上海交通大学学报（医学版） ›› 2024, Vol. 44 ›› Issue (12): 1552-1560.doi: 10.3969/j.issn.1674-8115.2024.12.008
• 论著 · 临床研究 • 上一篇
杨利灵1(
), 詹莎2, 薛晓燕2, 陈凯2, 刘青2, 王丽2, 王怡怡2, 吴萌2, 陆群峰1()
收稿日期:2024-05-20
接受日期:2024-07-02
出版日期:2024-12-28
发布日期:2024-12-28
通讯作者:
陆群峰
E-mail:youngll955@163.com;luluroom2004@163.com
作者简介:杨利灵（1996—），女，护师，硕士；电子信箱：youngll955@163.com。
基金资助:
YANG Liling1(), ZHAN Sha2, XUE Xiaoyan2, CHEN Kai2, LIU Qing2, WANG Li2, WANG Yiyi2, WU Meng2, LU Qunfeng1()
Received:2024-05-20
Accepted:2024-07-02
Online:2024-12-28
Published:2024-12-28
Contact:
LU Qunfeng
E-mail:youngll955@163.com;luluroom2004@163.com
Supported by:摘要：
目的·全面了解儿童造血干细胞移植后皮肤移植物抗宿主病（graft-versus-host disease，GVHD）评估与预防的临床现状，构建审查指标，并结合临床实际情况分析研究开展过程中的障碍因素与促进因素，制定变革策略。方法·以JBI循证卫生保健模式为理论指导框架，明确临床问题，构建循证实践团队，系统检索文献，评价和汇总证据，并结合证据构建审查指标及明确审查方法。采用渥太华研究应用模式，对证据的变革、潜在采纳者和实践环境3个维度进行障碍因素与促进因素分析，并制定相应的策略。结果·共纳入24条最佳证据，包含皮肤评估、皮肤防护、皮肤不良反应的处理、用药指导和随访与筛查5个维度。在此基础上构建22条审查指标。14条审查指标的执行率<60%，其中的10条审查指标的执行率为0；8条审查指标的执行率>60%，其中的6条审查指标执行率为100.00%。主要障碍因素为缺乏相关的培训、未形成合理的管理机制；主要促进因素有证据来源可靠、潜在相关者配合程度高。结合审查指标的执行率和障碍因素分析的结果，制定变革措施。结论·儿童造血干细胞移植后皮肤GVHD评估与预防的证据与临床实践存在较大差距；应基于障碍因素与促进因素，有效实施临床变革。
中图分类号:
杨利灵, 詹莎, 薛晓燕, 陈凯, 刘青, 王丽, 王怡怡, 吴萌, 陆群峰. 儿童造血干细胞移植后皮肤移植物抗宿主病评估与预防的审查指标制定与障碍因素分析[J]. 上海交通大学学报（医学版）, 2024, 44(12): 1552-1560.
YANG Liling, ZHAN Sha, XUE Xiaoyan, CHEN Kai, LIU Qing, WANG Li, WANG Yiyi, WU Meng, LU Qunfeng. Development of indicators and analysis of barriers for assessment and prevention of cutaneous graft-versus-host disease after haematopoietic stem cell transplantation in children[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2024, 44(12): 1552-1560.
| Dimension | Indicator | Population | Review method | Review adherence rate/% |
|---|---|---|---|---|
| Skin evaluation | 1. The nurse thoroughly examines the child's entire body for skin conditions prior to transplantation | Nurses (n=19) | Participatory observation | 100.00 |
| 2. The nurse thoroughly assesses the skin condition of the child's entire body on a daily basis during the transplantation period | Nurses (n=19) | Access to care record sheets | 0 | |
| 3. The nurse assesses the grade of the child's skin GVHD using the Glucksberg criteria within 7 d of transplantation | Nurses (n=19) | Access to care record sheets | 0 | |
| 4. The nurse is able to correctly select and use a skin GVHD assessment tool | Nurses (n=19) | Questionnaire method | 52.63 | |
| 5. The nurse uses a diary to record changes in the child's skin condition | Nurses (n=19) | Access to care record sheets | 0 | |
| 6. The nurse is able to use the body surface area method to indicate the area of the child's skin that has been damaged | Nurses (n=19) | Access to care record sheets; questionnaire method | 21.05 | |
| 7. The nurse marks the assessment sheet for the child indicating the use of photosensitive medication | Nurses (n=19) | Access to care record sheets | 0 | |
| Skin protection | 8. The caregiver trims cuts the child's nails short during the transplantation period | Caregivers (n=22) | Participatory observation; interview method | 81.80 |
| 9. Caregivers use lukewarm water for cleansing the child's skin, followed by towel drying or patting dry, and then apply moisturizer | Caregivers (n=22) | Interview method | 100.00 | |
| 10. Caregivers apply moisturiser to the child every 4‒6 h and after the application of steroid creams | Caregivers (n=22) | Participatory observation; interview method | 4.54 | |
| 11. Caregivers store moisturisers in a cool place | Caregivers (n=22) | Participatory observation | 100.00 | |
| 12. Caregivers should avoid exposing children to direct sunlight, particularly between 10:00 and 16:00 | Caregivers (n=22) | Interview method | 100.00 | |
| 13. The care givers is able to correctly protect the child from the sun | Caregivers (n=22) | Interview method | 100.00 | |
| Management of adverse skin reactions | 14. The nurse is able to correctly advise the physician to perform a skin culture for non-integrated skin | Nurses (n=19) | Questionnaire method | 0 |
| 15. The nurse is able to correctly manage non-integral skin breaks | Nurses (n=19) | Questionnaire method | 100.00 | |
| 16. The nurse is able to select appropriate skin care products for the care of the child's slow-healing wounds | Nurses (n=19) | Questionnaire method | 10.50 | |
| Guidance on the use of medication | 17. The nurse should inform the caregivers and the child of the side effects of tacrolimus ointment | Nurses (n=19) | Participatory observation; interview method | 0 |
| 18. The nurse should assess the skin condition of a child who has been using steroid creams for a long period of time | Nurses (n=19) | Participatory observation; interview method | 89.47 | |
