Construction of Pulmonary Embolism Prediction, Early Warning, and Precontrol MDT Collaborative Nursing Model Based on the Smith Model.

The purpose of this study was to construct a multidisciplinary collaborative nursing model for pulmonary embolism risk prediction, early warning, and precontrol based on the Smith model and evaluate the application effect and hospitalization satisfaction. 2,037 patients hospitalized in the thoracic surgery department from June 1, 2019, to May 31, 2021, were selected as the research subjects. The control group received routine pulmonary embolism prevention management, while the experimental group received safe, case-based, and programmatic multidisciplinary intervention management based on the Smith policy management model. The data were analyzed statistically. The experimental group's extubation and hospitalization time, D-dimer value, incidence of deep vein thrombosis, and pulmonary embolism on the seventh day after surgery were lower than those in the control group, and the satisfaction of hospitalization in the experimental group was higher than that in the control group. The implementation of the multidisciplinary collaborative nursing model of pulmonary embolism risk prediction, early warning, and precontrol based on the Smith model can promote the preventive effect of pulmonary embolism risk of surgical patients in our department and effectively improve the satisfaction of hospitalization, which is worthy for further promotion.

1. Introduction

Pulmonary embolism (PE) is a disease or pathophysiological syndrome caused by pulmonary circulation disorder caused by various endogenous or exogenous emboli blocking the main or branch of the pulmonary artery [1]. PE ranks the third most common cause of death from cardiovascular disease in the world [2] and ranks second among the early causes of death after thoracic surgery [3]. The main reason for the high fatality rate of PE is patients' insidious and complicated symptoms. 85% of acute pulmonary embolism (APE) is secondary to deep vein thrombosis (DVT), and only 30% to 50% of patients has been diagnosed [4], which also shows that patients with pulmonary embolism are prone to misdiagnosis. The 2018 Guidelines for the Diagnosis, Treatment, and Prevention of Pulmonary Thromboembolism in China [5] and the European Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism in 2019 [6] recommend multidisciplinary cooperation and step-by-step diagnosis of pulmonary embolism. Multidisciplinary team (MDT) refers to a medical service team that provides diagnosis, treatment, care, and rehabilitation for patients with the help of multidisciplinary knowledge, technology, and equipment [7]. This study intended to construct an MDT nursing model for PE risk prediction, early warning, and precontrol in thoracic surgery based on the Smith model [8] to achieve dynamic step-by-step management of PE risk patients to promote the prevention and treatment of thrombotic diseases. The results are satisfactory. The report is as follows.

2. Material and Methods

2.1. Normal Information

Patients who underwent thoracic surgery in our hospital from June 2019 to May 2021 and were hospitalized for thoracic surgery were selected as the research subjects. Among them, 1015 patients treated from June 2019 to May 2020 were set as the control group, with 523 males and 492 females, aged 41-78 (57.76 ± 6.12) years, 823 cases of adenocarcinoma, 134 cases of squamous cell carcinoma, and 58 other cases. The 1022 patients from June 2020 to May 2021 were set as the experimental group, with 516 males and 506 females, aged 43-77 years, 817 cases of adenocarcinoma, 144 cases of squamous cell carcinoma, and 61 other cases example. The gender, age, pathological results, and other general data of the two groups of patients were compared, and there was no significant difference (P > 0.05), which was comparable.

The inclusion criteria are as follows: patients with lung cancer, those who meet the indications for surgery and who are admitted to the thoracic surgery department after CT and clinical signs and who plan to undergo thoracoscopy for elective lung cancer surgery, those aged ≥18 years; those who have no contraindications to surgery or anesthesia, and signed informed consent for a surgery book writer. The exclusion criteria are as follows: patients with metastatic lung tumors, patients diagnosed with venous thrombosis in the past six months before admission, patients with coagulation dysfunction, patients with bleeding tendency, patients with NYHA grade > 3, patients with other systemic diseases or organic lesions, those who have contraindications to treatment, those who have incomplete case data, and those who are unwilling to be investigated.

2.2. Intervention Methods

Both groups of patients underwent thoracoscopic radical resection of lung cancer with general anesthesia and one-lung ventilation during the operation.

2.2.1. Control Group

Patients were routinely given perioperative thrombus prevention education, through face-to-face education, publicity posters, perioperative PE management manuals, small videos, WeChat push, and other channels before surgery to enhance the importance of patients and their families on thrombotic diseases, prevent patients from hypothermia during surgery, and return to the ward after surgery. Nurses closely observe the condition, teach the family members to manage the patient's position and chest tube, and guide the patient to perform ankle pump exercises in bed, get out of bed as soon as possible, drink plenty of water, and prevent constipation. The nurses performed anticoagulation therapy on the patients as prescribed by the doctor and used the D-dimer test results combined with the YEARS score table [9] to assess the risk of PE for the patients. The D-dimer blood test was performed. The patients were instructed to perform a color Doppler examination of both lower extremities before and seven days after the operation and complete the hospital satisfaction questionnaire at discharge.

