如何做出临床决策

如何做出临床决策？,田梅梅,How to Make Practice Decisions？,目的 Objectives,罗列临床决策制定的组分 List the components of evidence-based decision making.讨论临床决策制定的步骤 Discuss the process of evidencebased decision making.解释“投资回报”这个术语 Describe the term “return on investment”.探讨“投资回报”与循证实践项目的重要关系 Discuss the importance of ROI related to EBP projects.,循证实践的步骤 EBP process,临床问题Clinical Inquiry,设计一个可以检索的、可以找到答案的问题Formulate a Searchable, Answerable Question (PICOT),寻找最佳证据Search for the Best Evidence,快速实施证据的关键评价、评估与合并Rapid Critical Appraisal, Evaluation, and Synthesis of Evidence,结合临床专家意见与病人偏好整合证据Integrate the Evidence with Clinical Expertise and Patient Preference(s),产生证据Generate Evidence 内部：质量改进QI外部：科学研究 Research,评估证据应用的结果Evaluate Outcomes based on Evidence,传播结果Disseminate the Outcome(s),对某个问题仔细考虑后的评判 The passing of judgment on an issue under consideration.得出结论或作出决定后的行动 The act of reaching a conclusion or making up ones mind.所获得的或明确的一个结论或判断，一个定论 A conclusion or judgment reached or pronounced; a verdict.,决策 Decision,Regardless of who makes the decision, orhow the decision is made,不管是谁作的决策，或如何作出决策,证据,临床实践经验,病人和家属注重的,Be curious always, for knowledge will not acquire you; you must acquire it.” Sudie Black,永远保持好奇心，因为知识不会来找你;你必须自己去寻求苏狄.巴克,制定决策 Decision Making,知识Knowledge,证据 Evidence,经验 experience,外部证据：External Evidence科研Research标准Benchmarks,内部证据：Internal Evidence质量改进QI本科室资料unit-based data,临床工作者Clinician;个体与小组Individual and Group,病人和家属Patient and Family价值观与偏好Values and Preferences,我们知道什么What We Know,国际上应用的Intentionally applied,工具Tools,循证实践模型或框架Model/Framework(EBP),质量改进步骤 Quality ImprovementProcess PDSA (Plan Do Study Act)精益流程 Lean processes,知识的正规来源Formalized Sources of Knowledge,教育Education 课堂Classroom 临床Clinical证据 Evidence 效度Valid 信度Reliable 可行性Applicable,知识Knowledge,教育Education,内部和外部证据Internal andExternal Evidence,知识的实践来源Practical Sources of Knowledge,临床经验Clinical Experience 你个人的实践Your individual practice 你小组的实践Your group practice 咨询同事与专家Queries to colleagues and experts病人经验Patient Experience 价值观与偏好 Values and preferences 病人与家庭 Patient and family,知识Knowledge,临床经验Clinical Experience,病人经验Patient Experience,知识和病人偏好Knowledge and Patient Preferences,科研证据需要考虑到病人的关注点与偏好 Research evidence needs to be considered in light of the patients concerns and preferences需要评判性的判断，不仅仅是科研证据 Critical judgment is required, not only research evidence,评判性决断需要两部分Critical judgment requires two components 证据的强度 The strength of the evidence 证据如何被应用到一个特殊的临床决策中 How the evidence is applied to a particular clinical decision,应用证据Applying Evidence,证据与临床实际的匹配很少是完美的The fit between evidence and clinical reality is rarely perfect 每一个病人都有不同 Every patient is different 病人不会只表现于一个问题 Patients never exhibit only one problem 主动倾听 Active Listening 理智采集和考虑病人相关的特征和关注点 Judicious gathering and consideration of relevant patient particularities and concerns 伦理 Ethics 叙述式理解每一位病人“Narrative understanding” of each patient,良好的临床决策的元素Elements of Good Clinical Judgment,了解病人及家庭Knowing the patient and family 目标、生活方式、资源Goals, lifestyle, resources 你听到他们说什么What do you hear them saying? 他们真正想要的是什么What do they really want?