Disclosure of Invention
The invention aims to provide a medical nursing catheter information management system, unstructured catheter nursing doctor advice information is converted into structured data through a nursing execution list, intelligent summarization of nursing information can be realized according to nursing execution list selection results on a nursing mobile terminal, so that catheter nursing flow data can be accurately acquired, deviation of nursing information is avoided, data analysis and management are convenient to follow-up, in addition, full flow tracking and evaluation of patient hospitalization can be realized through a quality evaluation subsystem, and the problems pointed out in the background art are solved.
The embodiment of the invention is realized by the following technical scheme: the medical nursing catheter information management system comprises a nursing mobile terminal and a background management system, wherein the background management system comprises a catheter data management subsystem, and the catheter data management subsystem comprises an information input unit, an information processing unit and a storage unit;
the catheter data management subsystem is configured to input catheter nursing medical advice information through the information input unit, the information processing unit generates a nursing execution list based on the input catheter nursing medical advice information, the nursing execution list is issued to the nursing mobile terminal, catheter nursing flow data uploaded by the nursing mobile terminal is received, the catheter nursing flow data is sent to the storage unit for visual storage, and data are retrieved from the storage unit for distribution in response to data requests of all subsystems, wherein the catheter nursing flow data is a result of selecting the nursing execution list on the nursing mobile terminal, and all the subsystems comprise a data statistical analysis subsystem for realizing statistical analysis of the catheter nursing flow data, a nursing special-term handover subsystem for realizing management of shift data, a cross section monitoring subsystem for monitoring importance of monitoring targets and exposure factors, an outlet assessment subsystem for assessing the catheter nursing flow data and a quality assessment subsystem for evaluating quality of the whole process of catheter nursing.
According to a preferred embodiment, the quality evaluation subsystem is configured to be connected to the storage unit, the discharge evaluation subsystem and the HIS system, and the quality evaluation subsystem is responsive to the first request and obtains corresponding data from the storage unit and/or obtains corresponding discharge evaluation results from the discharge evaluation subsystem and/or obtains corresponding electronic medical records from the HIS system and performs data analysis processing to generate a nursing quality evaluation result according to the first request.
According to a preferred embodiment, the data stored in the storage unit is structured data.
According to a preferred embodiment, the catheter data management subsystem is further configured to perform a corresponding action if the care execution list selection result on the care mobile terminal meets a preset trigger condition, including but not limited to triggering a corresponding measure or distributing data to a corresponding subsystem.
According to a preferred embodiment, the care execution list includes a risk assessment list, a tube list, an observation list, a measure list, and a tube drawing list.
According to a preferred embodiment, the data statistics analysis subsystem is configured to be connected with the storage unit, and the data statistics analysis subsystem responds to a second request, acquires corresponding data from the storage unit according to the second request, and performs multidimensional data analysis processing to generate target data to be displayed.
According to a preferred embodiment, the multi-dimensional data analysis process includes a lateral dimension including data analysis processes with individual tube-in-patient, individual operator, and catheter risk levels, and a longitudinal dimension including data analysis processes for individual risk level patients, tube-in-record, observation-record, measure-record, tube-out-record, and post-tube-out-care-record.
According to a preferred embodiment, the cross section monitoring subsystem is configured to be connected with the storage unit, responds to a third request, acquires corresponding data from the storage unit according to the third request, performs data analysis and processing, and performs cross section monitoring on importance of a monitoring target and exposure factors in nursing execution, wherein the exposure factors are complications generated by unplanned tube drawing, and the importance represents weight scores of the exposure factors for generating unplanned tube drawing.
According to a preferred embodiment, the special care delivery subsystem is configured to be connected with the storage unit, the storage unit responds to a fourth request, and obtains data in a corresponding time period from the storage unit according to the fourth request and performs data analysis processing so as to generate working content of the next time period, and feeds back the working content to a delivery procedure operation interface, and simultaneously sends a delivery snapshot to a peripheral display screen.
