】——陆瑶 史婷奇 程建平 孙玉娇 王丹若 张秋香
【摘要】针对护理临床决策支持系统的研发与应用开展品管圈活动，护理人员全程参与系统的设计、测试、上线培训、应用效果评价等。一方面，护理临床决策支持系统实现了10个智能化功能，如智能诊断、智能采集等；另一方面，系统上线后，全年护理不良事件发生率由0.49‰下降至0.19‰，护理病历质控问题发生率由34例/季度降至12例/季度，护理文书结构化率由48%提升至96%，全院护理文书书写总时间由302小时/天下降至139小时/天，护理病历质控时间由15分钟/份缩短为6分钟/份，血糖监测单位时间由670秒/次缩短为282秒/次。系统应用提升了护理质量和工作效率，值得推广。
【关键词】临床决策支持系统；护理临床决策支持系统；护理质量；患者安全；品管圈
中图分类号：R197.323；R47文献标识码：B
Development and Application of Nursing Clinical Decision Support System/LU Yao,SHI Tingqi,CHENG Jianping,et al.//Chinese Health Quality Management，2020,27(5):98-102
Abstract Using the research-oriented quality control circle approach, activities were taken on the development and application of nursing clinical decision support system.The nursing staff participated in the whole system design, testing, online training, application effect evaluation.The nursing clinical decision support system realized 10 intelligent functions, such as intelligent diagnosis and intelligent collection.Furthermore, after launch of the system, the incidence of nursing adverse events throughout the year dropped from 0.49 ‰ to 0.19 ‰, the incidence of nursing records quality control problem fell from 34 cases per quarter to 12 cases per quarter, nursing documents structured rate increased from 48% to 96%, and partial nursing documents writing time from 302 hours/day dropped to 139 hours/days, nursing medical records quality control reduced from 15 minutes to 6 minutes per copy, blood sugar monitoring unit time shortened from 670 to 282 seconds per time.The application of the system improved the quality of nursing care and work efficiency, which was worthy of promotion.
Key words Clinical Decision Support System;Nursing Clinical Decision Support System;Quality of Care;Patient Safety;Quality Control Circle
Firstauthor's address Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu,210008, China
1主题选定
圈员通过头脑风暴法提出3个备选课题，采用评价法从上级重视度、重要性、迫切性、圈能力4个维度进行打分，选定得分最高的“护理临床决策支持系统研发与应用”为本期活动主题。经QC-Story判定，本期活动主题为课题研究型。
名词定义：临床决策支持系统（Clinical Decision Support System, CDSS）是一种利用人工智能技术与方法，针对半结构化或非结构化临床问题，基于知识推理和逻辑运算，自动完成电子病历中相关患者数据的采集、处理、分析，并在恰当的时机通过恰当的人机交互方式向决策者提供价值信息辅助决策的信息系统［1］。
选题背景：近年来，临床决策支持系统已成为医学与人工智能结合的重要发展方向。《国务院办公厅关于促进“互联网+医疗健康”发展的意见》（国办发〔2018〕26号）明确指出，要研发基于人工智能的临床决策支持系统［2］。临床工作中，护士需获取和整合大量患者信息，与护理常规、工作流程、服务规范匹配后做出决策［3］。因此，迫切需要将CDSS应用于护理领域。目前，临床决策支持系统主要用于单个护理领域，如压疮分期评估［4-7］、低血糖管理［8］、跌倒评估与管理［6-7,9］、围产期护理［10］、脓毒血症护理［11］、机械通气患者护理［12］等。对课题进行查新发现，未见数据库、知识库、人机交互技术等交叉融合的护理临床决策支持系统相关研究。
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