目的 开展嵌合抗原受体T细胞（chimeric antigen receptor T cell,CAR-T）治疗血液肿瘤患者护理管理的循证实践,评价其在提高护士和血液肿瘤患者的CAR-T细胞治疗护理相关知识水平,完善相关流程,缓解患者焦虑抑郁情绪、提高生活质量,及降低患者细胞因子释放综合征（cytokine release syndrome,CRS）、免疫效应细胞相关神经毒性综合征（immune effector cell associated neurotoxicity syndrome,ICANS）不良反应的发生率及严重程度的临床效果。方法 通过文献筛选、评价及汇总,总结CAR-T细胞治疗血液肿瘤患者护理管理的最佳证据。通过专家会议对最佳证据进行本土化调试,并依据最佳证据制定审查指标。以“基于证据的持续质量改进模式”为理论框架在湖南某两所三级甲等医院开展循证实践,2023年5月—2023年8月对符合纳入标准的护士、患者及系统层面进行基线审查。2023年9月根据基线审查结果,分析证据引入临床过程中的促进与障碍因素,并制订行动策略,进行实践改革。2023年10月—2024年1月进行效果评价,比较循证实践前后各审查指标的执行率、护士和患者CAR-T细胞治疗护理相关知识水平、患者焦虑抑郁情绪、生活质量及并发症的发生率与严重程度。结果 循证实践期间共纳入护士25名,基线审查期间纳入患者18例,效果评价期间纳入患者17例。循证实践后,各审查指标执行率均有提升,护士相关知识水平得分由（57.20±8.43）分提高到（82.20±6.78）分,患者相关知识调查问卷正确率由应用前的16.7%~94.4%提高到74.4%~100%,平均正确率由75.0%提高至96.9%,焦虑、抑郁评分由（52.44±2.12）分、（52.56±2.62）分降低至（49.94±2.77）分、（49.29±3.26）分,FACT-G得分由（67.94±8.31）分提高至（78.06±9.46）分,差异均具有统计学意义（P<0.05）。结论 循证实践的开展可完善CAR-T细胞治疗护理相关资料与流程,提高护士及患者的CAR-T细胞治疗护理相关知识水平,规范护士对CAR-T细胞治疗患者的护理管理,缓解患者焦虑抑郁的情绪,提高生活质量,可一定程度上减轻并发症的严重程度。
Abstract
Objective To construct an evidence-based management of patients with hematologic tumors treated with CAR T cells, to evaluate its clinical effects in improving nurses' and hematologic tumor patients' CAR-T cell therapy knowledge, improving related procedures, relieving patients' anxiety and depression, improving quality of life, and reducing the incidence and severity of related adverse reactions about CRS and ICANS. Method Through literature screening, evaluation and summary, the best evidence of nursing management of patients with hematologic tumors treated with CAR T cells was summarized. Through the expert demonstration meeting, the best evidence was localized debugging, and the review index was formulated according to the best evidence. Based on the theoretical framework of “evidence-based continuous quality improvement model”, evidence-based practice was carried out in two tertiary level A hospitals in Hunan Province. A baseline review was conducted on nurses and patients who met the inclusion criteria and at the system level from May 2023 to August 2023. In September 2023, based on the results of the baseline review, analyze the factors that may be encountered in promoting and impeding the introduction of evidence into the clinical process, and develop action strategies for practice reform. Effect evaluation was conducted from October 2023 to January 2024, and the implementation rate of each review indicator before and after evidence-based practice, the knowledge level of nurses and patients related to CAR T cell therapy, the incidence and severity of anxiety and depression and related complications of patients were compared. Results A total of 25 nurses were included in the evidence-based practice period, 18 patients were included in the baseline review period, and 17 patients were included in the effect evaluation period. After the evidence-based practice, the implementation rate of each review index was improved, the score of nurses' relevant knowledge level was increased from (57.20±8.43) to (82.20±6.78), and the accuracy of patients' relevant knowledge questionnaire was increased from 16.7%-94.4% before the application to 74.4%-100%. The average accuracy increased from 75.0% to 96.9%, and the scores of SAS and SDS decreased from (52.44±2.12) and (52.56±2.62) to (49.94±2.77) and (49.29±3.26). The FACT-G score increased from (67.94±8.31) to (78.06±9.46), and the differences were statistically significant (P<0.05). Conclusion The evidence-based practice of nursing management of patients with hematologic tumor treated with CAR-T cell therapy can improve the relevant department data and procedures, improve the knowledge level of nurses and patients with CAR-T cell therapy, standardize nurses' nursing management of patients with CAR-T cell therapy, relieve patients’ anxiety and depression, and improve the quality of life of patients. It can reduce the severity of complications to some extent.
关键词
嵌合抗原受体T细胞 /
血液肿瘤 /
循证护理 /
循证实践
Key words
chimeric antigen receptor T cells /
hematologic tumor /
evidence-based nursing /
evidence-based practice
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基金
湖南省教育厅科学研究项目“基于CAR-T疗法血液肿瘤患者护理模式的构建及临床应用”（20C1183）
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