降低肝癌患者腹腔镜肝切除术后并发症发生率
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发布人:yaot 发布时间:2/6/2024 10:12:14 AM  浏览次数:1006次
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——张英 郭敬 郑璐尤楠杨凤霞陈锦

【摘要】成立医、护、技、管多学科协作团队,针对降低肝癌患者腹腔镜肝切除术后并发症发生率开展品管圈活动。建立了术前、术中、术后3大创新改进策略,包括:创建“FLAG”评估策略,精准预测残肝功能,精确规划手术方案;构建“4D”策略,精准切除肿瘤病灶,精确控制术中出血;创建“4P”策略,精准预测术后风险,精确实施风险管理。通过改进,肝癌患者腹腔镜肝切除术后并发症发生率从22.76%降低至7.09%,促进了患者快速康复,降低了医疗风险。
【关键词】品管圈;问题解决型品管圈;肝癌;腹腔镜肝切除术;并发症
中图分类号:R735.7;R197.323 文献标识码:B
Reducing the Incidence of Complications after Laparoscopic Hepatectomy in Patients with Liver Cancer/ZHANG Ying,GUO Jing,ZHENG Lu,et al.//Chinese Health Quality Management,2024,31(1):58-64
Abstract A multidisciplinary team of medicine, nursing, technology and management was established to carry out quality control circle activities aimed at reducing the incidence of complications after laparoscopic hepatectomy in patients with liver cancer. Three innovative improvement strategies were established before operation, during operation and after operation, including: creating a "FLAG" evaluation strategy, accurately predicting residual liver function, and accurately planning surgical programs; establishing the "4D" strategy to accurately remove tumor lesions and accurately control intraoperative bleeding; creating a "4P" strategy to accurately predict postoperative risks and accurately implement risk management. Through the improvement, the complication rate of patients with liver cancer after laparoscopic hepatectomy was reduced from 22.76% to 7.09%, which promoted the rapid recovery of patients and reduced the medical risk.
Key words Quality Control Circle; Problem Solving Quality Control Circle; Liver Cancer; Laparoscopic Hepatectomy; Complication
Firstauthor's address The Second Affiliated Hospital of Army Military Medical University,Chongqing,400037, China

1主题选定

全体圈员围绕肝癌患者行腹腔镜肝切除治疗全流程进行梳理,列出16个关键质量点,利用亲和图归纳整理出4个备选主题,再采用共识标准法从重要性、迫切性、可行性、圈能力4个维度进行“5、3、1”评价,最终确定本期活动主题为“降低肝癌患者腹腔镜肝切除术后并发症发生率”。
名词定义:原发性肝癌主要指起源于肝细胞或肝内胆管细胞的一类恶性肿瘤疾病[1]。腹腔镜肝切除术是指利用腹腔镜技术对肝脏肿瘤进行手术切除治疗,达到荷瘤肝段完整切除及病理学切缘阴性[2]。腹腔镜肝切除术后并发症指行腹腔镜肝切除术的肝癌患者从全麻清醒返回病房至出院的围手术期出现与手术行为相关的损伤、缺失和功能障碍,包括肝功能不全、腹腔内出血、腹腔内感染、腹水、胆漏、静脉血栓、肝功能衰竭等[3-5]。
患者纳排标准:(1)纳入标准。①根据国家卫生健康委《原发性肝癌诊疗规范(2019年版)》[1]首诊为肝癌患者,年龄>18岁,有腹腔镜肝癌切除手术指征;②影像学评估无肿瘤远处转移;③Child-Pugh肝功能B级及以上;④患者和法定代理人签署知情同意书。(2)排除标准。①既往有肝脏手术切除治疗史;②术前接受放、化疗或介入治疗;③腹腔镜手术中转开腹病例;④住院期图1改善前肝癌患者腹腔镜肝切除住院治疗流程间死亡病例。
衡量指标:肝癌患者腹腔镜肝切除术后并发症发生率=肝癌患者腹腔镜肝切除术后发生并发症人数/同期肝癌患者行腹腔镜肝切除术总人数×100%。其中,每例患者术后出现一种并发症即判定为发生并发症人数,出现两种以上并发症按照类别分别记录发生项次。
选题背景:肝癌是常见的消化系统恶性肿瘤[6]。2020年我国肝癌发病人数约41万,死亡人数约39万,均居全球第一位[6],给群众健康带来了极大危害。腹腔镜肝切除术因创伤小、住院费用少、可及性广等特点,已成为肝癌根治性治疗的首选方式。据统计,全国腹腔镜肝切除率为77%[7]。由于肝脏解剖关系复杂、血管变异繁多、腹腔镜手术操作难度较大等原因,肝切除术后并发症发生率为7.6%~25.0%[8-11],不仅延长了患者住院时间,而且增加了非计划性再手术的可能性,加重了患者经济负担[12-13]。基线调查发现,陆军军医大学第二附属医院肝胆外科2019年6月-2020年5月腹腔镜肝切除术后并发症发生率为23.06%,亟需改进。

2活动计划拟定

本期活动时间为2020年6月-2021年12月。根据PDCA循环[14],P阶段时长占总时长的31.33%,D阶段时长占总时长的43.37%,C阶段时长占总时长的15.66%,A阶段时长占总时长的9.64%。同时,明确圈员分工,按计划推进,确保准时完成。

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