According to a preferred embodiment, the discharge evaluation subsystem is configured to be connected with the storage unit, and the discharge evaluation subsystem responds to a fifth request, obtains corresponding data from the storage unit according to the fifth request, performs data analysis processing, generates a discharge evaluation result according to a preset evaluation rule and a preset evaluation knowledge base, and formulates a discharge protection order information, health education information and a return visit plan according to the discharge evaluation result.
According to a preferred embodiment, the quality assessment subsystem is further configured to adjust the quality of care assessment result based on a preset quality control requirement.
The technical scheme of the medical nursing catheter information management system provided by the invention has at least the following advantages and beneficial effects: (1) According to the invention, unstructured catheter nursing doctor advice information is converted into structured data through the nursing execution list, intelligent summarization of nursing information can be realized according to a nursing execution list selection result on the nursing mobile terminal, so that catheter nursing flow data can be accurately acquired, deviation of the nursing information is avoided, and subsequent data analysis and management are facilitated; (2) According to the invention, the quality evaluation subsystem acquires corresponding structured data from the storage unit and/or acquires corresponding discharge evaluation results from the discharge evaluation subsystem and/or acquires corresponding electronic medical records from the HIS system and performs data analysis processing, so that a nursing quality evaluation result is generated, and the full-flow tracking and evaluation of patient hospitalization at a preset time node can be realized.
Detailed Description
For the purpose of making the objects, technical solutions and advantages of the embodiments of the present invention more apparent, the technical solutions of the embodiments of the present invention will be clearly and completely described below with reference to the accompanying drawings in the embodiments of the present invention, and it is apparent that the described embodiments are some embodiments of the present invention, but not all embodiments of the present invention. The components of the embodiments of the present invention generally described and illustrated in the figures herein may be arranged and designed in a wide variety of different configurations.
Example 1
Fig. 1 is a block diagram of a medical care catheter information management system according to the present invention. Referring to fig. 1, the medical care catheter information management system includes a care mobile terminal and a background management system.
The background management system comprises a catheter data management subsystem; the catheter data management subsystem further comprises an information input unit, an information processing unit and a storage unit.
In this embodiment, the catheter data management subsystem is configured to enter catheter care order information generated by a healthcare worker for an inpatient through the information entry unit, generate a care execution list by the information processing unit based on the entered catheter care order information, and issue the care execution list to the care mobile terminal. It should be noted that, the catheter nursing medical advice information may include non-standard description information, and after the information processing unit optimizes and sorts the non-standard description information in the catheter nursing medical advice information, the formed nursing execution list is composed of standardized description structured data; in this embodiment, referring to fig. 2, the care execution list includes a risk assessment list, a tube setting list, an observation list, a measure list, and a tube drawing list.
Further, the catheter data management subsystem is further configured to receive catheter care flow data uploaded by the care mobile terminal, send the catheter care flow data to the storage unit for visual storage, and call the data from the storage unit for distribution in response to a data request of each subsystem, wherein the catheter care flow data is a care execution list selection result on the care mobile terminal, and the data stored in the storage unit is structured data; each subsystem comprises a data statistical analysis subsystem for realizing statistical analysis of catheter nursing flow data, a nursing special handing-over subsystem for realizing data management of a shift, a cross section monitoring subsystem for monitoring the importance of a monitoring target and an exposure factor in a cross section, an discharge evaluation subsystem for evaluating the catheter nursing flow data and a quality evaluation subsystem for evaluating the quality of the whole process of catheter nursing.
According to the invention, unstructured catheter nursing doctor advice information is converted into structured data through the nursing execution list, intelligent summarization of nursing information can be realized according to a nursing execution list selection result on the nursing mobile terminal, so that catheter nursing flow data can be accurately acquired, deviation of the nursing information is avoided, and subsequent data analysis and management are facilitated; in addition, the comprehensive data analysis processing is carried out on the whole process of the catheter nursing through the quality evaluation subsystem, so that a nursing quality evaluation result is generated, the whole process tracking and evaluation of patient hospitalization by a preset time node can be realized, the systematicness and the comprehensiveness of the nursing quality management are improved, and the continuous improvement of the nursing service quality is facilitated.
