本文關鍵詞： 胰十二指腸切除術 循證實踐 營養(yǎng)支持 KTA模式　出處：《第二軍醫(yī)大學》2017年碩士論文　論文類型：學位論文

【摘要】：目的本研究旨在構建胰十二指腸切除術患者(pancreaticoduodenectomy,PD)圍手術期營養(yǎng)支持管理方案并驗證其臨床應用效果,以期促進證據(jù)轉化,提高PD患者圍手術期營養(yǎng)支持質量,促進患者康復。具體研究目的包括:(1)評鑒、綜合PD患者圍手術期營養(yǎng)支持循證證據(jù)并選取適用于引入臨床實踐的證據(jù);(2)描述PD患者圍手術期營養(yǎng)支持現(xiàn)狀,分析利益相關人群(醫(yī)生、護士、營養(yǎng)師、管理者)感知的循證實踐的阻礙與促進因素以及患者對圍手術期營養(yǎng)支持的體驗與需求;(3)構建PD患者圍手術期營養(yǎng)支持管理方案;(4)評價該方案的臨床應用效果。方法以KTA證據(jù)行為轉化模式為概念框架,通過對國內外圍手術期營養(yǎng)支持的指南評價、PD患者圍手術期營養(yǎng)支持的相關系統(tǒng)評價再評價以及PD患者術前營養(yǎng)評價工具的研究,獲得PD患者圍手術期營養(yǎng)支持的最佳證據(jù);通過專家會議法選取適合引入臨床實踐的證據(jù)并建立審查標準;通過參與式觀察與質性研究評估試點病房證據(jù)應用的促進及阻礙因素,最佳證據(jù)與臨床實踐之間差距;通過專家會議法構建PD患者圍手術期營養(yǎng)支持管理方案,有針對性消除障礙因素;通過醫(yī)護人員自身前后對照試驗研究和PD患者非同期前后對照研究獲得干預方案的應用效果。結果1.通過系統(tǒng)的證據(jù)檢索,共納入5部圍手術期營養(yǎng)支持指南;同時通過術前營養(yǎng)評估工具的研究,即應用NRS2002、PG-SGA、NRI、PNI、BMI5種營養(yǎng)評價工具評價100例PD患者術前營養(yǎng)狀況,獲得NRS2002、PG-SGA與患者術后結局、實驗室營養(yǎng)指標相關,且對術后并發(fā)癥具有中度診斷價值,PD患者術前擬優(yōu)先選用NRS2002評分,再結合使用PG-SGA評估,最終評鑒、匯總出PD患者圍手術期營養(yǎng)支持現(xiàn)有的最佳證據(jù)。2.通過專家會議法獲得PD患者圍手術期營養(yǎng)支持最佳證據(jù)五個模塊,即術前營養(yǎng)評價、術前營養(yǎng)支持、術后營養(yǎng)支持、營養(yǎng)制劑、營養(yǎng)管理模式,共9條證據(jù),并制定了7條實踐審查標準。3.試點病房的圍手術期營養(yǎng)支持的臨床實踐與最佳證據(jù)之間存在較大差距,循證實踐受諸多因素影響。3.1試點病房循證實踐的現(xiàn)況:審查標準執(zhí)行情況不佳,缺乏規(guī)范的營養(yǎng)管理制度及流程。3.2通過15名醫(yī)務人員半結構式訪談,獲得循證實踐的阻礙因素,包括證據(jù)、應用過程、組織管理、患者、醫(yī)生因素,促進因素包括營養(yǎng)專項培訓、建立多學科協(xié)作的營養(yǎng)小組、制定規(guī)范的營養(yǎng)管理制度、取得領導層的支持。3.3通過10例pd患者圍手術期營養(yǎng)支持體驗的質性研究,獲得該類患者術后面臨飲食壓力和管飼營養(yǎng)的痛苦,渴望專業(yè)、延續(xù)的營養(yǎng)指導,臨床醫(yī)務人員應重視該類患者圍手術期營養(yǎng),采用多學科合作的營養(yǎng)支持小組模式,強化營養(yǎng)教育,促進患者參與自我營養(yǎng)管理。4.通過專家會議法構建pd患者圍手術期營養(yǎng)支持管理方案,包括圍手術期營養(yǎng)支持管理規(guī)范、圍手術期營養(yǎng)支持流程、營養(yǎng)支持小組管理模式、營養(yǎng)支持輔助文本以及能量計算軟件。并制定方案實施計劃,通過營養(yǎng)培訓、領導宣講與支持,分階段推進方案實施,逐步將證據(jù)引入臨床。5.方案的實施與效果評價5.1方案的實施:方案于2016年9月啟動,通過三個階段,即人員培訓階段、方案試運行階段、方案應用階段,循序漸進地將pd圍手術期營養(yǎng)支持相關證據(jù)應用到臨床營養(yǎng)管理系統(tǒng)中。5.2效果評價5.2.1采用自身前后對照研究,獲得試點病房醫(yī)護人員干預前(2016年5月~8月)、干預后(2016年9月~2017年1月)各審查標準的執(zhí)行情況,結果顯示在5個月的干預期間,干預組醫(yī)護人員的各審查標準執(zhí)行率顯著高于對照組(p0.05)。5.2.2采用非同期對照研究,獲得試點病區(qū)干預前53例pd患者、干預后47例pd患者臨床結局指標比較情況[兩組患者基線一致(p≥0.05)],結果顯示干預后患者的術后住院天數(shù)、總住院天數(shù)較干預前縮短,并發(fā)癥的發(fā)生率較干預前減少,住院期間患者體重下降值、醫(yī)療費用較干預前減少(p0.05)。兩組患者術后第1、3、7天總蛋白、前白蛋白、白蛋白值差異無統(tǒng)計學意義(p0.05)。術后第1天總膽紅素值較干預前降低(p0.05),術后第1、3、7天總膽紅素值差異無統(tǒng)計學意義(p0.05)。5.2.3醫(yī)務人員在方案實施過程中經歷了懷疑與期待、磨合與主動、反思與創(chuàng)新的體驗歷程,來自組織層面的督促、激勵、約束與強化,有利于提高醫(yī)護人員對方案的依從性,激發(fā)其創(chuàng)造力。結論1.本研究匯總了pd患者圍手術期營養(yǎng)支持最佳證據(jù),內容包括術前適宜的營養(yǎng)評價工具nrs2002和pg-sga、術前營養(yǎng)支持、術后營養(yǎng)支持、營養(yǎng)制劑選擇、營養(yǎng)管理模式五個模塊,旨在為pd患者圍手術期營養(yǎng)支持提供參考依據(jù)。2.本研究應用KTA知識轉化模式開展PD患者圍手術期營養(yǎng)支持循證實踐,通過確定問題、證據(jù)綜合、裁剪形成符合利益相關人群需要的證據(jù)并引入臨床,分析障礙因素及促進策略,構建管理方案引入證據(jù)并實施監(jiān)測與評價,有效促進了證據(jù)轉化,縮短了證據(jù)與實踐的差距。3.本研究構建的PD患者圍手術期營養(yǎng)支持管理方案,是建立在循證基礎上,考慮了臨床情境及患者需求,具有較好的可行性和有效性。
[Abstract]:The purpose of this study was to construct pancreatoduodenectomy patients (pancreaticoduodenectomy, PD) of perioperative nutritional support management scheme and verify its clinical effect, in order to promote the transformation of PD evidence, improve the perioperative nutritional support in patients with quality, promote the rehabilitation of the patients. The main contents include: (1) evaluation, comprehensive perioperative PD nutrition support evidence for selection and introduced into clinical practice evidence; (2) to describe the PD of perioperative nutritional support in patients with the status quo, analysis of stakeholder groups (doctors, nurses, nutritionists, managers) aware of evidence-based practice and promote patients to hinder factors and around the experience and demand of nutritional support the period of