摘要
本研究在电子病历系统的基础上建立及优化全流程院内静脉血栓栓塞症(VTE)防治管理系统,提升VTE防控管理的便捷性、高效性,实现持续、动态、有效的监测等优势管理,降低VTE的发生率,提升医疗质量与安全。首都医科大学附属北京友谊医院于2020年开发建立医院VTE防治管理系统,通过系统管理实践,探索住院患者VTE防治管理有效途径。以2020年1月1日至2022年12月31日的所有住院患者作为研究对象,基于临床路径建立标准化诊疗路径,以医院信息管理系统(HIS)电子病历系统为基础,自主开发院内VTE防治管理系统,制定符合医院特色的VTE评估量表、风险评估量表等,并将相关工作量表嵌入电子病历中,系统整合临床数据,统一分析并结构化,实现VTE风险评估、VTE风险预警、VTE规范防治、VTE质量控制等系统功能,并对院内VTE防治管理系统实施效果进行评价与分析,对比系统管理前后住院患者VTE防治管理效果。结果显示,对比系统管理前后,住院患者VTE动态风险评估率及预防措施采取率均显著增高,医院VTE动态风险评估率由2020年的55.9%提升至2022年的88.0%,差异具有统计学意义(χ^(2)=15551.302,P<0.001);VTE预防措施采取率由2020年的22.8%提升至2022年的61.2%,差异具有统计学意义(χ^(2)=4669.675,P<0.001)。综上,基于电子病历系统的院内VTE防治管理系统的应用,能够有效提升VTE防治管理的规范化、科学化及管理效率,进一步保证医疗安全,同时为临床医疗提供必要的决策支持。
To establish and optimize the venous thromboembolism(VTE),whole process prevention and treatment information system based on electronic medical record system.Improving the convenience and efficiency of VTE prevention and control management to achieve continuous,dynamic,effective monitoring and other advantages of the management,reduce the incidence of VTE and improve medical quality and safety.Beijing Friendship Hospital established a hospital VTE prevention and treatment management system in 2020.Through the system management,it explores effective ways to prevent and manage VTE in hospitalized patients.This study took all hospitalized patients from January 1,2020 to December 31,2022 as the research subjects,and standardized diagnosis and treatment pathway was established based on clinical pathway.The hospital independently developed VTE prevention and management system,and built VTE assessment scales and risk assessment scales,based on the electronic medical record system of hospital information system.The relevant workload table is embedded in the electronic medical record.The system integrates clinical data,conducts unified analysis and structuring,realizes system functions such as VTE risk assessment,VTE risk warning,VTE standardized prevention and treatment,VTE quality control,etc.And evaluates and analyzes the implementation effect of the VTE prevention and management system in the hospital,comparing the VTE prevention and management effect of hospitalized patients before and after system management.The results showed that the medical staff′s awareness and ability of prevention and treatment of VTE were significantly improved.In 2020,the rate of VTE dynamic risk assessment reached to 55.9%,and which was increased to 88.0%in 2022(χ^(2)=15551.302,P<0.001).In 2020,the rate of VTE preventive measures was 22.8%,which was increased to 61.2%in 2022(χ^(2)=4669.675,P<0.001).In conclusion,the application of the hospital VTE prevention and treatment management system can effectively improve the standardization,scientific and management efficiency,which further ensure medical safety,and provide necessary decision support for clinical medicine.
作者
徐芳
田甜
王力华
赵传超
Xu Fang;Tian Tian;Wang Lihua;Zhao Chuanchao(Medical Service,Beijing Friendship Hospital,Capital Medical University,Beijing 100050,China;Information Technology Development Department,Beijing Economic Information Centre,Beijing 101160,China)
出处
《中华预防医学杂志》
北大核心
2025年第3期375-381,共7页
Chinese Journal of Preventive Medicine
基金
北京友谊医院科研启动基金管理专项(yyqdktgl2022-2)。
关键词
静脉血栓栓塞症
电子病历
防治管理系统
Venous thromboembolism
Electronic medical record
Prevention management system
作者简介
通信作者:田甜,Email:tbbtian@163.com。
