中国血液净化

中国血液净化 ›› 2018, Vol. 17 ›› Issue (02): 102-106.doi: 10.3969/j.issn.1671-4091.2018.02.007

• 血管通路 • 上一篇    下一篇

Donabedian 质量理论在血液透析患者血管通路持续质量改进中的应用

陶珍晖1,郭学1,宋妍1,冈金剑1,周鑫1,陈育青1   

  1. 1. 北京大学第一医院肾内科，北京大学肾脏疾病研究所，卫生部肾脏疾病重点实验室，慢性肾脏病防治教育部重点实验室
  • 收稿日期:2017-11-02 修回日期:2017-12-20 出版日期:2018-02-12 发布日期:2018-02-12
  • 通讯作者: 陈育青cyq@bjmu.edu.cn E-mail:cyq@bjmu.edu.cn

Application of Donabedian quality theory in continual quality improvement of vascular access in hemodialysis patients

  • Received:2017-11-02 Revised:2017-12-20 Online:2018-02-12 Published:2018-02-12

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摘要： 目的应用Donabedian 质量理论，构建血液透析患者血管通路的结构-过程-结果指标，并对其进行持续质量改进，探讨该质量理论指导下的三维指标能否提高血管通路管理质量。方法对北京大学第一医院血液净化中心维持性血液透析患者的血管通路进行持续质量改进。干预前采用常规的注重结果指标的持续质量改进方法，干预措施主要为在Donabedian 质量理论指导下，关注维持性血液透析患者血管通路的结构-过程-结果三维指标，观察该方法与常规的持续质量改进方法对血管通路质量的影响有无差异。结果干预前后，患者总数为148 例和203 例。干预前后，血管通路构成比方面，自体动静脉内瘘(arteriovenous fistula,AVF)比例由73.0%提高到81.8%(χ2=3.871，P=0.049), 中心静脉置管(central venous catheter,CVC)比例由24.3%下降到14.3%(χ2=5.717,P=0.017)；血管通路并发症方面，CVC 的导管功能不良发生率由0.94/1000 导管日下降到0.40/1000 导管日(χ2=9.786,P=0.002)，内瘘狭窄发生率由0.29/1000 患者日下降到0.08/1000 病人日(χ2=7.703, P=0.006)；在动静脉内瘘穿刺方法上，区域法穿刺由94.5%下降到77.7%(χ2=13.848,P=0.000)，而绳梯法穿刺由3.7%提高到13.7%(χ2=13.162, P=0.000)；患者由于血管通路并发症而住院的比例由23.8%降低到10.0%(χ2=9.037,P=0.003)。结论Donabedian 质量理论指导下的维持性血液透析患者血管通路的质量管理，其提高血管通路质量效果明显，是值得推广的一种管理模式。

关键词: Donabedian, 结构-过程-结果, 维持性血液透析, 血管通路, 持续质量改进。

Abstract: Objectives To construct the structure-process-outcome index of vascular access in maintenance hemodialysis (MHD) patients by using Donabedian quality theory, and to explore whether this theory can improve the quality of vascular pathways under the guidance of quality theory. Methods Continuous quality improvement was achieved in the vascular pathways of MHD patients in our center. Prior to intervention, routine quality improvement was used to prioritize the outcome measures. The intervention was mainly aimed at the three-dimensional index of the structure-process-outcome of vascular pathways in MHD patients under the guidance of Donabedian quality theory to observe whether the effect of improved methods on the quality of vascular access is valuable as compared with that of conventional continuous quality improvement. Results Before and after the intervention, the total number of patients was 148 cases and 203 cases, respectively. The ratio of arteriovenous fistula increased from 73.0% to 81.8% (χ2=3.871，P=0.049), and the ratio of central venous catheterization decreased from 24.3% to 14.3% (χ2=5.717,P=0.017). The incidence of central venous catheter malfunction decreased from 0.94/1,000 patients/day to 0.40/1,000 patients/day (χ2=9.786,P=0.002), and the incidence of fistula stenosis decreased from 0.29/1,000 patients/day to 0.08/1000 patients/day (χ2=7.703,P=0.006). In the fistula puncture method, the ratio of area puncture reduced from 94.5% to 77.7% (P=0.000), and the ratio of rope-ladder puncture increased from 3.7% to 13.7% (χ2=13.162,P=0.000). Hospitalization due to complications of vascular access reduced from 23.8% to 10.0% (χ2=9.037,P=0.003). Conclusion The management under the guidance of Donabedian quality theory significantly improved the vascular access quality in MHD patients, and this is the management model worthwhile to be widely introduced.

Key words: Donabedian, structure - process - outcome, maintenance hemodialysis, vascular access, continuous quality improvement