穿越时间与空间来推理Reasoning through time and place 从住院开始、新知识的提升、国际视角Since admission, development of new knowledge, global view 组织性环境与可及性Organizational context and feasibility评价和决定Appraising and deciding including evidence 你能为临床决策提供可靠的原理吗？Can you provide a solid rationale for the decision that is based on evidence,临床决策与循证事件的商业性The “Business” Side Of Decision Making and EBP投资回报的最大化Maximizing Return on Investment,什么是投资回报率？WHAT is ROI?,“Return on Investment”投资回报率（ROI）是指通过投资而应返回的价值，即企业从一项投资活动中得到的经济回报。它涵盖了企业的获利目标。利润和投入经营所必备的财产相关，因为管理人员必须通过投资和现有财产获得利润。投资回报率（ROI）=年利润或年均利润/投资总额100%,卫生保健中的意义Meaning in Healthcare,不应该发生额事件 Never Events基于价值的追求 Valuebased Purchasing有意义的应用 Meaningful Use病人保护医疗支付法律与再入院率 Patient Protection Affordable Care Act and readmissions集束化 Bundling可信赖的医疗机构 Accountable Care Organizations医疗之家 Medical Homes基于价值的效益 Valuebased Benefit,为什么重要？Why is ROI important to EBP?,不应该发生的事件 Never Events 手术异物遗留Object left in during surgery 空气栓塞Air embolism 血型不合Blood incompatibility 输错血型 Transfusion with the wrong type of blood,不应该发生的事件Never Events III -IV 期压疮 III or Stage IV pressure ulcers 跌倒和创伤Falls and trauma: 骨折Fracture 关节脱位Joint dislocation 头部外伤Head injury 挤压伤Crushing injury 烧伤Burn 电休克Electric shock 导尿管伴随性尿路感染Catheterassociated urinary tract infection 导管相关性血流感染Vascular catheterassociated infection,为什么重要？Why is ROI important to EBP?,临床医疗过程Clinical Process of Care急性心梗指标AMI indicators心力衰竭指标 HF indicators 肺炎Pneumonia 抗生素的选择Antibiotic Selection 静脉血栓的预防Venous thromboembolism prophylaxis,为什么重要？Why is ROI important to EBP?,病人经验Patient Experience 护患交流Communication with Nurses医患交流 Communication with Doctors 医院工作人员的反应力Responsiveness of Hospital Staff疼痛管理 Pain Management用药沟通Communication about Medicines 医院整洁与安静Hospital Cleanliness & Quietness 出院指导Discharge Information 对医院的综合评分Overall Rating of Hospital,为什么重要？Why is ROI important to EBP?,病人结果Patient Outcomes 急性心梗30天死亡率Acute Myocardial Infarction (AMI) 30Day Mortality Rate (shown as survival rate) 心力衰竭30天死亡率Heart Failure (HF) 30Day Mortality Rate (shown as survival rate)肺炎30天死亡率Pneumonia (PN) 30Day Mortality Rate (shown as survival rate),为什么重要？Why is ROI important to EBP?,提升病人结果Improved Patient Outcomes 最大化的报销 Maximize Reimbursement 声誉-优于竞争者Reputation, Outperforming Competitors病人满意度 Patient Satisfaction 增加市场份额Increased Market Share降低照护成本 Decreased Cost of Care 减少投诉Decreased Litigation,循证实践中的投资回报率The ROI of EBP,提升临床结果Improved Clinician Outcomes 团队凝聚力/团队工作 Group Cohesion/Teamwork 护理满意度Nursing Satisfaction 留职意愿Intent to Stay 护士留职Nurse Retention病人结果和满意度Patient Outcomes and Satisfaction 声誉，优于竞争者Reputation, Outperforming Competitors增加市场份额Increased Market Share减少投诉Decreased Litigation,循证实践中的投资回报率The ROI of EBP,实际应用到你的病人,只有证据，永远不足如何将证据“外推”。应用于个案有效且重要的证据能实际应用到我自己的病人身上吗？适用性,你的病人与研究文献所收录的病人，有无明显差异？如，女性乳癌的研究，能否应用到男性评估你的病人接受与研究文献所实施形同的治疗或处置，益处、害处将有多大 1.应用前景，请先修正文献结果 2.你的单位或自己是否有能力或资源实施相同的治疗或处置？实施质量是否与研究机构相当？,如何将证据“外推”应用于个案,是否清楚与病人及家属说明沟通 1.治疗或处置的益处与害处，病人及家属是否清楚了解 2.病人与家属的价值观与喜好，是否清楚评估是否有其他更好的代替治疗方案病人的依从性：是否理智上同意合作，但潜意识行为并不配合，实际行为依从性差实际追踪病人的结构：详细病历记录,如何将证据“外推”应用于个案,“脐带”连接母子间的生命及亲情,对家属而言有不可抹灭