Palmer June, Bozas George, Stephens Andrew, Johnson Miriam, Avery Ged, O'Toole Lorcan, Maraveyas Anthony
BMC Health Serv Res. 2013 Jun 27;13:235. doi: 10.1186/1472-6963-13-235.
Most patients with pulmonary embolism (PE) spend 5-7 days in hospital even though only 4.5% will develop serious complications during this time. In particular, the group of patients with incidentally diagnosed PE (i-PE) includes many patients with low risk features potentially ideal for outpatient management; however the evidence for their optimal management is lacking hence relative practices may vary considerably. We describe the development process, components, links and function of a nurse-led service for the management of patients with i-PE, developed in accordance to the UK Medical Research Council complex intervention guidance.
Phase 0 (Theoretical underpinning): The Pulmonary Embolism Severity Index (PESI) was selected for patient risk assessment and the American Society of Clinical Oncology (ASCO) guideline for the management of PE in cancer patients (2007) was selected as quality measure. Historical registry and audit data from our centre regarding i-PE incidence and management for the period between 2006 and 2009 illustrating the then current practices were reviewed. Phase 1 (Modelling): Modelling of the pathway included the following: a) Identification of training needs, planning and implementation of training schemes and development of transferable competencies and training materials. b) Mapping patient pathways and flow and c) Production of key documentation and Standard Operating Procedures for the delivery of the service.
Phase 2 (Implementation and testing of the intervention): During the initial 12 months of implementation, remedial action was taken to address identified deficiencies regarding patient referral to the pathway, compliance with treatment protocol, patient follow up, selection challenges from the use of PESI in cancer patients and challenges regarding the "first-pass" identification of i-PE.
We have developed and piloted a complex intervention to manage cancer patients with incidental PE in an outpatient setting. Adherence to evidence- based care, improvement of communication between professionals and patients, and improved quality of data is demonstrated.
大多数肺栓塞（PE）患者住院5 - 7天，尽管在此期间只有4.5%的患者会出现严重并发症。特别是，偶然诊断为PE（i-PE）的患者群体包括许多具有低风险特征的患者，这些患者可能非常适合门诊管理；然而，缺乏关于其最佳管理的证据，因此相关实践可能差异很大。我们描述了一项由护士主导的服务的开发过程、组成部分、联系和功能，该服务用于管理i-PE患者，是根据英国医学研究理事会的复杂干预指南开发的。
第0阶段（理论基础）：选择肺栓塞严重程度指数（PESI）进行患者风险评估，并选择美国临床肿瘤学会（ASCO）关于癌症患者PE管理的指南（2007年）作为质量衡量标准。回顾了我们中心2006年至2009年期间关于i-PE发病率和管理的历史登记和审计数据，以说明当时的现行做法。第1阶段（建模）：该路径的建模包括以下内容：a）确定培训需求、规划和实施培训计划以及开发可转移的能力和培训材料。b）绘制患者路径和流程，以及c）编制关键文件和服务提供的标准操作程序。
第2阶段（干预的实施和测试）：在实施的最初12个月内，采取了补救措施，以解决在患者转诊至该路径、遵守治疗方案、患者随访、在癌症患者中使用PESI的选择挑战以及i-PE的“首次”识别方面发现的缺陷。
我们已经开发并试点了一项复杂干预措施，用于在门诊环境中管理偶然发生PE的癌症患者。证明了坚持循证护理、改善专业人员与患者之间的沟通以及提高数据质量。
