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Reporting System of Patients' Safety Management Established By the Delphi Method about Psychological Evaluation, Intervention and the Psychological Critical Value
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摘要:
目的 探讨通过专家咨询法建立患者安全管理的心理评估、干预以及心理危急值报告体系的可行性。 方法 结合文献检索，采用改良德尔菲法对筛选的14项患者安全管理的心理评估与干预指标进行讨论。向43位专家发放问卷，征求心理评估维度的意见和各维度量化评分、评估方法、评估分级、评估原则等建议。根据专家意见，计算专家权威系数及各指标评分均值和变异系数，初步构建患者安全管理的心理评估、干预及心理危急值报告体系，并对该体系的可行性进行讨论。 结果 共经6次专家讨论，并向专家发放问卷43份，回收问卷35份(81.4%)。在14项评估指标重要性和紧迫性的评价中，专家积极性系数为0.97，重要性Kendall W协调系数为0.241(P＜0.001)，紧迫性Kendall W协调系数为0.283(P＜0.001)。专家权威系数为0.68~0.74。经专家讨论，认可“自杀风险”“抑郁”“焦虑”“治疗期望过高”“医患关系期待”“兴奋激越”“幻觉”“妄想”“谵妄”“酒瘾”“吸毒”“医生职业耗竭”12项指标纳入患者安全管理的心理评估体系；评估方法应包括患者自评和医护观察。专家认为应对患者安全管理的心理评估结果进行分级干预，最高预警级别按照危急值的标准进行衡量和设置。建立患者安全管理的心理评估指标及相应干预措施体系具有可行性。 结论 患者安全管理的心理评估指标和分级干预体系已通过专家咨询法建立初步框架，在此基础上可进一步制订细则，并进行试实践。 Abstract:Objective To explore the feasibility of establishing a reporting system of patients' safety management by the Delphi method about psychological evaluation, intervention and the psychological critical value. Methods Based on literature review, we used the modified delphi method to study 14 indexes of safety management of patients in terms of psychological evaluation and intervention. Questionnaires were sent to 43 experts to solicit the opinions about patients' safety management regarding psychological assessment dimensions, suggestions on quantitative score, assessment method, assessment grading, and assessment principles of each dimension. According to the experts' opinion, the average value and the coefficient of variation of each index were calculated to form the preliminary construction of a reporting system of patients' safety management in terms of psychological evaluation, intervention and psychological critical value, and the feasibility of the system was discussed. Results After six rounds of discussion of the experts, 43 questionnaires were sent to experts, and 35 ones (81.4%) were returned. In the evaluation of the importance and urgency of the 14 assessment indicators, the coefficient of experts' participation was 0.97; the Kendall W coefficient of importance was 0.241 (P < 0.001), the coefficient of the urgency was 0.283 (P < 0.001). The authority coefficient of experts ranged from 0.68 to 0.74. After the discussion of the experts, 12 indicators were approved to be included in the psychological evaluation system about patients' safety management: suicide risk, depression, anxiety, excessive treatment expectation, expectation of doctor-patient relationship, agitation, hallucination, delusion, delirium, alcohol addiction, drug abuse and occupational exhaustion. The evaluation method should include patients' self-evaluation and medical observation. According to the consulting meeting of the experts, graded intervention should be performed in the results of psychological assessment of patients' safety management, and the highest warning level should be measured and set according to the standard of the critical value. The expert-group considered that it is feasible to establish psychological evaluation indexes and corresponding intervention measures. Conclusions The system framework of indicators of psychological assessment and hierarchical intervention system for the management of patients' safety has been established by the delphi method. On this basis, detailed methods and tools can be further formulated and trial practice can be carried out. 