여성건강간호학회지제12권제4 호, 2006년 12월 Korean J Women Health Nurs Vol.12 No.4, 316-325, December, 2006 Original Article Development of a Critical Pathway for Patients with Uterine Artery Embolization Chung Kyung-Hee 1), Ko Young-Sook 2), Lim Jeong-Ah 3) 1) Assistant Professor, Department of Nursing, Science, Nambu University 2) Full-time lecturer, Department of Nursing, Kwangyang Health College 3) Supervisor Nurse, Muan Public Silver Hospital 자궁동맥색전술환자를위한표준진료지침개발 정경희 1), 고영숙 2), 임정아 3) 1) 남부대학교간호학과조교수 2) 광양보건대학간호과전임강사 3) 무안노인요양병원간호감독 Abstract Purpose: The purpose of this study was to develop a Critical Pathway for Uterine Artery Embolization patients. Method: There were 6 steps that were taken. Step 1 was selecting a diagnosis, and Step 2 was organizing a development team consisting of 7 experts. Step 3 analyzed the medical records, and Step 4 drew up a preliminary Critical Pathway. Step 5 tested the clinical validity of the preliminary Critical Pathway, and Step 6 developed the final Critical Pathway. Result: The contents of the medical practices observed in the medical records were investigated in seven areas: monitoring/assessment, treatment, medication, diet, activity, consults, and education/discharge plan; and a total of 73 items was identified. The validity of the 73 items was examined by a group of specialists. 68 items were adopted, 4 items revised, 1 item removed, and 1 item was added. Using the results, a preliminary Critical Pathway was drawn up. According to the results from examining the clinical validity of the preliminary Critical Pathway with five patients for five weeks, 3 items which showed discrepancy were revised and another 3 items were added. Then, the final Critical Pathway was completed. Conclusion: This Critical Pathway needs to be clinically applied and continuously to measure its effects in terms of the length of stay, cost effectiveness, and the patients and staffs satisfaction. Key words : Critical pathway, Uterine artery embolization 서 론 과학의발달에따른의료시술의발달과함께전국민의료보험확대실시는의료수요의증가와의료비의상승및의료기관간의경쟁심화등국내의료환경의급격한변화를가져오게되었다. 이에따라의료소비자측면에서는비용을절감시키는효과가있으면서도질적인의료서비스를제공받음으로써만족도를증가시키고, 의료제공자측면에서는수익을증 투고일차심사완료일차심사완료일차심사완료일최종심사완료일 : 2006. 10. 23 1 : 2006. 11. 3 2 : 2006. 11. 23 3 : 2006. 12. 11 : 2006. 12. 13 Address reprint requests to : Lim, Jeong-Ah(Corresponding Author) Muan Public Silver Hospital 165 Sungdong-ri Muan-town Muan-county, Chonnam 534-804, Korea Tel: 82-61-453-7007 Fax: 82-61-453-7223 E-mail: pigangel8871@hanmail.net 316 여성건강간호학회지 12(4), 2006년 12월
자궁동맥색전술환자를위한표준진료지침개발 대시킬수있는방안에대한모색이필요하게되었다. 또한 정부도증가하는의료비로인한보험재정난을해결하기위하여의료기관에대한보험심사를강화하고, 1997년부터일부질병군과수술치료에대하여포괄수가제의도입과함께사례관리가시작되었다. 또한 2000년부터는간호관리료차등수가제를도입하여의료계로하여금의료경영측면에대한관심을고조시키면서환자에대한서비스의개선과비용절감등의효율적인의료개선을위한노력을촉구하고있다 (Lee & Doh, 2002). 사례관리란특정사례집단에대하여한정된시간틀내에서가능한모든건강자원을이용하고, 다학제간팀의노력을통하여환자의결과를향상시키는데초점을둔계획된접근으로, 이를도식화한것이 Critical Pathway 이다 (Latini & Foote, 1992). Critical Pathway는다학제간팀에의하여개발된실무지침서이며, 우리나라에서는 1997년이후몇가지질병군을대상으로 Critical Pathway를개발하여적용한결과재원일수및비용을감소시켰고, 환자만족도는향상되었음을보고하고있다 (Chung, Joo, & Chung, 2000; Hwang, Shin, Lee, & Lee, 2003; Lee & Doh, 2002; Noh & Park, 2000). 