attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Sat Jun 02 07:00:07 CST 2018, time=2018-06-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=320514, encodeId=b37a32051491, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Fri Jun 01 08:05:51 CST 2018, time=2018-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=320504, encodeId=50733205044e, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=130, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Jun 01 07:44:27 CST 2018, time=2018-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=320477, encodeId=cf643204e789, content=coolway, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLCclExeQ6LOGMD4dTsia4Ty4HtZCxRmG5vO5XIKfKX3a3vusfhHSej4Iib517vmhFW7RQgh7bpDp1yw/0, createdBy=50951609779, createdName=baihao215, createdTime=Fri Jun 01 07:24:15 CST 2018, time=2018-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=320462, encodeId=9718320462ea, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Fri Jun 01 07:03:31 CST 2018, time=2018-06-01, status=1, ipAttribution=)]
    2018-06-01 明月清辉

    谢谢分享.学习了

    0

  8. 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attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Sat Jun 02 07:00:07 CST 2018, time=2018-06-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=320514, encodeId=b37a32051491, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Fri Jun 01 08:05:51 CST 2018, time=2018-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=320504, encodeId=50733205044e, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=130, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, 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topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Fri Jun 01 07:03:31 CST 2018, time=2018-06-01, status=1, ipAttribution=)]
    2018-06-01 飛歌

    学习了很有用不错

    0

  9. 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createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Jun 01 07:44:27 CST 2018, time=2018-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=320477, encodeId=cf643204e789, content=coolway, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLCclExeQ6LOGMD4dTsia4Ty4HtZCxRmG5vO5XIKfKX3a3vusfhHSej4Iib517vmhFW7RQgh7bpDp1yw/0, createdBy=50951609779, createdName=baihao215, createdTime=Fri Jun 01 07:24:15 CST 2018, time=2018-06-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=320462, encodeId=9718320462ea, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Fri Jun 01 07:03:31 CST 2018, time=2018-06-01, status=1, ipAttribution=)]
    2018-06-01 baihao215

    coolway

    0

  10. 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topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Fri Jun 01 07:03:31 CST 2018, time=2018-06-01, status=1, ipAttribution=)]
    2018-06-01 1209e435m98(暂无昵称)

    学习了.谢谢分享

    0

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