作者贡献: 史丽丽负责收集材料、数据处理、撰写稿件；魏镜负责研究设计、召集专家进行讨论、稿件审校；洪霞参与研究设计、数据处理。利益冲突: 无 -
表 1 专家咨询会及问卷发放与回收进程
形式 时间 参与人员 主要讨论内容 会议1 2018-03-14 北京协和医院医疗、医务管理、信息及心理生理中心专家17位 报告研究的目标与定位，开放性征求意见与建议；对项目中的关键指标进行讨论 会议2 2018-03-17 精神卫生专业专家，包括精神科临床、医院管理、伦理法律专家14位 同会议1 会议3 2018-04-13 综合医院精神卫生专家13位 对前期收集的信息进行报告；结合文献，讨论建立患者安全心理评估指标和干预体系的可行性 会议4 2018-05-16 北京协和医院护理人员12位 报告前期进展及预试验情况，对患者安全相关心理评估和干预的可行性进行讨论 问卷 2018-04-13至
2018-05-16以上所有专家 填写咨询问卷，对评估指标进行量化 会议5 2018-06-06 北京协和医院住院患者代表 10例 介绍项目目标，征求患者的意见与建议 会议6(末次会议) 2018-07-04 会议1中的专家16位，会议4中的专家4位，北京协和医院医院管理专家2位，国家卫生健康委员会医政医管专家1位 报告研究进度和结果，开放式讨论，征求专家反馈意见 
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表 2 专家一般资料(n=35)
指标 具体明细 专业背景 精神心理学13位，临床医学(内科、外科)10位，临床护理学11位，精神卫生兼医疗管理学1位 职称 正高15位，副高4位，中级11位，初级5位 最高学位 博士18位，硕士3位，本科13位，专科1位 学会/协会任职 常委及以上14位，委员6位，无任职15位
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表 3 14项评估指标的重要性和紧迫性评价结果(n=34)
评估指标 重要性 紧迫性 评分(x±s) 变异系数 评分(x±s) 变异系数 自杀风险 9.85±0.56 0.06 9.71±0.87 0.09 危害他人安全 9.47±1.05 0.11 9.76±0.55 0.06 吸毒 8.65±1.81 0.21 7.94±2.17 0.27 抑郁 8.21±1.68 0.21 7.41±1.96 0.26 兴奋激越 8.03±1.53 0.19 7.94±1.89 0.24 纠纷投诉 8.03±2.13 0.26 7.15±2.51 0.35 谵妄 7.94±2.27 0.29 7.85±2.26 0.29 医生职业耗竭 7.74±2.19 0.28 7.03±2.36 0.33 酒瘾 7.71±1.62 0.21 7.03±1.88 0.27 焦虑 7.47±2.01 0.26 6.88±2.16 0.29 妄想 7.44±2.09 0.28 6.97±2.07 0.30 医患关系期待 7.44±2.16 0.29 6.56±2.35 0.36 治疗期望过高 7.35±2.26 0.31 6.50±2.63 0.40 幻觉 7.26±2.17 0.30 6.85±2.30 0.34
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表 4 专家对14项评估指标的判断依据及权威程度(n=28)
评估指标 理论分析(x±s，分) 实践经验(x±s，分) 同行了解(x±s，分) 直观感觉(x±s，分) 判断依据 专家权威系数* 抑郁 2.37±0.84 2.74±0.45 2.00±0.78 2.44±0.64 0.91 0.74 谵妄 2.32±0.77 2.61±0.63 1.93±0.73 2.36±0.78 0.89 0.73 幻觉 2.19±0.74 2.68±0.55 1.79±0.57 2.25±0.75 0.89 0.73 自杀风险 2.03±0.82 2.72±0.53 2.07±0.88 2.52±0.69 0.88 0.72 焦虑 2.22±0.85 2.59±0.64 1.85±0.77 2.42±0.70 0.88 0.72 危害他人安全 1.86±0.80 2.75±0.44 1.89±0.75 2.59±0.73 0.86 0.71 妄想 2.11±0.74 2.50±0.75 1.82±0.72 2.36±0.73 0.86 0.71 医患关系期待 2.04±0.71 2.61±0.63 1.68±0.72 2.36±0.68 0.86 0.71 医生职业耗竭 2.21±0.79 2.39±0.63 1.75±0.70 2.21±0.69 0.86 0.71 兴奋激越 2.00±0.77 2.54±0.64 1.82±0.67 2.44±0.64 0.85 0.71 酒瘾 2.07±0.86 2.46±0.64 1.79±0.79 2.36±0.78 0.85 0.71 纠纷投诉 1.64±0.68 2.61±0.57 1.71±0.66 2.50±0.58 0.83 0.70 治疗期望过高 1.85±0.82 2.37±0.69 1.67±0.68 2.33±0.73 0.82 0.69 吸毒 1.98±0.79 2.07±0.72 1.79±0.74 2.14±0.80 0.80 0.68 *按27人计算，因1人未填写熟悉程度
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表 5 评估工具推荐(n=21)
评估工具 自杀
风险危害他人
安全纠纷
投诉谵妄 幻觉 妄想 兴奋
激越酒瘾 吸毒 治疗期望
过高抑郁 焦虑 医患关系
期待医生职业
耗竭观察法 3 4 3 4 3 3 3 3 4 5 3 4 6 2 访谈法 2 2 2 4 3 3 2 2 4 4 3 4 5 2 他评量表 1 1 1 3 2 2 1 1 1 1 3 2 1 1 自评量表 4 0 0 0 0 0 0 0 0 1 8 8 1 2
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