자궁질환중의하나인자궁근종은양성종양으로 30세에서 45세사이의여성에게발병율이높고부인과자궁적출술의가장흔한원인이되고있다 (Yoon, Kim, Moon, & Cho, 2001). 지금까지자궁근종치료는주로자궁을적출해내는수술법으로치료해왔으나우리나라에서는 2000년부터수술적치료방법이외에자궁을보존하는시술법인자궁동맥색전술을시행하고있다. 자궁동맥색전술은비교적시술이간편하고, 재원기간이짧고, 회복과정이예견가능하지만색전술후심한악취를동반한괴사조직을포함한분비물이일정기간동안배출되며동맥의색전이진행되는과정에서발생되는심한통증으로인하여활동량감소, 식욕감퇴, 변비등의 2차적인문제가발생함으로써입원비용의증가와함께입원기간이연장되거나퇴원후재입원하는사례가발생되고있다 (Kim, 2003; Park et al., 1999; Rheu, Park, & Song, 2001). 그럼에도불구하고수술을하지않고효과적이고안전한치료방법으로자궁을보존치료한다는점에서색전술을선호하는대상자들이증가하고있다. 따라서자궁동맥색전술환자를대상으로표준화된환자관리지침서인 Critical Pathway를개발하여적용함으로써색전술후에발생되는다양한증상을효과적으로관리할수있으며, 대상자의만족도향상및재원일수의단축을기대할수있다. 그리고의료제공자들에게는표준화된관리지침에따른중재활동의수행으로의료행위의지연이나누락이방지됨으로써의료서비스의질적인향상은물론비용효과적인서비스를제공할수있을것이다. 1. 연구의목적 본연구의목적은자궁동맥색전술환자를대상으로환자중심적이고질적이며, 비용효과적인표준화된환자관리도구인 Critical Pathway 를개발하는것이다. 2. 용어의정의 1) Critical Pathway Critical Pathway 란효과적인환자관리를위한사례관리도 구의하나로특정환자집단을위해다학제간팀에의해개발된실무지침서로정해진재원일수내에기대되는환자결과에도달하기위해시간내에일어나야할예측가능한주요핵심사건들을보여주는요약된양식을의미한다 (Coffey et al., 1992; Kim, Park, & Kim, 2000; Zander, 1988). 2) 자궁동맥색전술자궁근종환자를대상으로우측대퇴동맥에카테터를삽입하고근종으로가는양측자궁동맥을통하여 Polyvinyl alcohol 또는 Gelform을주입함으로써동맥혈류를완전히차단시켜자궁근종을괴사시키는시술방법이다 (Goodwin, Vedantham, McLucas, Farno, & Perrella, 1997; Heaston, 1979; Ravina et al., 1995). 연구방법 1. 연구설계 본연구는자궁동맥색전술환자를위한환자관리계획서인 Critical Pathway 를개발하는방법론적연구이다. 2. 연구대상 본연구는 G시에위치한 500병상의종합병원에서 2004년 8 월부터 2005년 1월까지자궁동맥색전술을받고퇴원한환자 의의무기록지 27례중자궁동맥색전술적응증이외에부인 과적질환이없는자, 혈우병등내과적질환이없는자, 현 재임신상태가아닌자의의무기록지 25례를대상으로예비 Critical Pathway 를작성하였다. 예비 Critical Pathway의임상 타당도검증은 2005년 3월 20일부터 4월 30일사이에입원하 여자궁동맥색전술을받은대상자 7례중내과적인질환을 동반한 2 례당뇨병 ( 1 례, 치료중인결핵 1 례를 ) 제외하고본 연구대상자선정기준에적합한 5 례를대상으로하였다. 여성건강간호학회지 12(4), 2006년 12월 317
정경희 고영숙외 3. 연구진행절차 1) 1 단계: Critical Pathway 개발을위한대상의선정 Critical Pathway의개발을위한대상은진료형태와간호중재활동은비교적일정하지만시술후통증과관련된다양한불편감및합병증의발생으로재원일수의연장이초래되고있는자궁동맥색전술을선정하였다. 5단계에서확인된예비 Critical Pathway의실무적용시차이 를보인내용을전문가집단과합의하에수정ㆍ보완하여자궁동맥색전술환자를위한최종 Critical Pathway 를작성하였다. 연구결과 1. 예비 Critical Pathway 작성 2) 2 단계: Critical Pathway 개발팀구성자궁동맥색전술환자를위한 Critical Pathway 개발팀은산부인과전문의 2 인, 영상의학과전문의 1 인, 모성간호학교수 1 인, 산부인과수간호사 1 인, 질관리실수간호사 1인및산부인과병동간호사 1인등총 7인으로구성하여내용타당도검증을위한전문가집단으로선정하였다. 3) 3 단계: Critical Pathway 적용범위와내용및기간결정 Critical Pathway에포함시킬의료행위내용을결정하기위해 2004년 8월부터 2005년 1월까지자궁동맥색전술을받고퇴원한환자중본연구의대상자선정기준에맞는환자의의무기록지 25 례를분석하였다. 의무기록지조사는입원시부터퇴원시까지시행된모든의료와간호행위내용을 8개영역으로분류하여시간의흐름에따라조사하여기록하고그시행빈도를파악하였다. 4) 4 단계: 예비 Critical Pathway 작성예비 Critical Pathway의각항목에대한내용타당도를검증하기위해전문가집단 7인에게총 73문항의질문지를배부하였다. 질문지는 4점의 Likert 척도를이용하여각문항별로 전혀적절하지않다 를 1 점, 적절하지않다 2 점, 적절하다 3 점, 매우적절하다 를 4점으로타당도점수를산정한후문항별 CVI(Content Validity Index) 를산출하였다. 그결과전문가집단 7인이상이 3점혹은 4점을주어 86% 이상의합의가이루어진문항을유의한항목으로선정하였고 (Lynn, 1986), 1점혹은 2점을주어 71% 이하의합의률을보인문항은개발팀이제시한부적절성에대한의견을참고로수정ㆍ보완및삭제한후예비 Critical Pathway 를작성하였다. 5) 5 단계: 예비 Critical Pathway의임상타당도검증 2005년 3월 20일부터 4월 30일까지자궁근종으로자궁동맥 색전술을받은환자 5명을대상으로하여예비 Critical Pathway 의임상타당도검증을실시하였다. 6) 6 단계: 자궁동맥색전술환자를위한최종 Critical Pathway 개발 1) Critical Pathway 예비 시행기간및영역별의료행위내용결정 Critical Pathway에포함될영역별의료행위내용과시 행기간을결정하기위하여본연구의기준에맞는대상자의의무기록지 25례를대상으로입원일부터퇴원일까지수행된모든의료행위및간호행위를의무기록지조사양식을이용하여파악하였다. 