operation; (3) to construct the PD of perioperative nutritional support in patients with management scheme; (4) to evaluate the clinical effects of the scheme. Methods KTA behavior transformation model as the conceptual framework of evidence, through to the domestic and external Guide for the evaluation of perioperative nutritional support in patients with PD related research, evaluation system of peri operative nutrition support and re evaluation of PD patients with preoperative nutritional evaluation tools, to obtain the best evidence of peri operative nutrition support in patients with PD; selected by the expert meeting for the introduction of clinical practice of evidence and establish the standard of review; through participation observation and qualitative evaluation factors that hinder and promote the pilot ward evidence application, the gap between the best evidence and clinical practice; to construct the PD of perioperative nutritional support in patients with management scheme through expert meeting method, to eliminate obstacles; the medical staff through self controlled non synchronous control study before and after the intervention in patients with application effect experimental study and PD. Results 1. through systematic evidence retrieval, included 5 perioperative nutrition support guidelines; at the same time through preoperative nutritional assessment The research tools, namely the application of NRS2002, PG-SGA, NRI, PNI, BMI5 nutrition evaluation tool to evaluate 100 cases of PD patients with preoperative nutritional status, NRS2002, PG-SGA and outcome of patients after surgery, laboratory of nutrition indicators related, and has moderate diagnostic value of postoperative complications in PD patients, preoperative NRS2002 score to be preferred then, combined with the use of PG-SGA evaluation, the final evaluation, summarize the PD of perioperative nutritional support in patients with the best available evidence obtained by expert PD.2. of perioperative nutritional support in patients with the best evidence of five modules, namely the preoperative nutrition evaluation, preoperative nutrition support, nutritional support, postoperative nutrition, nutrition model a total of 9 lines of evidence management, and to develop, there is a big gap between the 7 practice examination standard.3. pilot unit of perioperative nutritional support in clinical practice and the best evidence, evidence-based practice is influenced by many factors in.3.1 wards The status of evidence-based practice: review of the implementation of standards is poor, lack of standardized nutrition management system and process of.3.2 by medical personnel from 15 semi-structured interviews, obtained the hindering factors, including evidence of evidence-based practice, application process, organization management, patient, doctor factors, promoting factors including nutrition training, establishing nutrition group multidisciplinary collaboration, develop nutrition standardized management system, to obtain the support of the leadership of.3.3 by PD in 10 cases of perioperative nutritional support in patients with a qualitative study on diet, pressure and feeding the pain, face to obtain this kind of patients for professional, nutritional guidance continues, clinical staff should pay attention to peri operative nutrition of the patients, the nutritional support group model of multi subject cooperation, strengthen nutrition education, promote the patients to participate in self nutrition management of.4. through the expert meeting method. Perioperative PD patients Nutrition management