【作者】 刘佳；

【导师】 周敏；

【作者基本信息】 山东大学 ， 护理（专业学位）， 2024， 硕士

【摘要】 目的:1.基于实施性研究综合框架(Consolidated Framework for Implementation Research,CFIR)开展质性研究,挖掘重症监护病房(Intensive Care Unit,ICU)感染性休克集束化治疗实施过程中的阻碍因素。2.针对阻碍因素,借助CFIR-ERIC实施策略匹配工具拟定变革策略,制定ICU感染性休克集束化治疗实施干预措施。3.应用ICU感染性休克集束化治疗实施干预措施,探讨其可用性及应用效果。方法:1.质性研究:采用目的抽样法,于2023年5～6月选取山东省济南市某三级甲等医院17名ICU护士和医生作为访谈对象。以CFIR为指导制定访谈提纲,采用半结构式访谈法收集资料,访谈文本导入Nvivo 12软件,根据CFIR编码手册,采用内容分析法进行资料分析,确定ICU感染性休克集束化治疗实施的阻碍因素。2.干预措施的制定:通过CFIR官网下载CFIR-ERIC实施策略匹配工具,将质性研究部分中识别的阻碍因素输入匹配工具,结合ICU科室实际情况,确定每个阻碍因素优先推荐的变革策略,进而制定“ICU感染性休克集束化治疗实施干预措施(初稿)”。通过召开专家小组会议,讨论干预措施内容并修改,形成“ICU感染性休克集束化治疗实施干预措施(终稿)”。3.干预研究:于2023年7～8月在山东省济南市某三级甲等医院ICU科室应用感染性休克集束化治疗实施干预措施。以ICU护士及收治的感染性休克患者为研究对象。护士为自身前后对照研究设计。感染性休克患者为历史对照研究设计,以2022年12月～2023年4月入院的感染性休克患者为对照组,2023年9月～2024年1月入院的感染性休克患者为试验组。干预措施应用前后,收集护士感染性休克集束化治疗知识得分,分别收集对照组和试验组感染性休克患者集束化治疗总完成率及各组成部分完成率、ICU住院时间、死亡率。采用SPSS 25.0统计学软件进行数据录入及分析,统计方法包括统计描述、独立样本t检验、Wilcoxon配对秩和检验、χ2检验等,P<0.05具有统计学意义。结果:1.通过质性访谈,共识别出9个ICU感染性休克集束化治疗实施的阻碍因素,分别为:药品相关部门协作程度低;医护人员相对不足;医护沟通存在延迟;集束化治疗部分措施适应性欠缺;科室缺乏目标与反馈机制;科室部分物品储备不足;集束化治疗培训效果差,渠道有限;医护人员对集束化治疗认知缺乏;护士在集束化治疗落实中被动执行。2.通过召开专家小组会议,最终制定的“ICU感染性休克集束化治疗实施干预措施”包括组建实施工作组、开展培训、物资规范化管理、质量控制四个部分,并针对护士制定了感染性休克集束化治疗知识问卷。3.最终收集护士资料71例;收集ICU感染性休克患者资料105例,其中,对照组55例,试验组50例。结果显示:(1)干预措施应用前护士感染性休克集束化治疗知识中位得分为82分,应用后中位得分为96分,比应用前提高(P<0.05),差异具有统计学意义。(2)两组感染性休克患者的性别、年龄、基础疾病等一般资料具有可比性(P>0.05)。(3)两组感染性休克患者1小时和3小时乳酸测量完成率均为100%。乳酸复测方面,对照组完成率为43.64%,试验组完成率为64.00%,差异具有统计学意义(P<0.05)。1小时血培养采集方面,对照组完成率为16.36%,试验组完成率为36.00%,差异具有统计学意义(P<0.05)。3小时血培养采集方面,对照组完成率为30.91%,试验组完成率为54.00%,差异具有统计学意义(P<0.05)。3小时抗菌药物启用方面,对照组完成率为40.00%,试验组完成率为60.00%,差异具有统计学意义(P<0.05)。集束化治疗总完成率及其他组成部分,与对照组相比,试验组的完成率均有提高,但未发现统计学差异(P>0.05)。(4)试验组感染性休克患者ICU死亡率(22.00%)低于对照组(40.00%),差异具有统计学意义(P<0.05);但在ICU住院时间方面,两组患者并无统计学差异(P>0.05)。结论:1.本研究以CFIR为指导,通过对医生和护士质性访谈,分析得出9个ICU感染性休克集束化治疗实施过程中的阻碍因素,结果真实、可靠。2.应用CFIR-ERIC实施策略匹配工具确定变革策略,通过专家小组会议,制定ICU感染性休克集束化治疗实施干预措施,制定过程科学合理,具有临床适用性。3.应用ICU感染性休克集束化治疗实施干预措施,结果发现,该措施可以提高护士感染性休克相关知识的掌握程度,提高感染性休克集束化治疗组成部分完成率,降低ICU死亡率,该措施可用性较强,应用效果较好。更多还原