의무기록지조사대상자의일반적특성은 <Table 1> 과같다. 의무기록지조사내용을분석한결과재원일수가 3일인대상자는 10 명이였고, 4일인대상자는 11명이였으며, 5일인대상자는 4 명인것으로조사되었다. 이에전문가집단의의견을수렴한결과시술에필요한검사들은외래진 <Table 1> General characteristics of medical records (N=25) Item Classification n(%) Age(yrs) 31-35 2 ( 8) 36-40 7 (28) 41-45 9 (36) 46-50 7 (28) Marital status Married 23 (92) Unmarried 2 ( 8) Number of delivery 0 5 (20) 1 2 ( 8) 2 13 (52) 3 5 (20) Operation time 2 hours and a half 14 (56) 3 hours 6 (24) 3 hours 30min 3 (12) 4 hours 1 ( 4) > 4 hours 1 ( 4) Hemoglobin(g/dl) 10.0 below 10 (40) 10.0 over 15 (60) Chief complaint Menstrual pain 7 (28) Menstrual pain with excessive menstruation 8 (32) Excessive menstruation 9 (36) Dysmenorrhea 1 ( 4) Uterine Myoma 1 11 (44) (Number) 2 9 (36) 3 4 (16) 4 over 1 ( 4) Length of hospital 3 days 10 (40) stay 4 days 11 (44) 5 days 4 (16) 318 여성건강간호학회지 12(4), 2006년 12월
자궁동맥색전술환자를위한표준진료지침개발 료일에시행하여입원기간이지연되지않도록하고, 입원당 일시술을시행하는것으로결정하여 Critical Pathway의적용 기간은 3 일이적절한것으로합의하였고, Lee 등(2000) 의연 구에서도색전술후입원기간이평균 고로하여본연구의횡축인 입원일부터퇴원일까지총 3일이었던점을참 Critical Pathway의적용기간은 3 일로정하였다. 그리고 Critical Pathway의종축의의료행위내용은선행연구와현재국내ㆍ외에서개발하여사용하고있는다양한진단명별 Critical Pathway 를조사한결과감시/ 사정, 처치, 투약, 식이, 활동, 검사, 협의진료, 교육및퇴원계획등의 8개영역으로구분하는경우가대부분이었다. 그러나본연구에서는의무기록지조사결과검사영역의의료행위내용은일반적으로혈액검사, 소변 검사, 심전도, 흉부 X- 선검사, 자궁경부세포진검사및자궁경부확대촬영, 골반MRI 등의검사가입원전외래진료시에대부분완료되었고, 입원기간동안은한건의검사도이루어지지않은것으로조사되어검사영역은종축의의료행위내용에포함하지않았다. 따라서본연구의종축은감시/ 사정, 처치, 투약, 식이, 활동, 협의진료, 교육및퇴원계획등총 7 개영역으로구분하였다. 의무기록지분석결과종축의 7개영역의의료행위내용별처방및시행기간에따른빈도는 <Table 2> 와같다. 2) 전문가집단의내용타당도검증 25례의의무기록지분석결과를토대로 Critical Pathway 종 <Table 2> Prescription according to the contents of medical actions and frequency according to the period of application in the results of analyzing medical record Area Time of highest frequency Monitoring/Assessment Measure vital signs q 4hrs Admission before going to the operating room Measure vital signs q 8hrs After operation 1 st day after operation Measure vital signs q12hrs 2 nd day after operation discharge Check nursing history and the results of outpatient tests, and make physical, On admission social and mental assessment Observe pains, fever, bleeding from the operation site assess vaginal discharge and lumbago q8hrs after operation discharge Assess sleeping After operation discharge Observe the function of IV PCA and nausea 48 hours after operation Assess gastrointestinal disturbance - after taking Mypol 1 st day after operation discharge Observe the function of foley catheter Until before removing foley catheter Observe self voiding 3 hours after removing foley catheter Assess defecation and discharge On the day of discharge Treatment Receive the consent to operation and consent to IV PCA Before operation Remove denture and accessories Before operation Insert foley catheter and prepare the skin of the operation site 30 minutes before moving to the MRA room Send to the MRA room 2:00 pm on the day of admission Prepare supplies when moving to the MRA room When moving to the MRA room - sand