| ObjectiveBased on the evidence,the medication management scheme for patients with dysphagia was constructed,implemented and its effect was evaluated,so as to provide reference for improving the current situation of medication management practice for patients with dysphagia.MethodsThis study is divided into two stages:Stage Ⅰ Evidence synthesis of medication management in patients with swallowing disorders Based on the "6S" evidence pyramid principles,this paper systematically searched the relevant guidelines,evidence summary,systematic evaluation and expert consensus on medication management of dysphagia patients,and summarized the best evidence of medication management of dysphagia patients through literature quality evaluation,evidence rating and evidence extraction.Stage Ⅱ Application of evidence for medication management in patients with swallowing disorders This phase With ottawa research application model(Ottawa Model Of Research Use,OMRU)as a guide,including three steps: current situation evaluation,evidence application and effect evaluation.1.Evaluation of medication management of patients with swallowing disorders First of all,set up a team to determine the best evidence suitable for clinical introduction from the feasibility,suitability,clinical significance and effectiveness through expert argumentation,and formulate review indicators based on the included evidence to carry out the review of clinical status;Secondly,based on the review results and interviews with key insiders,this paper systematically analyzes the obstacles and promoting factors of introducing evidence into clinic from three aspects: evidence-based change,potential adopters and practical environment.2.Construction and application of medication management program for patients with swallowing disorders Based on the analysis results of the above obstacles and promoting factors,the research team initially worked out a medication management plan for patients with dysphagia.After two rounds of Delphi expert letters and inquiries,the plan was further revised and optimized,and it was applied for 12 months in neurology,neurosurgery and geriatrics with a high incidence of dysphagia in a third-class first-class hospital in Jiangsu Province,and the plan was continuously improved through dynamic monitoring.3.Effect evaluation of medication management program for patients with swallowing disorders Using the design of interruption time series,the influence of the implementation of the program on the instantaneous level change and long-term trend of inappropriate medication,aspiration and adverse drug reactions in patients with dysphagia was evaluated.The influence of the implementation of the scheme on the system level and the practitioner level is evaluated by using the before-and-after control design.Results1.Evidence synthesis: This study finally included 12 documents,including 2 summaries of special evidence,2 guides,6 summaries of evidence and 2 expert consensus.Finally,23 pieces of evidence including multidisciplinary cooperation,education and training,screening and evaluation,dosage form selection,compensatory methods,gastrointestinal tube medication,crushed drug management,efficacy monitoring and recording were summarized.2.Evidence application:2.1 Current situation assessment(1)After three rounds of expert evaluation,22 pieces of best evidence were finally included in this study,and 25 review indicators were formulated on the principle of credibility,effectiveness and measurability for the finally included evidence,so as to investigate the current situation of clinical practice in evidence application departments.The results show that the compliance rate of six indicators at the system level is 0;There are 17 indicators at the practitioner level,of which 8 compliance rates are less than 60% and 2 indicators at the patient level are less than 60%;(2)According to the questionnaire survey of 75 nurses in the three departments,the knowledge dimension score was 40.11±7.05,belief dimension 35.03±6.61,behavior dimension 73.08±11.27,and the standardized score of percentage system was66.78 ± 11.75,70.06 ± 13.22 and 69.60 ± 10.73,indicating that the knowledge,attitude and behavior related to the medication management of swallowing disorder among nurses are low,and there is a large gap between the clinical status and the best evidence;(3)Based on the review results and personal in-depth interviews,the main obstacles in the application of evidence are analyzed as follows: the evidence at the evidence level has not been transformed into a form accessible to nurses;Nurses at the level of potential adopters have poor knowledge,practice and heavy workload;The practical environment is lack of processes and tools,and the communication channels of multidisciplinary cooperation are not smooth.The main promoting factors are the sound evidence-based project management system and incentive mechanism,the strong willingness of management to change,and the creativity of practitioners,which provide a basis for the formulation of the next stage of change strategy.2.2 Scheme construction and application:(1)Scheme construction: The results of expert inquiry on medication management scheme for patients with dysphagia:(1)In the two rounds of expert inquiry,15 questionnaires were distributed and 15 were recovered,and the enthusiasm of experts was 100%;(2)In the first round of expert inquiry,the expert’s judgment basis(Ca)was 0.913,familiarity(Cs)was 0.911,authority(Cr)was 0.912,and the expert’s coordination coefficient was 0.354;(3)In the second round of expert inquiry,the expert’s judgment basis(Ca)was 0.933,familiarity(Cs)was 0.926,authority(Cr)was 0.930,and the expert’s coordination coefficient was 0.637.After two rounds of expert consultation,the expert opinions tend to be consistent,and the medication management plan for patients with dysphagia is optimized according to the expert opinions;(2)Scheme application: The optimized medication management scheme for patients with dysphagia is applied to clinical evidence and dynamically monitored in clinical practice,so as to realize evidence visualization,internalization of adopters’ behaviors and supportive practice environment,and ensure the scientificity,safety and feasibility of the medication management scheme for patients with dysphagia.2.3 Effect evaluation: In this stage,the effect is mainly evaluated from three aspects:patients,practitioners and system environment.(1)At the patient level,the interruption time series design was used to evaluate the outcome indicators at the patient level:(1)After the implementation of the medication management plan for dysphagia,the estimated values of the level change of the incidence of inappropriate medication,aspiration and adverse reactions were 16.971,10.038 and 15.050,respectively,with statistical significance(P < 0.006,P < 0.001,P < 0.000),indicating that the plan was implemented;(2)The changes(β 1+β 3)of the incidence of inappropriate medication,aspiration and adverse reactions in patients with dysphagia after the implementation of the medication management plan were-2.102,-0.956 and-1.719 respectively,all of which were negative,indicating that the implementation of the plan had a significant long-term trend effect on reducing the incidence of inappropriate medication,aspiration and adverse reactions in patients.(2)Practitioner level:(1)The compliance rate of nursing review indicators increased significantly,among which 18 review indicators were all more than 80%;(2)After the application of evidence,the knowledge,attitude and behavior of nursing staff were 51.33 ±7.80,44.84 ± 5.40 and 81.04 ± 14.55,respectively,and the standardized scores of the percentage system were 85.55 ± 13.00,89.68 ± 10.80 and 77.18 ± 13.86,respectively,and the difference was statistically significant(P <0.000).(3)System environment level:(1)Form the final draft of medication management plan for patients with swallowing disorders;(2)Formulated the standard paths and procedures for patients with swallowing disorders: including drug administration process for patients with oral eating and swallowing disorders and nasal feeding administration process for coma patients;(3)Formulated supplementary medication compensation strategies to provide personalized safe drug administration guidance;(4)Formulated under the guidance of the pharmacist,the list of fasting drugs in the three departments,and implanted into the hospital information system to form the information control and medication management mode under the multidisciplinary cooperation mechanism.Conclusions1.This study synthesizes the best evidence of medication management for patients with dysphagia,which can provide potential methodological guidance and reference for clinical medication management practice for patients with dysphagia.2.The medication management scheme for patients with dysphagia based on evidence-based construction is scientific,safe and clinically applicable;The implementation of the program promoted the optimization of medication management system for patients with dysphagia,significantly improved the evidence-based compliance of nursing staff in medication management for patients with dysphagia,thus ensuring the safety and effectiveness of medication for patients with dysphagia. |
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