【Abstract】 Objectives:1.Conduct qualitative research based on the Consolidated Framework for Implementation Research(CFIR)to explore the barriers in the implementation of septic shock bundle in intensive care unit(ICU).2.In view of the barriers,use the CFIR-ERIC implementation strategy matching tool to formulate change strategies and develop interventions for the implementation of septic shock bundle in ICU.3.To investigate the availability and effect of the interventions for septic shock bundle in ICU.Methods:1.Qualitative study:17 ICU nurses and doctors from a Grade-A tertiary hospital in Jinan,Shandong Province were selected as interview subjects from May to June 2023 by using the objective sampling method.The interview outline was developed under the guidance of CFIR,and data were collected by semi-structured interview method.The interview texts were imported into Nvivo 12 software,and data were analyzed by content analysis method according to CFIR coding manual,so as to identify the barriers for the implementation of septic shock bundle in ICU.2.Development of interventions:Download the CFIR-ERIC implementation strategy matching tool from the official website of CFIR,input the barriers identified in the qualitative study into the matching tool,and combine the actual situation of ICU departments to determine the priority recommended change strategies for each barrier,and then develop the"Interventions for the implementation of septic shock bundle in ICU(Preliminary draft)".By holding an expert group meeting to discuss the contents of the interventions and modify it,the"Interventions for the implementation of septic shock bundle in ICU(Final draft)" was formed.3.Intervention study:The interventions of septic shock bundle were implemented in the ICU department of a Grade-A tertiary hospital in Jinan,Shandong Province from July to August 2023.Nurses and septic shock patients in ICU were studied.The nurses were designed for the before and after self control study.Patients with septic shock were a historical control study design.Patients with septic shock admitted between December 2022 and April 2023 were the control group,and those admitted between September 2023 and January 2024 were the experimental group.Before and after application of the interventions,the scores of nurses’ knowledge of septic shock bundle were collected,and the total completion rate,completion rate of each component,length of ICU stay and mortality of septic shock patients in the control group and the experimental group were collected respectively.SPSS 25.0 statistical software was used for data entry and analysis.Statistical methods included statistical description,independent sample T-test,Wilcoxon paired rank sum test,Chi-square test,etc.P<0.05 was statistically significant.Results:1.Through qualitative interviews,the consensus identified 9 barriers to the implementation of septic shock bundle in ICU,which were as follows:low level of collaboration between drug-related departments;relative shortage of medical staff;delayed communication between healthcare and nursing;lack of adaptability of some measures of septic shock bundle;lack of goals and feedback mechanisms in the department;insufficient stocking of some items in the department;ineffective and limited access to training on septic shock bundle;lack of awareness of the bundle among medical staff;passive execution by nurses in the implementation of bundle.2.Through the expert meeting,the final formulation of the "Interventions for the implementation of septic shock bundle in ICU" includes four parts:the establishment of implementation working group,training,standardized management of materials,quality control program.A knowledge questionnaire on bundle of septic shock was developed for nurses.3.Data of 71 nurses were collected.Data of 105 patients with septic shock in ICU were collected,including 55 cases in control group and 50 cases in experimental group.The results show:(1)Before the application of the interventions,the median score of nurses’ knowledge of septic shock bundle was 82 points,and after the application,the median score was 96 points,which was higher than that before the application(P<0.05),and the difference was statistically significant.(2)The sex,age and underlying diseases of the two groups were comparable(P>0.05).(3)The completion rates of 1-hour and 3-hour lactate measurement in septic shock patients in both groups were 100%.In terms of lactic acid retest,the completion rate was 43.64%in the control group and 64.00%in the experimental group,the difference was statistically significant(P<0.05).In 1-hour blood culture collection,the completion rate was 16.36%in the control group and 36.00%in the experimental group,the difference was statistically significant(P<0.05).In the 3-hour blood culture collection,the completion rate was 30.91%in the control group and 54.00%in the experimental group,the difference was statistically significant(P<0.05).In terms of 3-hour antibiotic initiation,the completion rate was 40.00%in the control group and 60.00%in the experimental group,with statistical significance(P<0.05).Compared with the control group,the total completion rate and other components of bundle were improved in the experimental group,but no statistical difference was found(P>0.05).(4)The ICU mortality of septic shock patients in the experimental group(22.00%)was lower than that in the control group(40.00%),the difference was statistically significant(P<0.05);There was no significant difference in length of ICU stay(P>0.05).Conclusions:1.This study was guided by CFIR,and through qualitative interviews with doctors and nurses,nine barriers in the implementation of septic shock bundle in ICU were analyzed,and the results were real and reliable.2.The implementation strategy matching tool of CFIR-ERIC was used to determine the change strategy,and interventions for the implementation of septic shock bundle in ICU was constructed through expert group meetings with scientific construction process and clinical applicability.3.Applying the interventions implemented in the ICU septic shock bundle,the results found that the interventions can improve the nurses’ knowledge related to septic shock,improve the completion rate of the septic shock bundle component,and reduce the mortality rate of ICU,with strong availability of the interventions,and the application of the results is better.更多还原