bag, pethidine 50mg, ceftezole1.0g, IV PCA Applying sand bag For 6 hours after operation When applying an angio seal -apply sand bag For 2 hours after operation - remove the indwelling catheter 4 hours after operation Remove foley catheter 9:00 am on the 1st day after operation Dressing of operation site 1 st day after operation discharge Remove IV PCA and IV line 1 hour before discharge Medication Inject fluid Before operation the day of discharge Test skin reaction to antibiotic Before operation Antibiotics - Non-oral (Ceftezole 1.0g and Ribocin 1A.qd) The day of operation, 2nd day after operation - Non-oral (Ceftezole 1.0g and Ribocin 1A, q12hrs) 1 st day after operation Analgesics - Non-oral (Dicnol 1A) After operation discharge(if necessary) - Oral (Mypol 2T) 1 st day after operation discharge(if necessary) Barbiturates - (Midazolam 5mg IV) After operation discharge(if necessary) Analgesics - Non-oral (Macperan 1A IV) After operation discharge(if necessary) Maintain IV PCA For 48 hours after operation 여성건강간호학회지 12(4), 2006년 12월 319
정경희 고영숙외 <Table 2> Prescription according to the contents of medical actions and frequency according to the period of application in the results of analyzing medical record(continued) Area Time of highest frequency Diet NPO 6 hours before operation, 2 hours after operation Intake water 2 hours after operation Regular diet 1day after operation discharge Activity Absolute bed rest For 12 hours after operation Bed rest 1 hour before operation, 12 hours after operation for 6 hours Angio seal applying-absolute bed rest For 4 hours after operation Ward ambulation 1 st day after operation discharge Test Routine Lab, Chest x-ray, Ultrasound sonogram, Cervicogram, EKG, pelvic MRI Check on out patient department Consultation Department of imaging medicine Before operation Department of anesthesia Before operation Education/Discharge plan Guide to life in the ward On the day of admission Guide to uterine artery embolization On the day of admission -cautions before and after operation On the day of admission Range of activities, sex life, contraception, pain control 1 st day after operation discharge Personal hygiene 1 st day after operation discharge Management of vaginal discharge 1 st day after operation discharge Symptoms and signs that requires a visit to the hospital 1 st day after operation discharge Matters concerning the first menstruation 1 st day after operation discharge Date of outpatient department visit 1 st day after operation discharge Education on discharge 1 st day after operation Explain the discharge procedure On the day of discharge Explain how to take drugs On the day of discharge Re-education on discharge On the day of discharge <Table 3> Correction and elimination and addition after the verification of its contents by expert groups Section Area Period Contents Contents Before correction After correction Revise Monitoring/ After operation Measure vital signs q 8hrs Measure vital signs q 4hrs Assessment -after operation 1 st day after