Clinical Effect of Nursing Based on the Kano Model in Emergency Multiple Injuries.

Multiple injury refers to the injury of two or more anatomical parts of the body caused by mechanical injury factors. Even if only one injury exists alone, it can endanger limbs or lives. Therefore, nursing plays an important role in its treatment. Here, we investigated the application and clinical effect of nursing based on the Kano model in emergency multiple injuries. A case-control study was designed, where 48 patients with multiple injuries in the emergency department were divided into the control group to perform routine care and 48 patients were divided into the study group to carry on nursing based on the Kano model. The first-aid indexes, success rate of rescue, inflammatory response indicators, satisfaction rate of nursing, incidence of adverse events, and prognosis were compared between the two groups. A monofactor analysis showed that the emergency response time, admission time, and emergency department rescue time were shorter in the study group than those in the control group, indicating a higher success rate of rescue with nursing based on the Kano model. For the immunity of patients, the scores of mental states and the serum levels of inflammatory factors were lower in the study group than those in the control group. In addition, the rate of nursing satisfaction and good prognosis in the study group was significantly higher than those in the control group, and the incidence of adverse events was significantly lower than that in the control group. These results indicated that nursing based on the Kano model in patients with emergency multiple injuries can reduce the body inflammatory reaction, reduce the risk of adverse events, improve the prognosis of patients, and obtain high patient satisfaction.

1. Introduction

Multiple injuries in the emergency department are acute and critical, which involve injury at two or more sites. It mostly occurs after traffic accidents. Due to its critical and complex condition and high fatality rate, multiple injuries have become a difficult research topic in the Department of Emergency Surgery [1, 2]. Effective nursing intervention during the treatment of multiple injuries in the emergency department is of great significance to promote a favorable outcome [3]. However, routine care procedures are formulated mostly based on the characteristics of common diseases. Therefore, the interventions are not systematic and targeted, which result in a low effective rate and low satisfaction rate of nursing in patients [4]. Patient satisfaction is the most intuitive and representative criterion for the quality evaluation of clinical nursing work; thus, it is important to implement targeted interventions based on the satisfaction [5]. Nursing based on the Kano model is to meet the needs of patients and to follow the progression of patient's conditions for better quality of service. The Kano model for nursing intuitively sorts the importance of nursing intervention items, summarizes the factors affecting nursing quality to implement corresponding interventions, improves the quality of nursing service and the efficiency of department operation, and meets the pathophysiological needs of patients to the greatest extent [6]. Xu has found that the nursing satisfaction and nursing quality in surgical emergency are significantly improved after the application of nursing based on the Kano model [6]. However, they often have varied conditions and need different treatment methods.

There is no systematic study on the application value of nursing based on the Kano model in the emergency department yet. Therefore, we aimed to investigate the application value of nursing based on the Kano model on multiple injuries in the emergency department. The clinical indexes mainly included first-aid indexes (emergency response time, admission time, and emergency department rescue time), the mental state, success rate of rescue, the inflammatory response indicators, the satisfaction rate of nursing, incidence of complications (fever, electrolyte imbalance, and infection), and prognosis.

2. Materials and Methods

2.1. Clinical Data

Clinical data of 96 patients with multiple injuries in the emergency department between January 2019 and December 2020 were randomized into the study group (received nursing based on the Kano model) and control group (received routine care) according to different nursing methods. Patients were eligible if they had a clear history of trauma, had an injury severity score ≥16 points, were aged equal to or older than 18 years and younger than 70 years, and were conscious and communicable. Patients were excluded if they had mental disease, coagulation dysfunction, metabolic or immune system diseases, or were admitted to the hospital within 12 h after injury. We obtained the approval of the ethics committee of Fuqing City Hospital Affiliated to Fujian Medical University, and informed consent was also collected.

2.2. Grouping and Nursing

The control group received routine care, including close monitoring of the patient's vital signs, identification of the injury site, and symptomatic treatments (maintenance of blood volume, rapid establishment of venous access, and wound hemostasis, etc.). Endotracheal intubation was adopted to keep airway unobstructed if necessary. Preoperative measures such as matched blood were prepared according to the patient's condition [7]. The study group received nursing based on the Kano model in addition to the routine care [8]. Nursing based on the Kano model includes M (must-be quality), O (one-dimensional quality), A (attractive quality), I (indifferent quality), R (reverse quality), and Q (answer to questions). Patients were evaluated according to the Kano model. See Table 1 for details.

Table 1

Evaluation according to the Kano model (N).