Example 2
The present embodiment further describes a quality evaluation subsystem based on the technical solution provided in embodiment 1:
In this embodiment, the quality assessment subsystem is used to achieve quality assessment of the catheter care overall procedure, and is configured to interface with the storage unit, the discharge assessment subsystem, and the HIS system; the quality evaluation subsystem responds to the first request, and the first nursing information obtained from the storage unit according to the first request corresponds to a nursing execution list, namely, the quality evaluation subsystem comprises risk evaluation information, management information, observation information, measure information, management drawing information and post-management drawing nursing information; in response to the first request, the second care information acquired by the quality assessment subsystem from the discharge assessment subsystem includes discharge assessment results, discharge advice information, health education information, and return visit plans; in addition, in response to the first request, the quality evaluation subsystem may also obtain historical data of the electronic medical record from the HIS system; generating a nursing quality evaluation result by carrying out data analysis and processing on one or more data acquired above; further, after passing the relevant audit, an overall quality assessment of the patient during the course of catheter care is formed.
According to the invention, the quality evaluation subsystem acquires corresponding structured data from the storage unit and/or acquires corresponding discharge evaluation results from the discharge evaluation subsystem and/or acquires corresponding electronic medical records from the HIS system and performs comprehensive data analysis processing, so that a nursing quality evaluation result is generated, full-process tracking and evaluation of patient hospitalization at a preset time node can be realized, the systematicness and comprehensiveness of nursing quality management are improved, and continuous improvement of nursing service quality is facilitated.
Example 3
The present embodiment is based on the technical solution provided in embodiment 1, and performs supplementary explanation for the catheter data management subsystem:
In this embodiment, the catheter data management subsystem is further configured to perform a corresponding action if the result of selecting the nursing execution list on the nursing mobile terminal meets the preset trigger condition, where the action includes, but is not limited to, triggering a corresponding measure or distributing data to a corresponding subsystem.
The above scheme is illustrated below:
When the tube setting list is executed, after the tube setting is recorded through a printing function, and the tube setting scale, the tube setting executing time and the time of ending the service life of the catheter are generated, when the tube setting is successful, triggering to generate the next observation time and the next time of executing the conventional measure; when the catheterization list is executed, 10 catheters are implanted into the patient, and when the risk assessment list is executed, the patient is in a high risk state, and according to the treatment condition, the risk state of the patient is updated after the catheters implanted into the patient are continuously pulled out; when the observation list is executed, the condition that the catheter of the patient is fixed is found to be loose, the unplanned tube drawing of the patient is warned in a high-risk state before the re-fixing measure is not implemented, and the unplanned tube drawing state is updated after the fixing measure is implemented again; when the watch list is executed, a set option, such as one or more complications, is selected and checked in the list, and the data is distributed to the HIS system, informing the doctor of the treatment.
The processes are linked with each other, so that the defect brought by timeliness of nursing measures can be effectively avoided, and the state of a patient can be prompted in real time.
Example 4
The present embodiment is based on the technical solution provided in embodiment 1, and performs a supplementary explanation for the quality evaluation subsystem:
in this embodiment, the quality assessment subsystem is further configured to adjust the care quality assessment result based on a preset quality control requirement.
Specifically, the scoring basis of the nursing quality evaluation result comprises: the whole catheter nursing process has the advantages that whether missing items exist in each nursing process, whether nursing documents are comprehensively recorded, whether special medicines and the use conditions of instruments are comprehensively recorded and the like;
The basis for adjusting the nursing quality evaluation result based on the preset quality control requirement comprises the following steps: whether an adverse event is generated in nursing work, whether post-treatment measures and treatment principles of the adverse event are carried out according to the specification requirements, whether time nodes of the adverse event generation and exposure factors of the adverse event are related to the skills of nursing staff, whether the adverse event generation and exposure factors of the adverse event generation and the exposure factors of the adverse event generation are related to the nursing bed protection ratio, whether the adverse event generation and the exposure factors of the adverse event generation are related to the execution weight, whether the adverse event generation and the exposure factors of the adverse event generation and the shift change are not explicitly related, and the like;
Further, in the adjustment basis, whether the post-treatment measures and the treatment principle of the adverse event generation are carried out according to the standard requirement or not requires manual review by staff; whether the adverse event and the exposure factors thereof are related to nursing bed protection ratio or not, the process considers different departments, and the corresponding bed protection ratios are different; the weight scores of all indexes of the quality evaluation system can be adjusted or consulted with the score indexes issued by the authority according to the quality control requirements of hospital nursing.