operation -on the day operation Elimination 1 st day after operation Remove the indwelling catheter-9am Remove the indwelling catheter -for 6 hours after operation Assess gastrointestinal disturbance -after taking Mypol Assess gastrointestinal disturbance -after operation discharge Activity After operation Absolute bed rest-12 hours Absolute bed rest -6 hours after operation Monitoring/ Assessment After operation Observe lumbago -after operation discharge Addition Medication 2 nd day after operation Oral Iron prescription -if Hemoglobin 8.0g/dl less 축에포함될 7개영역의각각의의료행위내용을횡축의시 행기간에따라설문지를구성하여전문가집단의내용타당도를검증한결과총 73문항중 60문항은전문가집단에서 100% 의합의가이루어졌고, 8문항은 86% 이상의합의를보였으며 5문 항은 71% 이하의합의률을보였다. 내용타당도검증결과 71% 이하의합의률을보인 5문항중 4 문항은수정하고, 1문항은삭제하였으며, 1 문항을추가하였다. 내용타당도검증후수정, 삭제및추가된내용은 <Table 3> 과같다. 320 여성건강간호학회지 12(4), 2006년 12월
자궁동맥색전술환자를위한표준진료지침개발 구체적인내용을살펴보면, 감시 / 사정영역에서시술후부터 시술 1일째까지활력징후를 8시간간격으로시행하였던것 을시술당일에는환자상태변화를조기에확인할수있도록하기위해 4 시간간격으로시행하는것으로수정하였다. 시술후 1일째유치도뇨관제거는감염예방과조기이상을위해시술 6 시간후에제거하기로하였다. 위장장애사정은 Mypol 복용후부터에서퇴원시까지에서시술후부터퇴원시까지로수정하였다. 그이유는 IV PCA 사용으로오심과구토증상이시술당일부터시작될뿐아니라시술 1일째통증관리를위해 prn으로 Mypol을복용하게되면속쓰림증상이나타나기때문에오심, 구토및속쓰림등을위장장애사정에통합하여시술후부터퇴원시까지사정하는것으로수정하였다. 활동영역에서시술후 12시간동안절대안정을 6시간동안적용하는것으로수정하였다. 시술후감시 / 사정영역의허리통증사정은통증사정에포함하여시행하기로하고삭제하였다. 투약영역에서시술후 2일째에만약시술전혈색소수치가 8.0g/dl 이하일때는퇴원약에경구용철분제를처방하는것을추가하였다. 이상에서살펴본전문가집단의내용타당도검증결과를토대로임상타당도검증을위한자궁동맥색전술환자용예비 Critical Pathway 가개발되었다. 2. 예비 Critical Pathway의임상타당도검증 2005년 3월 20일부터 4월 30일까지자궁근종으로자궁동맥 색전술을받은환자 5명을대상으로예비 Critical Pathway의 임상타당도검증을실시하였다. 임상타당도검증대상자들의 일반적인특성을살펴보면연령은평균 41 세이며, 출산횟수는 평균 1.4 회였다. 그리고혈색소는평균 10.1g/dl 이며, 총시술 시간은평균 2시간 40 분이였고, 평균재원일수는 3.2 일이였다. 임상타당도검증대상자 5명중 4명은예비 Critical Pathway 에서정한시술후 2일째특별한문제가없는상태로퇴원하 였으며, 1명은시술후 3일째에퇴원하여재원일수가 1일연 장되었다. 3. 자궁동맥색전술환자를위한최종 Critical Pathway 작성 임상타당도를검증한결과수정이된항목은처치영역에서 시술 6시간후유치도뇨관제거 를 시술 1일째 9AM에제거 하는것으로수정하였다. 이는예비 Critical Pathway에서는감염관리및조기이상을목적으로시술일에제거하는것으로하였으나임상타당도검증과정에서 2례의경우지속적인통증과출혈성경향으로활동이지연되었고, 나머지 3례의경우에서도시술이보통오후 5시에완료되고그로부터 6 시간후에유치도뇨관을제거하게되면늦은저녁시간이되어버리기때문에대상자들이자연배뇨를위해노력을하게되어수면방해가되는것으로나타나시술 1일째 9AM에제거하기로수정하였다. 또한처치영역의 시술동의서와 IV PCA 사용동의서받기 는협의진료영역에서수행되므로, 처치영역에서는 시술동의서와 IV PCA 사용동의서확인 으로수정하였다. 그리고교육 / 퇴원계획영역에시술전교육내용으로 시술후통증및 IV PCA 유지와관련된오심, 구 <Table 4> Final critical pathway for uterine artery embolization patient Name: Age Medical record No Admitting days Others Area Day of admission/day of operation 2 nd day of admission 3 rd day of admission (1 st day after operation) (2 nd day after operation) {Before operation} Measure vital signs q 4hrs Taking nursing history (past history, obstetrical history, allergy, current condition) Check the results of outpatient tests Assess physical condition Assess social and mental condition {After operation} Measure vital signs q 8hrs Observe the function of IV PCA Observe fever and bleeding from the operation site Assess leukorrhea Assess gastrointestinal disturbance Assess sleeping and pains Assess appetite Measure vital signs q 12hrs Observe the function of IV PCA Observe fever and bleeding from the operation site Assess