| Follow-up and screening | 19. On discharge, nurses should instruct caregivers and children to carry out their own comprehensive skin checks once a month | Nurses (n=19) | Participatory observation; interview method | 0 |
| 20. At discharge, the nurse should instruct the caregivers and the child on the correct frequency of skin follow-up visits | Nurses (n=19) | Questionnaire method; participatory observation | 0 | |
| 21. At the time of discharge, nurses should instruct female children to have regular gynaecological outpatient follow-up visits | Nurses (n=19) | Questionnaire method; interview method | 0 | |
| 22. At discharge, nurses should instruct male children to have regular follow-up visits to the urology clinic | Nurses (n=19) | Questionnaire method; interview method | 0 |
表1 儿童造血干细胞移植后皮肤GVHD评估与预防的审查指标及审查方法
Tab 1 Indicators and review methods for assessment and prevention of cutaneous GVHD after haematopoietic stem cell transplantation in children
| Dimension | Indicator | Population | Review method | Review adherence rate/% |
|---|---|---|---|---|
| Skin evaluation | 1. The nurse thoroughly examines the child's entire body for skin conditions prior to transplantation | Nurses (n=19) | Participatory observation | 100.00 |
| 2. The nurse thoroughly assesses the skin condition of the child's entire body on a daily basis during the transplantation period | Nurses (n=19) | Access to care record sheets | 0 | |
| 3. The nurse assesses the grade of the child's skin GVHD using the Glucksberg criteria within 7 d of transplantation | Nurses (n=19) | Access to care record sheets | 0 | |
| 4. The nurse is able to correctly select and use a skin GVHD assessment tool | Nurses (n=19) | Questionnaire method | 52.63 | |
| 5. The nurse uses a diary to record changes in the child's skin condition | Nurses (n=19) | Access to care record sheets | 0 | |
| 6. The nurse is able to use the body surface area method to indicate the area of the child's skin that has been damaged | Nurses (n=19) | Access to care record sheets; questionnaire method | 21.05 | |
| 7. The nurse marks the assessment sheet for the child indicating the use of photosensitive medication | Nurses (n=19) | Access to care record sheets | 0 | |
| Skin protection | 8. The caregiver trims cuts the child's nails short during the transplantation period | Caregivers (n=22) | Participatory observation; interview method | 81.80 |
| 9. Caregivers use lukewarm water for cleansing the child's skin, followed by towel drying or patting dry, and then apply moisturizer | Caregivers (n=22) | Interview method | 100.00 | |
| 10. Caregivers apply moisturiser to the child every 4‒6 h and after the application of steroid creams | Caregivers (n=22) | Participatory observation; interview method | 4.54 | |
| 11. Caregivers store moisturisers in a cool place | Caregivers (n=22) | Participatory observation | 100.00 | |
| 12. Caregivers should avoid exposing children to direct sunlight, particularly between 10:00 and 16:00 | Caregivers (n=22) | Interview method | 100.00 | |
| 13. The care givers is able to correctly protect the child from the sun | Caregivers (n=22) | Interview method | 100.00 | |
| Management of adverse skin reactions | 14. The nurse is able to correctly advise the physician to perform a skin culture for non-integrated skin | Nurses (n=19) | Questionnaire method | 0 |
| 15. The nurse is able to correctly manage non-integral skin breaks | Nurses (n=19) | Questionnaire method | 100.00 | |
| 16. The nurse is able to select appropriate skin care products for the care of the child's slow-healing wounds | Nurses (n=19) | Questionnaire method | 10.50 | |
| Guidance on the use of medication | 17. The nurse should inform the caregivers and the child of the side effects of tacrolimus ointment | Nurses (n=19) | Participatory observation; interview method | 0 |
| 18. The nurse should assess the skin condition of a child who has been using steroid creams for a long period of time | Nurses (n=19) | Participatory observation; interview method | 89.47 | |
| Follow-up and screening | 19. On discharge, nurses should instruct caregivers and children to carry out their own comprehensive skin checks once a month | Nurses (n=19) | Participatory observation; interview method | 0 |
| 20. At discharge, the nurse should instruct the caregivers and the child on the correct frequency of skin follow-up visits | Nurses (n=19) | Questionnaire method; participatory observation | 0 | |
| 21. At the time of discharge, nurses should instruct female children to have regular gynaecological outpatient follow-up visits | Nurses (n=19) | Questionnaire method; interview method | 0 | |
| 22. At discharge, nurses should instruct male children to have regular follow-up visits to the urology clinic | Nurses (n=19) | Questionnaire method; interview method | 0 |
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