Example 5
The embodiment further describes the data statistical analysis subsystem based on the technical scheme provided in embodiment 1:
in this embodiment, the data statistics analysis subsystem is configured to be connected to the storage unit, and the data statistics analysis subsystem responds to the second request, obtains corresponding data from the storage unit according to the second request, performs multidimensional data analysis processing, and generates target data to be displayed in combination with a hospital management requirement, a department management requirement, a nursing unit management requirement, and a nursing group management requirement, where the target data may be a pie chart, a line chart, a histogram, a line segment chart, and the like, and may also include other types of report patterns.
In one implementation of this embodiment, the target data to be displayed is all catheter states of the tube drawing process; in addition, the data statistics analysis subsystem is also configured to trace back the tube drawing process, wherein the process comprises risk assessment, tube placement, observation, measures and the like.
Further, the multidimensional data analysis process includes a lateral dimension including data analysis process with a single tube patient, a single operator, and a catheter risk level, and a longitudinal dimension including data analysis process for each risk level patient, a tube placement record, an observation record, a measure record, a tube withdrawal record, and a post-tube withdrawal care record.
In one possible implementation, the data analysis object of the data statistics analysis subsystem is a nursing quality sensitivity index, including the occurrence rate of unplanned tube drawing of the catheter, suspected infection and occurrence rate of catheter correlation, confirmation record of catheter correlation infection, data statistics of infection and occurrence rate of catheter correlation, process tracing of infection and occurrence rate of catheter correlation, and the like. The occurrence rate of the unplanned tube drawing of the catheter represents the specific gravity of the unplanned tube drawing of the catheter to the total tube drawing quantity in a specific area within a set time period, wherein the specific area can be a nursing group or a department or a hospital area.
For example, the data statistics analysis subsystem analyzes the data of the occurrence rate of unplanned tube drawing of the catheter, and performs data analysis on the situation that the directional clinical features corresponding to the observation list and the measure list in the storage unit are described and abnormal tube drawing results are generated.
According to the embodiment, various reports are generated by carrying out multidimensional statistical analysis on various data in the catheter nursing process, so that the decision-making requirements of a hospital management layer, a department, a nursing unit and a nursing group are supported, and the potential problems are identified and the nursing process is improved; by taking the nursing quality sensitivity index as a data analysis object of the data statistical analysis subsystem, the abnormal tube drawing result is statistically analyzed, so that the monitoring capability of the unplanned tube drawing incidence rate of the catheter is improved, and the nursing quality problem can be found and improved in time.
Example 6
The embodiment further describes the cross section monitoring subsystem based on the technical scheme provided in embodiment 1:
In this embodiment, the cross section monitoring subsystem is configured to connect with the storage unit, and the cross section monitoring subsystem responds to the third request, obtains corresponding data from the storage unit according to the third request, performs data analysis processing, and performs cross section monitoring on importance of the monitoring target and the exposure factor in the nursing execution process, where the exposure factor is a complication generated by unplanned tube drawing, and the importance represents a weight fraction of each exposure factor for generating unplanned tube drawing.
The importance is calculated as follows: acquiring a multidimensional judgment matrix of the unplanned tube drawing, wherein the multidimensional judgment matrix is used for describing the correlation among a plurality of importance indexes of the unplanned tube drawing exposure factors; and calculating the importance degree of each exposure factor according to the multidimensional judgment matrix.