leukorrhea Assess gastrointestinal disturbance Assess sleeping and pains Assess defecation Measure vital signs q 4hrs Assess discharge Monitoring/ Observe fever, bleeding from the operation site Assess appetite Assessment and the function of IV PCA Assess vaginal discharge Assess gastrointestinal disturbance Assess sleeping and pains Observe the function of indwelling catheter - Until before removing the indwelling catheter Observe self voiding - After 3 hours from removing the indwelling catheter 여성건강간호학회지 12(4), 2006년 12월 321
정경희 고영숙외 <Table 4> Final critical pathway for uterine artery embolization patient(continued) Name: Age Medical record No Admitting days Others Area Day of admission/day of operation 2nd day of admission 3rd day of admission (1st day after operation) (2nd day after operation) {Before operation} Confirm the permission note to operation and IV PCA Remove denture and accessories Insert foley catheter - Fix at the left inguinal area Prepare the skin of the operation site - 30 minutes before going to the MRA room Dressing the operation site (9AM) Maintain IV PCA Remove the foley catheter (9AM) Dressing the operation site (9AM) Remove IV PCA - 1 hour before discharge Remove IV line - 1 hour before discharge Treatment Supplies to be prepared when moving to the MRA room - sandbag, Ceftezole1.0g, IV PCA, Pethidine 50mg. {After operation} Apply a sandbag to the operation site - 6 hours - Apply an angio seal - 2 hours Remove the foley catheter - After 4 hours when applying an angio seal Medication Diet Activity Consultation Education/ Discharge Planning {Before operation} H/S 1L IV start: Lt arm Ceftezole skin test {After operation} 5% D/S 1L IV Ceftezole 1.0g IV qd Ribocin 1amp IM Maintain IV PCA (prn) For pains: Dicnol 1amp IM Midazolam 5mg IV For nausea: Macperan 1amp IV {Before operation} NPO after admission - Even water is not allowed {After operation} NPO for 2 hours After 2 hours - Begin with water {Before operation} Bed rest - From 1 hour before operation {After operation} Absolute bed rest : For 6 hours - Rt leg straight position : For 4 hours when applying an angio seal Best rest : After 6 hours Department of Imaging Medicine: Request operation Department of Anaesthesia: Request IV PCA Guide to life in the ward Guide to uterine artery embolization - Cautions before and after operation - Education on pains after operation, the maintenance of IV PCA, related nausea and vomiting symptoms H/S 1L IV 5% D/S 1L IV Ceftezole 1.0g IV q12hrs Ribocin 1amp IM q12hrs Maintain IV PCA (prn) Ordinary meal For pains: Dicnol 1amp IM Midazolam 5mg IV Mypol 2T PO q8hr For nausea: Macperan 1amp IV Walking inside the ward Education on discharge - Range of activities -Sex life, contraception - Pain control - Symptoms and signs that requires a visit to the hospital - Personal hygiene - Matters concerning the first menstruation - Management of vaginal discharge - Date of outpatient department visit 5% D/S 1L IV Ceftezole 1.0g IV qd Ribocin 1amp IM qd Maintain IV PCA (Prescription