| ObjectiveIn order to standardize the nursing practice of preventing VTE and provide the oretical guidance and basis for the scientificity of nursing prophylaxis in China,we should construct the clinical implementation of nursing prophylaxis programme for VTE and carry out clinical transformation application.Methods1.Control Research: 55 patients with VTE in a hospital from January 2015 to December 2018 were selected to be included in the VTE group,and 108 patients without VTE were selected to be included in the non-VTE group according to the ratio of 1:2.We took control research on the two groups to screen out risk factors and built a risk prediction model.54 cases of VTE and non-VTE patients in the same hospital from January 2013 to December 2014 were selected for verification.2.Investigation of current situation: 297 nurses from different hospitals were investigated on current situation of nursing prophylaxis and management for VTE by self-designed questionnaire.3.The construction of nursing prophylaxis programme for VTE: Based on the current practice situation of nursing prophylaxis for VTE,the relevant evidence-based guidelines were retrieved,and the quality was evaluated by AGREE ? system.Then according to the focus of the situation analysis,the evidence was extracted,analyzed and integrated to build the preliminary programme of nursing prophylaxis for VTE.The final draft of nursing prophylaxis programme for VTE was confirmed by experts meeting research.4.Analysis of inhibitory factors and stimulative factors of clinical conversion: the intervention strategies developed and implemented in the system,the questionnaire research at the levels of nurses and patients,qualitative research and field observation research.5.The implementation and evaluation of nursing prophylaxis programme for VTE:(1)Clinical trial: According to the inclusion and exclusion criteria of the subjects,the orthopedic patients were enrolled with convenient sampling.Patients in the control group were enrolled without the implementation of prophylaxis programme for VTE.Patients in the experimental group adopted the prophylaxis proposal for VTE.From the perspective of process indicators,outcome indicators and evidence-based outcome indicators for the implementation of evidence,we have evaluated the assessment rate of thrombotic risk and the timeliness of the assessment,the implementation rate of basic prevention,physical preventive measures and relevant health education performed by nurses,accuracy rate of thrombotic risk assessment,compliance with postoperative physical precautions,patients and family members' cognition about VTE prophylaxis,and the incidence of VTE,the velocity of deep venous blood flow and the changes of blood vessel diameter in postoperative patients.T-test was used for measuring data conforming to normal distribution.Chi-square test or Fisher exact probability method was used for comparison of rates.Wilcoxon rank sum test was used for measuring data not conforming to normal distribution and composition ratio data not conforming to Chi square test.(2)Qualitative research: 11 nurses who participated in theprophylaxis programme for VTE in orthopedics department were interviewed in a semi-structured way to understand the feelings and evaluation of nurses after the implementation of the programme.Results1.Multiple regression analysis showed that respiratory infection / respiratory failure,liver and kidney disease,drinking history,D-dimer and Caprini thrombus risk level were all risk factors of VTE in hospital.The model constructed by the above risk factors had better prediction availability.Evaluating the risk of thrombusand implementing preventive measures,improving VTE nursing prophylaxis related medical records were key points of VTE prophylaxis.2.It was lack of standardization in VTE nursing prophylaxis in most of hospitals.Some hospitals did not pay enough attention to VTE prophylaxis.Some nurses had not sufficient knowledge of VTE prophylaxis.3.The preliminary construction of nursing prophylaxis programme for VTE: 13 guidelines were finally brought into the study.Among them 9 were highly recommended and 4 were recommended.The evidence in the guide was extracted,synthesized and summarized to draw up the proposal of VTE prophylaxis including 84 recommendations.12 experts made final revision to the plan and determined the recommended level.Clinical programme of nursing prophylaxis for VTE were finally confirmed including five aspects and 73 recommendations with 66 high recommendations,7 low recommendations,7 no-recommended temporarily,and 4 combining with other projects.4.The construction of clinical programmeof nursing prophylaxis for VTE:(1)The scores of 30 nurses were 45.09±13.73.There was a statistical difference between the assessment results of different level nurses(P < 0.01).The nurses have insufficient knowledge of VTE prevention,and the training object should focus on the junior nurses.(2)We found that nurses could correctly understand the programme of nursing prophylaxis for VTE during the interview.There were still some problems including inadequate medical cooperation,inconvenient purchase of anti-embolism stockings(AES),and lack of intermittent pneumatic compression device in some departments.We should make more convenienceby informatizationand multiple ways of propaganda and education.(3)We found that the assessment process was convenient and the assessment of thrombus risk was completed by doctors in field observation.AES were purchased by family members after education by doctors.Nurses implement preventive measures and health education according to doctor's orders.The inhibitory factors that affected the implementation of the programme might be the heavy workload of nursing,lack of nurses' participating in the risk assessment,and AES needing patients' families to purchase and so on.(4)Based on the analysis of the stimulative factors and inhibitory factors of evidence transformation application,we have made reforms at the system level,nurse level and patient level,and have formulated 10 interventional strategies to promote transformation application.5.The implementation and evaluation of nursing prophylaxis programme for VTE:(1)There was no significant difference between the two groups in gender composition ratio,BMI,comorbidities,smoking history,drinking history,preoperative APTT,platelet count and Caprini thrombus risk score(P > 0.05).(2)The process indicators of assessment implementation: the risk assessment rate of thrombus by nurses was 100%,the timeliness rate of thrombus risk assessment in hospital was 87.94%,the implementation rate of two basic prevention health education was 98.58%,and the implementation rate of six AES related health education was more than 89%.(3)Outcome indicators of evidence implementation: the accuracy of preoperative and postoperative thrombus risk assessment of patients in the experimental group was higher than that of the control group;the compliance of patients in the experimental group wearing AES was significantly better than that of the control group;the mastery score of thrombus prevention knowledge of patients / family members in the experimental group was higher than that of the control group(P< 0.05).(4)Outcome indicators of Evidence itself: there was no significant difference in the incidence of VTE between the control group and the experimental group.However,there was 1 case of VTE in the control group(0.61%),and 1 case occurred after discharge(0.61%)and VTE did not occur in the experimental group.There was no significant difference in blood flow velocity and diameter of external iliac vein,femoral vein and popliteal vein in pre and post operation between the experimental group and the control group(P > 0.05).The difference of blood flow velocity of popliteal vein between the two groups before and after the application of VTE prevention program was close to statistical significance(P = 0.0576).(5)During the interview we found that the implementation of nursing prophylaxis programme for VTE was helpful to standardize clinical nursing behaviors,improve nursing quality,and promote the embodiment of professional value of nurses,which still needs continuous exploration in clinical transformation and application.ConclusionNursing prophylaxis programme for VTE based on the best evidence provides standard nursing practice reference for clinical nurses to prevent VTE.After clinical application,it is feasible for nurses to improve the timely and accurate rate of risk assessment of thrombus in patients,the compliance of patients with physical prevention measures,and the mastery of health education knowledge of thrombus prevention in patients. |
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