The method for acquiring the multidimensional judgment matrix of the unplanned tube drawing specifically comprises the following steps: determining a plurality of importance indexes of the same exposure factor, and constructing a multidimensional judgment matrix according to the plurality of importance indexes; using the formulaCalculating the random consistency ratio of the multi-dimensional judgment matrix,,Represents a general consistency index of the multi-dimensional judgment matrix,Representing the maximum eigenvalue of the multi-dimensional decision matrix,Indicating the total number of exposure factors,Representing an average random consistency index of the multi-dimensional judgment matrix; judging whether the random consistency ratio of the multi-dimensional judgment matrix is smaller than a consistency ratio threshold value, and if not, updating the multi-dimensional judgment matrix.
According to the multidimensional judgment matrix, calculating the importance of each exposure factor specifically comprises the following steps: determining the weight of each exposure factor by using a feature vector method according to the multidimensional judgment matrix; obtaining a factor score for each exposure factor; using the formulaCalculating importance of exposure factors,Representing the feature vector.
In this embodiment, the cross-section monitoring subsystem is further configured to establish a database unit based on clinical sensitivity indicators for storing clinical sensitivity indicators such as catheter-related infection rate, unplanned extubation rate, ventilator-related pneumonia rate, in-hospital pressure injury incidence of two or more phases of inpatients, inpatient nosocomial infection rate, inpatient restraint rate, nursing level duty, clinical symptom characteristics and quantitative indicators, and the like, to assist caregivers in timely finding and solving problems occurring in the nursing process, thereby enhancing scientificity and accuracy of nursing monitoring.
Example 7
The present embodiment further describes a care specific handover subsystem based on the technical solution provided in embodiment 1:
In this embodiment, the care-specific handover subsystem is configured to connect with the storage unit, where the storage unit responds to the fourth request, and obtains data in a corresponding time period from the storage unit according to the fourth request, and performs data analysis processing, so as to generate working content in a next time period, and feed back the working content to the handover procedure operation interface, and send the handover snapshot to the peripheral display screen.
In one possible implementation, the generated work content for the next time period includes nursing work emphasis for all of the caretaker patients within M departments or N care groups, which may include routine precautions, special precautions, observations, measures, high risk indicators, high risk clinical characteristics of the patient, and so forth.
Based on the setting of the special nursing sub-system, the guide of work emphasis and notice can be provided for the nursing staff of the delivery office, so that smooth delivery of nursing work is realized, and continuity and safety of the nursing work are ensured.
Example 8
The discharge evaluation subsystem is further described based on the technical scheme provided in embodiment 1:
In this embodiment, the discharge evaluation subsystem is configured to be connected to the storage unit, and the discharge evaluation subsystem responds to the fifth request, obtains corresponding data and a current state of the patient from the storage unit according to the fifth request, performs data analysis processing, generates a discharge evaluation result by combining a preset evaluation rule and a preset evaluation knowledge base, and formulates discharge protection advice information, health education information and a return visit plan according to the discharge evaluation result. It should be noted that, in this embodiment, the generated discharge evaluation result is also subjected to a manual review to check whether it is accurate.
In one possible implementation, the preset evaluation rules include patient vital sign evaluation rules, tube-on-patient discharge evaluation rules, post-tube risk evaluation rules, patient skin evaluation rules, patient consciousness state evaluation rules, patient compliance evaluation rules, patient activity evaluation rules, and the like; the preset evaluation knowledge base comprises a patient discharge nursing advice knowledge base, a patient health education knowledge base, a return visit period management knowledge base and the like.
Based on the setting of the discharge evaluation subsystem, the risk and the required nursing measures after the discharge of the patient are evaluated by analyzing the catheter nursing data during the hospitalization period of the patient, including the generation of corresponding discharge nursing advice information, health education information and return visit information, so that the safety of the patient after the discharge can be further ensured.
The above is only a preferred embodiment of the present invention, and is not intended to limit the present invention, but various modifications and variations can be made to the present invention by those skilled in the art. Any modification, equivalent replacement, improvement, etc. made within the spirit and principle of the present invention should be included in the protection scope of the present invention.