on discharge) Cephradine 4T bid for 5days Reocid 4T bid for 5days Toraren 4T bid for 5days Mypol 6T tid for 4days If hemoglobin below 8.0g/dl - Add orally administered iron supplement (prn) For pains: Dicnol 1amp IM Midazolam 5mg IV Mypol 2T PO q8hr For nausea: Macperan 1amp IV Defecation lenitive Magmil 2T bid Ordinary meal Walking inside the ward Explain the discharge procedure Explain how to take drugs Re-education on discharge Instruct to take orally administered iron supplement when hemoglobin is below 8.0~10.0g/dl 322 여성건강간호학회지 12(4), 2006년 12월
자궁동맥색전술환자를위한표준진료지침개발 토에대한교육 을추가하였는데, 이러한교육이좀더구체적으로이루어진다면, 시술후통증에대한수용정도가높아지고, 불안감감소에도도움이되어진통제의추가사용이감소되고수면의질또한향상시킬수있으며, 이러한효과는활동의증진과식욕증진및변비예방에도도움이될수있을것으로사료되어추가하였다. 한편, 통증및 IV PCA 유지로인하여임상타당도검증대상 5례모두에서오심과구토증상을경험한것으로나타났는데, 그중 1례에서는시술후 2 일째에진토제가투여되었고, 1례에서는식욕감퇴가매우심하여식이섭취가 8 시간이상지연된것으로나타나감시/ 사정영역에 IV PCA 가유지되는시술후부터퇴원시까지 식욕사정 을추가하기로하였다. 그리고시술후 IV PCA 및유치도뇨관유지, 시술부위에 Sand bag 적용으로인하여 6시간동안시술한쪽의다리를구부리지않는자세를유지해야하고, 통증으로인하여활동이지연되는것과함께식이섭취또한지연되는등의이유로 2례에서변비가발생되어내과협의진료를통하여대변완화제를투여하였다. 따라서투약영역에시술후 2일째에 prn 으로 대변완화제 투여를추가하였다. 그리고시술전 혈색소 8.0~ 10.0g/dl이하 인대상자의경우퇴원후경구용철분제복용지시를교육 / 퇴원계획영역에추가하였다. 임상타당도검증후위와같은수정과정을거쳐최종 Critical Pathway 를개발하였다<Table 4>. 논 의 예비 Critical Pathway 개발을위하여자궁동맥색전술을받고퇴원한환자의의무기록지 25례를분석한결과대상자들의평균연령은 41.5세로 Cho(2004) 의연구에서자궁근종호발연령이 41.5(±4.23) 세인것과유사하였다. 본연구에서자궁동맥색전술평균시술시간은 2시간 40분으로 Park 등(1999) 의연구결과에서총시술시간이 1시간 30 분인것과차이를보였다. 본연구에서평균시술시간이 1시간이상이더소요된이유는의무기록지분석시시술시간적용시점을병실에서시술실로이동하는시점부터시술이끝나고다시병실로돌아온시점까지를총시술시간으로계산하였기때문인것으로사료된다. 그러나예비 Critical Pathway 의임상타당도검증과정에서 5례의대상자들로부터시술시간을시술시작시점부터끝나는시간까지로계산하여분석한결과 4례의경우는 Park 등(1999) 의연구결과에서보고된평균시간과유사하였다. 그러나 1례의경우총시술시간이 4시간 15분으로평균보다 2 시간이더소요되었는데, 이경우는자궁동맥혈관이상증으로카테터삽입시간이길어짐으로써시술시간이지연된이유에서였다. 예비 Critical Pathway에대한임상타당도를검증한결과평 균재원일수는 3.2 일이었다. 이결과는 Critical Pathway 개발대상의무기록지분석대상자들의재원일수 3.9일보다는 0.7 일감소하여 Park 등(1999) 과 Lee 등(2000) 의연구에서보고한평균재원일수 3 일과유사하였다. 그러나자궁적출술환자를대상으로 Critical Pathway를개발하여적용한 Noh와 Park (2000) 의연구에서의실험군의총재원일수 4.6일보다는 1.4 일이단축되었다. Park 등(1999) 은자궁동맥색전술은수술적방법에비해재원기간을단축할수있고, 사회활동을하고있는환자들의경우퇴원후 3일이내에사회에복귀할수있는장점이있다고보고하였다. 따라서자궁근종환자들에게자궁동맥색전술과함께 Critical Pathway를함께적용하게되면재원기간의단축및빠른사회복귀가가능함을확인할수있었다. 자궁동맥색전술후가장많은불편감은하복부통증인것으로보고되었다(Son, Sunwoo, Lee, & Ahn, 2000). 본연구에서도의무기록지 25례를조사한결과자궁동맥색전술후심한하복부통증이 25 례모두에서발생되었고, 25례중재원일수가 5일인것으로나타난대상자 4명중 1명은심한하복부통증으로퇴원이 2 일이나지연되었으며, 통증의강도가출산통보다더심한정도라고표현하였다. 특히의무기록지조사대상자 25례중 1례와임상타당도검증대상자 5례중 1례에서는자궁동맥의이상증이있었던사례로자궁의세동맥이그물망처럼얽혀있어색전술을시행할때카테터삽입에기술적인어려움이발생되어시술시간이 2 시간이상지연되었다. 그결과심한통증이유발되었으며, 시술후자가통증조절장치(PCA) 유지와함께다른진통제들이추가로투여되었음에도불구하고통증조절에어려움이있었다. 또한통증조절을위하여다량의진통제및수면제등을사용함으로써식욕감퇴와변비등의 2 차적인문제를초래한것으로나타났다. 따라서자궁동맥색전술대상자들에게가장중요한간호관리및중재요소는통증관리임을알수있었다. 특히자궁동맥이상증이있는것으로확인된대상자들의경우개발된 Critical Pathway를지속적으로적용을함으로써통증사정및통증관리를위한더구체화되고표준화된프로토콜의개발이필요할것으로사료된다. 본연구에서는의료제공자용 Critical Pathway 개발에만초점을두었으나환자와가족들이이해하기쉬운용어와내용그리고애니메이션이나삽화를삽입하여환자용 Critical Pathway를추가로개발ㆍ적용하여대상자들이치료과정을미리알게한다면, 과정을미리알지못하여발생하는불안감및의료진에대한불만을감소시켜환자만족도를증가시킬수있을것으로사료된다. 또한표준화된간호와의료행위를묶음코드로전산화하여처방전달체계 (OCS) 와전자의무기록 (EMR) 에저장관리함으로써의사의처방을즉시서면으로받 여성건강간호학회지 12(4), 2006년 12월 323