scheme, including the perioperative nutrition management norms, perioperative nutrition support process, nutrition support team management, nutritional support aided text and energy calculation software. And formulate the implementation plan, through nutrition training, leadership and preaching support, in phases to promote the implementation of the program, will gradually implement the implement and evaluation the evidence into clinical.5. program 5.1 program: program started in September 2016, through three stages, namely the stage of personnel training, project commissioning phase, project application stage, step by step to PD perioperative nutrition support evidence evaluation to the.5.2 effect of clinical nutrition management system 5.2.1 by self control study, to obtain pilot ward medical staff before intervention (May 2016 ~8 months), intervention (September 2016 ~2017 January) implementation of the standard of review, the results show in 5 During the months of intervention, the intervention group of medical personnel the examination standard implementation rate was significantly higher than the control group (P0.05).5.2.2 using asynchronous control study, to obtain pilot wards before intervention in 53 PD patients, 47 PD patients after clinical outcomes compared two groups of patients [consistent baseline (P = 0.05). The results showed that after the intervention of patients with postoperative hospitalization days, total hospital stay shorter than that before the intervention, the incidence of complications compared with before intervention, patients with weight loss, reduce the medical expenses than before intervention (P0.05). The two groups of patients with Shu Houdi 1,3,7 days before the total protein, albumin, albumin values were not statistically different (P0.05). After first days of total bilirubin decreased significantly (P0.05), 1,3,7 days after operation there was no significant difference in total bilirubin (P0.05).5.2.3 medical personnel in the program implementation process through doubt and look forward to, and the main running Experience, reflection and innovation, from the organizational level of supervision, incentive, constraint and strengthening, is conducive to improve the compliance of medical staff on the plan, to stimulate their creativity. Conclusions: 1. this study summarizes the PD of perioperative nutritional support in patients with the best evidence, including preoperative appropriate nutritional evaluation tools of nrs2002 and pg-sga nutritional support, preoperative, postoperative nutritional support, nutrition, nutrition management model of five modules, in order to provide reference on the application of KTA.2. knowledge transformation model to support nutrition PD patients in the perioperative period in PD patients perioperative nutritional support of evidence-based practice, the problem of determining evidence synthesis, cutting forming in line with the interests of those in need of evidence and the introduction of clinical analysis of obstacle factors and promotion strategies, the construction management plan and implement the monitoring and evaluation of evidence into the evidence, effectively promote the transformation, shorten the The gap between evidence and practice.3. the perioperative nutrition support management plan of PD patients in this study is based on evidence-based consideration of clinical situations and patient needs, and has good feasibility and effectiveness.

【學位授予單位】：第二軍醫(yī)大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R473.6

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