Item	M	O	A	I	R	Kano quality
Hospital environment
Timely response to patient calls	12	22	11	2	1	O
Professional literacy of medical workers	9	26	8	3	2	O
First aid equipment	22	14	8	1	3	M
Convenient channels for emergency surgery and payment	13	21	9	2	3	O
Clear emergency signs	24	14	7	2	1	M
Clean and tidy environment	26	14	6	1	1	M
Service attitude
Services such as sending warm water and ordering meals	6	14	22	1	5	A
Detailed explanation of the condition and precautions	8	10	27	1	2	A
Nursing skills
Proficient wound management knowledge and skills and timelyassessment of patient's conditions	11	22	10	3	2	O
Preoperative preparation
Proficient skills of needle insertion and blood collection	25	14	7	2	0	M
Active participation in the rescue of multiple injuries	9	22	13	3	1	O
Respect for patient's privacy	26	9	8	3	2	M
Respect for the informed consent right	18	20	7	2	1	O
Assistance in hospitalization procedures	9	25	9	3	2	O
Equipped with security cameras	7	10	26	1	4	A
Clear list of charges	23	13	8	2	2	M
Health education and discharge guidance	21	14	8	2	3	M
Advice on regular follow-up	6	14	24	2	2	A

Then, corresponding nursing services were given based on specific evaluation results. First, the ward environment was improved, including regular ventilation and cleaning. The emergency hardware, equipment, and other related facilities were also improved. Nurses in the emergency department were organized to have regular theoretical learning and skill training, so as to enhance their surgical and emergency professional knowledge, first aid ability, and related skills. Second, the nursing quality was improved from the perspective of one-dimensional quality. The overall quality and service quality, spiritual outlook, communication skills, and abilities in emergency situations of the medical workers were improved. The health education was enhanced (to explain hospitalization-related precautions in detail to reduce hospitalization risk). Patients were assisted for the hospitalization procedures by providing them with convenient channels to ensure the effectiveness of the corresponding work and avoid long wait. Third, the nursing quality was improved from the perspective of attractive quality. Interventions based on the individual conditions of each patient were given to meet the pathological, physical, and psychological needs of the patients. Due to the sudden onset of multiple injuries in the emergency department, patients were often unprepared (such as daily necessities) and also lack psychological preparation when they are admitted to the hospital. Therefore, the patients were assisted with the preparation of daily supplies during hospitalization, and they, as well as their families, were also given health education, psychological counseling, and soft music to relieve fear, nervousness, and anxiety.

2.3. Detection of Inflammatory Indexes

The levels of interleukin-6 (IL-6), C-reactive protein (CRP), and procalcitonin (PCT)) were detected before and after intervention in the two groups. The detections were performed by using ELISA after collecting 5 mL of blood and centrifuging the blood to obtain the supernatant. The detection strictly followed the kit instructions. The specific antibody globulin was diluted to the optimal concentration (1–10 μg/mL), then the sample was loaded, bathed in water at 37°C for 3 h, and washed 3 times, 5 min each time. Thereafter, each well was added with 0.2 mL antigen-containing to-be-detected sample, incubated at 37°C for 1 h, and washed 3 times, 5 min each time. Then, 0.2 mL of the enzyme-labeled specific antibody solution was added and incubated for 1 h. After washing again thrice, 0.2 mL of the substrate solution was added and incubated at room temperature for 30 min. Last, the terminator was added and the optical density was detected.

2.4. Outcome Measures

First, the first-aid indices of the two groups were recorded, including emergency response time, admission time, and emergency department rescue time. Second, the mental state was evaluated by the Self-Rating Depression Scale (SDS) and Self-Rating Anxiety scale (SAS), respectively. SDS scores of 53–62, 63–72, and ≥73 points suggested mild, moderate, and severe depression, respectively. SAS scores of 50–59, 60–69, and ≥69 points suggested mild, moderate, and severe anxiety, respectively [9]. Third, the success rate of rescue was collected. It was seen as success rescue if the vital signs were stable after corresponding treatment. The rescue success rate=the number of successfully rescued cases/total number of cases 100%. Fourth, the levels of interleukin-6 (IL-6), C-reactive protein (CRP), and procalcitonin (PCT)) were compared before and after intervention in the two groups. Fifth, the incidence of complication (fever, electrolyte imbalance, and infection) was compared. Sixth, the satisfaction rate of nursing was assessed using a self-developed survey questionnaire [10]. A score of ≥9, 7-8, and <7 points suggested great satisfaction, satisfaction, and dissatisfaction, respectively. Satisfaction rate of nursing=(cases of great satisfaction + cases of satisfaction)/total number of cases × 100%. Lastly, the prognostic effects of the two groups were compared. Follow-up was carried out 1 month after the first aid. The prognosis was assigned into three degrees: excellent (patients were cured, and the functions of limbs and organs recovered to normal), good (the functions of limbs and organs were basically restored), and poor (patients still had disorders in their limb and organ functions). The favorable rate of prognosis = cases of excellent prognosis + cases of good prognosis/total number of cases × 100%.