정경희 고영숙외 지못하여수행이지연되는것을예방할수있고, 의무기록에 소요되는시간을줄일수있으며, 의료진간의의사소통의촉 진과함께예측가능한업무수행으로직접간호시간의증대와업무효율화, 간호의질적향상이증대될것으로사료된다. 또한기록의누락과중복기록등이감소될것이며, 연구를위한통계자료로도유용하게활용가능할것이다. 연구의제한점 본연구에서개발된 Critical Pathway는 G시의일개종합병원을대상으로하였으므로연구결과를일반화하여확대적용하는데신중을기할필요가있다. 결론및제언 본연구는자궁동맥색전술환자를대상으로하여환자중심적이고질적이며, 비용효과적인 Critical Pathway 를개발하였다. 1 단계로개발할진단명/ 시술명을선정하고, 2단계는자궁동맥색전술환자관리에직접참여하는 7명의전문가집단으로개발팀을구성하였으며, 3단계로의무기록지조사를통하여환자들에게수행된전반적인의료서비스내용을분석하고, 이를토대로의료영역별행위의내용과시행기간을결정하였다. 4단계에서는전문가집단의내용타당도검증을거쳐예비 Critical Pathway 를작성하였고, 5단계에서는예비 Critical Pathway의실무적용가능성을확인하기위해자궁동맥색전술을시행한 5 명의환자를대상으로임상타당도를검증한후, 6 단계에서최종 Critical Pathway 를확정하였다. 구체적인연구결과는다음과같다. 의무기록지분석을통하여조사된의료내용을감시 / 사정, 처 치, 투약, 식이, 활동, 협의진료, 교육퇴원계획 / 등 7개영역 으로영역화하여이를 축은입원에서퇴원까지로정하였다. Critical Pathway 의종축으로하고, 횡 예비 Critical Pathway 작성을위한의무기록지 25례를분석 한결과평균재원일수는 3.9 일이었다. 전체 25례중 84% 가 재원일수 3~4일인것으로분석되어전문가집단의의견과문헌고찰결과를종합하여본연구에서의횡축의적용기간은총 3 일로정하였다. 7개영역의의료행위내용을 73문항의질문지로작성하여전 문가집단의내용타당도검증을실시한결과 86% 이상의 합의를보인 68 문항을채택하였고, 71% 이하의합의를보인 5문항은수정또는삭제하여예비 Critical Pathway를작성 하였다. 예비 Critical Pathway의임상타당도검증은 5주동안기준 에맞는환자 원일수는 5 명을대상으로실시하였다. 이들의평균재 3.2 일이었다. 임상타당도검증시차이를보인의 료행위내용중 3 문항은수정보완하고, 3문항은추가하여 자궁동맥색전술환자를위한최종 하였다. Critical Pathway를완성 본연구의결과를토대로다음과같이제언한다. Critical Pathway 의감시/ 사정영역의효과적인중재활동수행을위하여체계화된관찰및사정기록지의개발이필요하다. Critical Pathway를지속적으로실무에적용하여자궁동맥색 전술후주요불편감인통증관리에대한근거중심실무프로토콜을개발할것을제안한다. 개발된의료제공자용 Critical Pathway를일반인들이쉽게이해할수있는용어로바꾸어환자용 Critical Pathway를개발하여사용할것을제안한다. Critical Pathway 를지속적으로실무에적용하여재원일수, 병상가동률, 비용효과, 직접간호시간, 환자및직원만족도등질관리요소들에대한효과를측정해볼것을제안한다. References Cho, M. S. (2004). Clinical effect of levonorgestrel-releasing intrauterine system (Mirena) on uterine myoma and adenomyosis. Unpublished master's thesis. Chonnam University, Gwangju. Chung, K. H., Joo, J. L., & Chung, H. S. (2000). The effect of critical pathway on the patients with cesarean section. J Korean Acad Nurs, 6(2), 128-135. Coffey, R. J., Richards, J. S., Remmert, C. S., LeRoy, S. S., Schoville, R. R., & Baldwin, P. J. (1992). An Introduction to critical paths. Qual Manag Health Care, 1(1), 45-54. Goodwin, S. C., Vedantham, S., McLucas, B., Farno, A. E., & Perrella, R. (1997). Preliminary experience with uterine artery embolization for uterine fibroids. J Vasc Interv Radiol, 8(4), 517-26. Heaston, D. K. (1979). Transcatheter arterial embolization for control of persistent massive puerperal hemorrhage after bilateral surgical hypogastric artery ligation. AJR, 133, 152-154. Hwang, G., Shin, T. H., Lee, H. K., & Lee, H. J. (2003). Development and application of critical pathway for nasal bone fracture patients. J Korean Soc Qual Assur Health Care, 10(2), 154-163. Kim, J. Y. (2003). Clinical effects of uterine artery embolization and laparoscopic treatment of uterine myoma. Unpublished master's thesis, Yonsei University, Seoul. Kim, Y. S., Park, J. W., & Kim, K. W. (2000). The analysis of studies about critical pathway in domestic and abroad from 1995 to 1999. J Korean Soc Qual Assur Health Care, 7(2), 156-167. 324 여성건강간호학회지 12(4), 2006년 12월
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