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• 国际视角 • 上一篇    

ICU小组长交接班基本信息文档设计:一项小组研究

Amy J. Spooner Leanne M. Aitken Amanda Corley Wendy Chaboyer   

  1. 查尔斯王子医院危重病房重症护理研究小组, 布理斯本, 澳大利亚(Amy J. Spooner,Amanda Corley);NHMRC护理研究中心, 昆士兰Menzies卫生学校, 格利菲斯大学(Leanne M. Aitken,Wendy Chaboyer);格利菲斯大学护理学院(Amy J. Spooner,Leanne M. Aitken);亚历山大王子医院危重病房(Leanne M. Aitken);伦敦城市大学医学院(Leanne M. Aitken)
  • 出版日期:2018-02-25 发布日期:2018-02-25

Developing a minimum dataset for nursing team leader handover in the intensive care unit: a focus group study

  • Online:2018-02-25 Published:2018-02-25

摘要: 背景:尽管对有系统结构的交接班文档(用于引导有效交接班)的需求在不断增加,针对ICU交接班的交班指导工具却是有限的。目的:此项研究的目的在于帮助ICU小组长收集患者的主要病情项目,更有效地进行班次之间的交接。方法:研究设在澳洲的一个有21张床位的危重病房内/外科ICU。参加人员为参与交接班的高资历护士。参与小组采用名义群体法(Nominal Group Technique,NGT)选择并且排序需要收集患者主要病情资料的重要性。接班的护士从前一班护士组长的交班内容中选择哪些项目应该包含在基本病情资料中。选择结果以出现频率和百分率作总结。结果:参与研究的三个小组由17位高资历护士组成。参与人员一致同意ISBAR(识别-基本情况-背景-检查分柝-建议)是指导临床交接班的一项有效的应用工具。经筛选应该包含在基本资料组成的项目(至少65%同意)包括识别(姓名、年龄、ICU住院天数)、基本情况(诊断、手术名称)、现状背景(主要病症)、主要病症的治疗措施、建议(下一班对患者的治疗和观察计划及跟进措施)。总的来说,检查项目中选出的67项中有30项(45%)被认为应该包含为基本资料的组成部分,具体到对身体特定系统的观察和治疗。其他和ISBAR没有关联的项目,例如ICU收住入院、工作人员和技术能力配置、手术病例等,以及患者病情(感染状态、感染部位、濒死计划)都作为重要考虑因素。其他增加的项目并应包含在交接班的内容仅在与患者病情有关时讨论。结论:研究结果表明,使用专为ICU设计的ISBAR能够帮助ICU小组长有效收集患者病情资料,更有效地进行交接班,并保证患者的安全和治疗计划得以实施。

Abstract: Background: Despite increasing demand for structured processes to guide clinical handover, nursing handover tools are limited in the intensive care unit. Objective: The study aim was to identify key items to include in a minimum dataset for intensive care nursing team leader shift-to-shift handover. Methods: This focus group study was conducted in a 21-bed medical/surgical intensive care unit in Australia. Senior registered nurses involved in team leader handovers were recruited. Focus groups were conducted using a nominal group technique to generate and prioritise minimum dataset items. Nurses were presented with content from previous team leader handovers and asked to select which content items to include in a minimum dataset. Participant responses were summarised as frequencies and percentages. Results: Seventeen senior nurses participated in three focus groups. Participants agreed that ISBAR (Identify-Situation-Background-Assessment-Recommendations) was a useful tool to guide clinical handover. Items recommended to be included in the minimum dataset (≥65% agreement) included Identify (name, age, days in intensive care), Situation (diagnosis, surgical procedure), Background (significant events, management of significant events) and Recommendations (patient plan for next shift, tasks to follow up for next shift). Overall, 30 of the 67 (45%) items in the Assessment category were considered important to include in the minimum dataset and focused on relevant observations and treatment within each body system. Other non-ISBAR items considered important to include related to the ICU (admissions to ICU, staffing/skill mix, theatre cases) and patients (infectious status, site of infection, end of life plan). Items were further categorised into those to include in all handovers and those to discuss only when relevant to the patient. Conclusion: The findings suggest a minimum dataset for intensive care nursing team leader shift-to-shift handover should contain items within ISBAR along with unit and patient specific information to maintain continuity of care and patient safety across shift changes.