2.5. Statistical Methods

SPSS22.0 was used to analyze the data. GraphPad Prism 8.0 was adopted to plot the figures. Measurement data were described by (mean ± SD) and compared by t-test. Count data were described as frequency (n) and composition ratio (%) and analyzed by χ2 test. P < 0.05 suggests markedly significant.

3. Results

3.1. Baseline Data

There were no significant differences in terms of sex, age, basic disease (hypertension, diabetes mellitus, and cerebral infarction), and cause of injury between the study group and the control group (all P < 0.05, Table 2).

Table 2

Comparison of baseline data between the two groups.

Group	Study group (n = 48)	Control group (n = 48)	t/χ2	P
Sex (male/female, n)	31/17	34/14	0.429	0.513
Age (years)	45.9 ± 13.1	47.0 ± 11.9	0.431	0.668
Basic disease
Hypertension	13	11	0.222	0.637
Diabetes mellitus	9	13	0.944	0.331
Cerebral infarction	5	6	0.103	0.749
Cause of injury (n)			5.367	0.147
Blast injury	2	5
Knife wound from fight	10	11
Fall injury	14	12
Injury from traffic accident	19	16
Others	3	4

3.2. First-Aid Indexes

The emergency response time, admission time, and emergency department rescue time were all significantly shorter after nursing based on the Kano model (P < 0.001), which indicated that the application of nursing based on the Kano model can accelerate the treatment effect and shorten the rescue time (Figure 1).

Figure 1

First-aid indexes. (a) The emergency response time. (b) The admission time. (c) The emergency department rescue time. P < 0.001 vs. control group.

3.3. SDS and SAS Scores

The SDS and SAS scores at baseline were similar between the two groups (P < 0.05). After nursing, they were markedly decreased (P < 0.001). It is suggested that nursing based on the Kano model can reduce the state of anxiety and depression in patients with multiple injuries from the emergency department (Figure 2).

Figure 2

SDS and SAS scores. (a) SAS score. (b) SDS score. SDS: Self-Rating Depression Scale; SAS: Self-Rating Anxiety Scale. ###P < 0.001 vs. before intervention; P < 0.01 and P < 0.001 vs. control group.

3.4. Success Rate of Rescue

The success rate of rescue was markedly higher than the control patients (97.92 vs. 85.42%, P < 0.05). It is suggested that nursing based on the Kano model can improve the success rate of rescue in patients with multiple injuries from the emergency department. See Table 3.

Table 3

Success rate of rescue.

Group	n	Successful	Not successful	Success rate of rescue (%)
Study group	48	47	1	97.92
Control group	48	41	8	85.42
χ 2				4.909
P				0.027

3.5. Inflammatory Response Indicators

The serum levels of inflammatory factors were similar before intervention (P < 0.05). After nursing based on the Kano model, they were notably lower (P < 0.001). It is suggested that nursing based on the Kano model decreased the levels of inflammatory response in patients with multiple injuries from the emergency department (Table 4).

Table 4

Inflammatory response indicators (mean ± SD).

Group	n	IL-6 (pg/mL)		CRP (mg/L)		PCT (ng/mL)
		Before intervention	After intervention	Before intervention	After intervention	Before intervention	After intervention
Study group	48	81.82 ± 29.51	15.80 ± 5.33###	19.89 ± 5.59	3.14 ± 0.68###	3.93 ± 1.88	0.26 ± 0.07###
Control group	48	84.71 ± 33.13	26.79 ± 7.61###	21.14 ± 6.33	4.91 ± 1.10###	4.05 ± 2.04	0.41 ± 0.13###
t		0.451	8.195	1.025	9.483	0.300	7.039
P		0.653	<0.001	0.308	<0.001	0.765	<0.001

IL-6 : interleukin-6; CRP : C-reactive protein; PCT: procalcitonin. Compared with before intervention, P < 0.001

3.6. Incidence of Complications

The incidence of complications was lower after nursing based on the Kano model than traditional nursing (P < 0.05). Coagulation dysfunction and bedsore were not observed in this study. It is suggested that nursing based on the Kano model can shorten the emergency response time and reduce the risk of complications in patients with multiple injuries from the emergency department (Table 5).

Table 5

The incidence of complications (n, %).

Group	n	Fever	Electrolyte imbalance	Infection	Total incidence
Study group	48	1 (2.08)	1 (2.08)	0 (0.00)	2 (4.17)
Control group	48	3 (6.25)	3 (6.25)	2 (4.17)	8 (16.67)
χ 2					4.019
P					0.045

3.7. Satisfaction Rate of Nursing

The satisfaction rate of nursing of the study group was higher (P < 0.05). It is suggested that nursing based on the Kano model can enhance the nurse-patient communication and improve the satisfaction rate of nursing (Table 6).

