基于HFMEA模型的急救流程优化对重型颅脑外伤患者救治质量的影响

刘伟董; 张玲; 劳彩利; 应立萍; 周尧英

doi:10.16766/j.cnki.issn.1674-4152.004274

基于HFMEA模型的急救流程优化对重型颅脑外伤患者救治质量的影响

doi: 10.16766/j.cnki.issn.1674-4152.004274

绍兴市人民医院急诊科，浙江绍兴 312000

基金项目:

浙江省医药卫生科技计划项目 2023KY1245

浙江省医药卫生科技计划项目 2023KY356

详细信息

通讯作者:
刘伟董，E-mail：604514607@qq.com

中图分类号: R605.97
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- 文章访问数: 5
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出版历程
- 收稿日期: 2025-06-18
- 网络出版日期: 2026-01-07

The influence of emergency process optimization based on the HFMEA model on the treatment quality of patients with severe craniocerebral trauma

Emergency Department, Shaoxing People's Hospital, Shaoxing, Zhejiang 312000, China

摘要

摘要: 目的构建基于医疗失效模式与效应分析(HFMEA)模型的重型颅脑外伤患者急救流程方案，旨在提高患者救治质量。方法选取2023年4月—2025年4月绍兴市人民医院急诊科收治的104例重型颅脑外伤患者，按照入院时间顺序进行分组，2023年4月—2024年3月入院的52例纳入对照组，予以常规急救流程干预；2024年4月—2025年4月入院的52例纳入观察组，在对照组基础上予以基于HFMEA模型的急救流程优化干预。从入院干预至入院72 h，对比2组时效性、操作规范性、救治效果、护患纠纷发生率及护理满意度。结果观察组分诊评估时间、接诊等待时间、紧急头颅CT检查时间、确诊至治疗决策时间、术前准备时间及进入急诊到手术时间均短于对照组(P＜0.05)；气道管理达标率[94.23%(49/52) vs.78.85%(41/52)]、颅内压管理达标率[88.46%(46/52) vs.71.15%(37/52)]均高于对照组(P＜0.05)；入院24 h、72 h的存活率均高于对照组(P＜0.05)，入院72 h格拉斯哥昏迷评分(GCS)评分[(9.09±1.56)分vs.(7.34±1.35)分]高于对照组(P＜0.05)；护患纠纷发生率与对照组比较差异无统计学意义(P＞0.05)；护理满意度评分高于对照组(P＜0.05)。结论基于HFMEA模型的急救流程优化可提高重型颅脑外伤患者救护时效、操作规范性、救治质量及护理满意度。
- 重型颅脑外伤 /
- 医疗失效模式与效应分析 /
- 风险优先指数 /
- 救治效果 /
- 时效性
Abstract: Objective To construct an emergency treatment process plan for patients with severe craniocerebral trauma based on the health failure mode and effects analysis (HFMEA) model, aiming to improve the quality of patient treatment. Methods A total of 104 patients with severe craniocerebral trauma admitted to the Emergency Department of Shaoxing People's Hospital from April 2023 to April 2025 were selected and grouped according to the order of admission time. The 52 cases admitted from April 2023 to March 2024 were included in the control group and received conventional emergency process intervention, meanwhile, 52 cases admitted to the hospital from April 2024 to April 2025 were included in the observation group. On the basis of the control group, emergency process optimization intervention based on the HFMEA model was given. From the intervention upon admission to 72 hours after admission, the timeliness, operation standardization, treatment effect, incidence of nurse-patient disputes and nursing satisfaction of the two groups were compared. Results The triage assessment time, reception waiting time, emergency head CT examination time, time from diagnosis to treatment decision, preoperative preparation time and time from entering the Emergency Department to surgery in the observation group were all shorter than those in the control group (P < 0.05). The compliance rates of airway management [94.23% (49/52) vs.78.85% (41/52)] and intracranial pressure management [88.46% (46/52) vs.71.15%(37/52)] were both higher than those of the control group (P < 0.05). The survival rates at 24 hours and 72 hours after admission were both higher than those of the control group (P < 0.05). The Glasgow Coma Scale (GCS) score 72 hours after admission [(9.09±1.56) points vs. (7.34±1.35) points] was higher than that of the control group (P < 0.05). The incidence of nurse-patient disputes showed no statistically significant difference compared with the control group (P>0.05). The score of nursing satisfaction was higher than that of the control group (P < 0.05). Conclusion The optimization of the emergency rescue process based on the HFMEA model can improve the rescue timeliness, operation standardization, treatment quality and nursing satisfaction of patients with severe craniocerebral trauma.
- Severe craniocerebral trauma /
- Analysis of medical failure modes and effects /
- Risk priority index /
- Treatment effect /
- Timeliness

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表 1 重型颅脑外伤患者急救流程中失效模式和原因及改进措施

Table 1. Failure modes, causes, and improvement measures in emergency procedures for patients with severe craniocerebral trauma

