制定儿科烧伤护理的临床流程措施：了解实践模式的差异。

Development of clinical process measures for pediatric burn care: Understanding variation in practice patterns.

机构信息

From the Center for the Assessment of Pharmaceutical Practices (CAPP), Department of Health Law, Policy and Management (L.E.K., L.A.S., E.C.D.), Boston University School of Public Health; Shriners Hospitals for Children-Boston (R.L.S., A.F.L., C.M.R., M.L.); Massachusetts General Hospital (R.L.S., A.F.L., C.M.R., J.C.S., F.J.S., M.M., R.G.T.); Harvard Medical School (R.L.S., M.H.L., C.M.R., J.C.S.), Boston, Massachusetts; McGill University (G.D.S.), Montreal, Quebec, Canada; Brigham and Women's Hospital (M.H.L.); Boston VA Healthcare (M.H.L.); Spaulding Rehabilitation Hospital (C.M.R., J.C.S.), Boston, Massachusetts; RTI International (M.S.-B.), Waltham, MA; Shriners Hospitals for Children-Northern California (T.P.), Sacramento, California; Shriners Hospitals for Children-Galveston (D.H.); University of Texas Medical Branch (W.M.), Galveston, Texas; and Shriners Hospitals for Children-Cincinnati (P.W., R.K.), Cincinnati, Ohio.

出版信息

J Trauma Acute Care Surg. 2018 Apr;84(4):620-627. doi: 10.1097/TA.0000000000001737.

DOI:10.1097/TA.0000000000001737

PMID:29140950

Abstract

BACKGROUND

There has been little systematic examination of variation in pediatric burn care clinical practices and its effect on outcomes. As a first step, current clinical care processes need to be operationally defined. The highly specialized burn care units of the Shriners Hospitals for Children system present an opportunity to describe the processes of care. The aim of this study was to develop a set of process-based measures for pediatric burn care and examine adherence to them by providers in a cohort of pediatric burn patients.

METHODS

We conducted a systematic literature review to compile a set of process-based indicators. These measures were refined by an expert panel of burn care providers, yielding 36 process-based indicators in four clinical areas: initial evaluation and resuscitation, acute excisional surgery and critical care, psychosocial and pain control, and reconstruction and aftercare. We assessed variability in adherence to the indicators in a cohort of 1,076 children with burns at four regional pediatric burn programs in the Shriners Hospital system. The percentages of the cohort at each of the four sites were as follows: Boston, 20.8%; Cincinnati, 21.1%; Galveston, 36.0%; and Sacramento, 22.1%. The cohort included children who received care between 2006 and 2010.

RESULTS

Adherence to the process indicators varied both across sites and by clinical area. Adherence was lowest for the clinical areas of acute excisional surgery and critical care, with a range of 35% to 48% across sites, followed by initial evaluation and resuscitation (range, 34%-60%). In contrast, the clinical areas of psychosocial and pain control and reconstruction and aftercare had relatively high adherence across sites, with ranges of 62% to 93% and 71% to 87%, respectively. Of the 36 process indicators, 89% differed significantly in adherence between clinical sites (p < 0.05). Acute excisional surgery and critical care exhibited the most variability.

CONCLUSION

The development of this set of process-based measures represents an important step in the assessment of clinical practice in pediatric burn care. Substantial variation was observed in practices of pediatric burn care. However, further research is needed to link these process-based measures to clinical outcomes.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

摘要

背景

儿科烧伤护理临床实践的差异及其对结果的影响很少得到系统的检查。作为第一步，当前的临床护理流程需要进行操作定义。施乐会儿童医院系统的高度专业化烧伤护理单位为描述护理流程提供了机会。本研究的目的是制定一套儿科烧伤护理的基于流程的措施，并检查一组儿科烧伤患者的提供者对这些措施的依从性。

方法

我们进行了系统的文献回顾，以编制一套基于流程的指标。这些措施由烧伤护理提供者的专家小组进行了改进，产生了四个临床领域的 36 个基于流程的指标：初始评估和复苏、急性清创手术和重症监护、心理社会和疼痛控制以及重建和后续护理。我们在施乐会医院系统的四个区域儿科烧伤项目中评估了 1076 名烧伤儿童队列中对这些指标的依从性的变异性。四个地点的队列百分比如下：波士顿，20.8%；辛辛那提，21.1%；加尔维斯顿，36.0%；萨克拉门托，22.1%。该队列包括 2006 年至 2010 年期间接受治疗的儿童。

结果

各站点之间和各临床领域之间的流程指标依从性存在差异。急性清创手术和重症监护的临床领域的依从性最低，各站点的范围为 35%至 48%，其次是初始评估和复苏（范围为 34%至 60%）。相比之下，心理社会和疼痛控制以及重建和后续护理的临床领域在各站点之间的依从性相对较高，范围分别为 62%至 93%和 71%至 87%。在 36 个流程指标中，89%的指标在临床部位之间的依从性存在显著差异（p < 0.05）。急性清创手术和重症监护的变异性最大。