Table 6

Satisfaction rate of nursing (n, %).

Group	n	Great satisfaction	Satisfaction	Dissatisfaction	Satisfaction rate
Study group	48	32 (66.67)	13 (27.08)	3 (6.25)	45 (93.75)
Control group	48	26 (54.17)	12 (25.00)	10 (20.83)	38 (79.17)
χ 2					4.360
P					0.037

3.8. Prognosis

The favorable prognosis rate of the study group was higher than that of the control group (P < 0.05, Table 7).

Table 7

Favorable prognosis rate (n, %).

Group	n	Excellent	Good	Poor	Favorable rate
Study group	48	21 (43.75)	23 (47.92)	4 (8.33)	44 (91.67)
Control group	48	15 (31.25)	22 (45.83)	11 (22.92)	37 (77.08)
χ 2					3.872
P					0.049

4. Discussion

Injury is a worldwide important cause of death. Surveys show that there are three peak death periods in injured patients in the emergency department. The first is a few minutes after the injury, accounting for about 50% of the casualties; the second is 6–8 hours after the injury, accounting for about 30% of the casualties; and the third is a few days or weeks after the injury, accounting for about 20% of the casualties [11,12]. Therefore, it is particularly important to take effective early measures in patients with multiple injuries in the emergency department.

However, the routine care of multiple injuries in the emergency department is mainly based on characteristics of the common diseases, focusing on the care for patients with severe diseases, barring enough interest to the psychological nation and character desires. So, the nursing measures are not targeted and systematic, resulting in unfavorable results and low satisfaction [13,14]. In recent years, with the popularization of the Kano model, nursing intervention based on the Kano model has been widely used in clinical practice. Nursing based on the Kano model is to analyze the needs of patients for nursing services, so as to improve the measures according to individual needs, provide high-quality nursing services, and obtain higher satisfaction [15,16]. The results of Nie showed that the quality of nursing service was significantly improved after patients received nursing based on the Kano model, showing a high satisfaction rate of 97.5% [17]. The research of Wang et al. showed that nursing based on the Kano model for patients with intracranial aneurysm rupture could effectively alleviate the negative emotions of patients, reduce the risk of complications, cure the symptoms faster, shorten the hospital stay, and improve patient satisfaction [18]. Our results suggested that, after intervention, the study group had shorter first-aid time, higher success rate of rescue, lower incidence of adverse events, and higher favorable prognosis rate than the control patients, which indicated that nursing based on the Kano model is not only suitable for acute and critical cases such as ruptured intracranial aneurysm but also can be applied to conditions in the emergency department. The possible reasons are as follows. Nursing based on the Kano model evaluates patient satisfaction about the quality of nursing service in the emergency department, clarifies the attributes of the service items, so as to provide patients targeted and effective nursing services, ensures the quality of nursing measures, and helps patients to have a favorable outcome [19-22].

Our results suggested that, after intervention, the study group had lower SDS and SAS scores than before intervention and higher satisfaction rate of nursing than control patients, suggesting that the nursing based on the Kano model can also alleviate the negative emotions and improve nursing satisfaction rate. The possible reasons are as follows. This study uses innovative tools to clarify the factors affecting the quality of nursing service in the emergency department, analyzes the needs of patients and understands the important and prioritized items that patients value, so as to continuously improve the quality of nursing service, meets the various needs of patients, alleviates their negative emotions, and improves the patients' recognition of nursing work [23]. In addition, inflammatory factors are commonly used for the evaluation of clinical inflammatory stress response [24-26]. Their contents are low in serum under normal physiological conditions, but if there is physical or mental stress, the levels can have abnormal increase. In this study, the levels of inflammatory factors in the study group were lower, indicating that nursing based on the Kano model can effectively alleviate the inflammatory response. The possible reasons are as follows. This nursing model fundamentally improves the quality of nursing work, ensures effective early treatment for patients, establishes a good nurse-patient relationship, relieves patients' negative emotions, and avoids nurse-patient disputes; thus, the degree of inflammatory reactions was reduced.

However, this study still has some limitations. The observation and research time was relatively short. Therefore, whether nursing based on the Kano model can improve the long-term prognosis still needs to be further explored.

5. Conclusion

In conclusion, nursing based on the Kano model for patients with multiple injuries in the emergency department can shorten the emergency response time, relieve patients' negative emotions, reduce the body's inflammatory response, improve the success rate of rescue, decrease the risk of adverse events, improve the prognosis in patients, and receive higher satisfaction rate from the patients. Nursing based on the Kano model plays an important role in promoting the prognosis of patients with multiple injuries in the emergency department, which is worthy of extensive application in Chinese hospitals.