失效模式	失效原因	改进措施
分诊评估不足	评估维度片面，未覆盖关键指标，如仅关注格拉斯哥昏迷(Glasgow coma scale，GCS)评分，忽略隐性风险；评估无固定流程，依赖个人经验	构建多维评估矩阵，确保全方位无死角筛查；制定分诊评估流程图，消除经验依赖；定期通过案例模拟强化人员培训
接诊等待时间长	分诊与接诊环节断裂、团队响应速度慢	建立分诊-接诊闭环联动，分诊时同步触发接诊预警：比如通过信息系统弹窗立即通知抢救团队，红标患者触发声光报警，确保团队30 s内响应。制定接诊响应时间表，团队在接到红标预警后1 min抵达分诊区，3 min内将患者转运至抢救单元
检查时间长	人员分工不明确、多部门协作不畅	设立创伤团队响应机制，规范好各抢救人员、各部门站位图；建立实时联动群，检查启动、患者出发、到达时间实时同步，实现各科室无缝衔接
气道管理不到位	插管技术不足、插管指征把握不严、缺乏患者插管标准操作规程	每季度进行气道管理模拟训练和考核；制定插管标准化操作流程，明确插管指征(GCS评分≤8分、经皮动脉血氧饱和度(percutaneous arterial oxygen saturation，SpO₂) < 90%、存在误吸风险)、时间节点(≤5 min)及操作步骤；定期召开质控会议，通报插管达标率，并提出改进计划
颅内压管理不到位	监测不及时、干预不规范	建立标准化颅内压监测流程，将GCS评分≤8分的患者立即纳入颅内高压高危名单，符合指征者尽快启动颅内压监测，同时床头贴标提醒，每小时记录颅内压、脑灌注压，同步监测GCS、瞳孔、生命体征，绘制趋势图，当颅内压＞20 mmHg或脑灌注压＜60 mmHg时自动标红预警。参考相关指南，制定阶梯式干预路径，及时过渡到高渗盐水、脑室引流或手术减压；每月召开分析会，分析颅内压管理不到位原因，制定优化措施
医患沟通不畅，交流时间长	患者及其家属对疾病认识不足，无法立即决策	护士决策辅助贯穿全流程，提前植入若硬膜外血肿＞30 mL、脑疝形成等需立即开颅，使患者思考时间提前
术前准备时间过长	多部门衔接不畅、急诊手术与择期手术存在冲突、术前准备流程不明确，缺乏标准化步骤	设立专职“急救流程协调员”(由高年资护士担任)，拥有跨部门调度权限，统一指挥术前准备全流程；资源弹性调配(如预留急诊手术间)；建立标准化术前准备流程表，明确各步骤时间，超时者予以问责
注：1 mmHg=0.133 kPa。

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表 2 2组重型颅脑外伤患者时效性指标比较(x±s, min)

Table 2. Comparison of timeliness Indicators between the two groups of patients with severe craniocerebral trauma(x±s, min)

组别	例数	分诊评估时间	接诊等待时间	紧急头颅CT检查时间	确诊至治疗决策时间	术前准备时间	进入急诊到手术时间
对照组	52	2.41±0.47	3.11±0.49	17.78±3.46	5.98±1.11	8.24±1.45	81.34±6.57
观察组	52	1.56±0.34	2.39±0.56	13.45±4.09	3.67±0.98	5.89±0.77	65.69±6.78
t值		10.566	6.977	5.828	11.250	10.322	11.953
P值		＜0.001	＜0.001	＜0.001	＜0.001	＜0.001	＜0.001

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表 3 2组重型颅脑外伤患者操作规范性指标、护患纠纷发生率及护理满意度比较

Table 3. Comparison of standardized operational indicators, incidence of nurse-patient disputes, and nursing satisfaction between the two groups of patients with severe craniocerebral trauma

组别	例数	气道管理达标[例(%)]	颅内压管理达标[例(%)]	护患纠纷[例(%)]	NSNS评分(x±s, 分)^b
对照组	52	41(78.85)	37(71.15)	3(5.77)	80.11±8.27
观察组	52	49(94.23)	46(88.46)	1(1.92)	85.23±5.23
统计量		5.283^a	4.833^a	0.260^a	3.528^c
P值		0.022	0.028	0.610	0.001
注：^a为χ²值，^c为t值。^b出院时对照组仅40例、观察组48例接受调查，其余死亡。

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表 4 2组重型颅脑外伤患者干预后救治效果比较

Table 4. Comparison of treatment effects between the two groups of patients with severe craniocerebral trauma after intervention

组别	例数	入院24 h存活[例(%)]	入院72 h存活[例(%)]	GCS评分(x±s, 分)
组别	例数	入院24 h存活[例(%)]	入院72 h存活[例(%)]	入院时	入院72 h
对照组	52	44(84.62)	40(76.92)	5.78±1.45	7.34±1.35^c
观察组	52	51(98.08)	48(92.31)	5.61±1.22	9.09±1.56^c
统计量		4.379^a	4.727^a	0.647^b	19.117^d
P值		0.036	0.030	0.519	＜0.001
注：^a为χ²值，^b为t值，^d为F值；与入院时比较，^cP＜0.05。

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