2.2.2. Experimental Group

The experimental group constructed a nurse-led multidisciplinary collaborative team of pulmonary embolism risk prediction, early warning, and control based on the Smith model based on the control group. Proposed (see Figure 1). In this study, the MDT was led by the head nurse of thoracic surgery and the responsible nurses in each group and cooperated with thoracic surgeons, cardiologists, radiologists, anesthesiologists, rehabilitation specialists, and psychotherapists and had a clear division of labor: the decision-making layer was made by the director of the nursing department, the director of thoracic surgery, and the director of cardiology; the implementation layer is in charge of thoracic surgeons and nurses, and the security layer is in charge of other specialists. By perfecting the four elements of “ideal policy plan, implementing agencies, target groups, and environmental factors” in the implementation of the Smith model, MDT makes targeted deployment of positive or negative feedback information in policy implementation, thereby improving pulmonary embolism. Execution efficiency of forecasting, early warning, and preventive control policies.

Figure 1

Model of policy implementation process.

(1) Simplified PE Prediction Method. All surgical patients were screened by the D-dimer test combined with the YEARS score table. The YEARS score table includes three items of clinical manifestations of DVT, hemoptysis, and PE which are the most likely diagnoses, and the evaluation results are divided into four cases of treatment: (1) 0 YEARS items, D − dimer < 1.0 mg/ml can exclude PE; (2) 0 YEARS items, D − dimer ≥ 1.0 mg/ml, CTPA is required; (3) ≥1 YEARS item, D − dimer < 0.5 mg/ml can exclude PE; and (4) ≥1 YEARS item, D − dimer ≥ 0.5 mg/ml, CTPA is required. MDT made bedside warning signs for patients who needed CTPA examination and identified patients with suspected PE.

(2) Personalized PE Early Warning Method. MDT conducts multidisciplinary consultations for patients with suspected PE. By referring to the hospital work manual, MDT revised the job responsibilities of each specialty and improved the multidisciplinary consultation process for suspected PE patients. MDT implements a multidisciplinary “four commons” of medical and nursing integrated work system, that is, joint rounds, joint assessment, joint implementation, and joint evaluation of surgical patients suspected of PE; MDT jointly formulates personalized anticoagulation for PE prevention and treatment for each suspected PE patient management; MDT jointly guides medical staff in the department to improve their ability to solve clinical problems; MDT organizes special cases into the PE patient treatment database, to find more relevant indicators for diagnosing PE, judging the condition, and predicting prognosis.

(3) Swift PE Precontrol Method. MDT established nurses as the first responder multidisciplinary PE rapid response emergency team. If a patient with a suspected PE logo has emergencies such as dyspnea, cough, shortness of breath, syncope, and palpitations, the nurses in the department quickly contact the MDT team members and collect the patient's age, gender, cancer type, medical history, heart rate, blood pressure, breathing, mental health status, blood oxygen saturation, and other clinical indicators; the main focus is the stability of the patient's cardiopulmonary function, contraindications to intervention, hemodynamic status, etc. MDT expert members hold multidisciplinary network conferences through the Internet, and participants can obtain the patient's test results and imaging data in real-time through the Internet. MDT members quickly discuss the diagnosis and treatment plan according to the patient's clinical manifestations, disease changes, comorbidities, etc. This process usually requires the participation of 8 to 10 experts and takes 15 to 20 minutes. After reaching a consensus, the doctors and nurses in the department will implement it. The clinical nurse is responsible for dynamic monitoring of the patient's condition.

2.3. Evaluation Method

Occurrence of pulmonary embolism and related indicators is as follows: (1) clinical efficacy: including extubation time, hospitalization time, and D-dimer test results before and seven days after surgery; (2) lower extremity color ultrasound examination results, DVT, and PE occurrence; and (3) hospitalization satisfaction survey: a self-made satisfaction survey was used to distribute to patients and their families when they were discharged from the hospital. The content included health education, technical level, service attitude, medical and nursing integration, and 20 multiple-choice questions, each with 5 points and a total score of 100 points, <60 points for dissatisfaction, 60-80 points for basic satisfaction, and ≥80 points for satisfaction, satisfaction (%) = (number of satisfied cases + number of basic satisfied cases)/total number of cases × 100%.

2.4. Statistical Methods

SPSS 25.0 software was used for data analysis, measurement data were expressed as mean ± standard deviation (x ± s), a t-test was conducted, count data was expressed as [n(%)], χ2 test was conducted, and the test level was α = 0.05. P < 0.05 was considered statistically significant.

2.4.1. Three Results

Comparison of clinical efficacy between the two groups, the extubation time, hospital stay, and D-dimer test results on the seventh day after surgery in the experimental group were better than those in the control group. The differences were statistically significant, as shown in Table 1

Table 1

Comparison of clinical efficacy between the two groups of patients (cases (%)).

Clinical information	Control group	Test group	t value	P value
Extubation time (h)	83.1 ± 7.9	78.4 ± 6.2	30.464	<0.01
Length of hospital stay (d)	7.3 ± 0.6	6.5 ± 0.8	25.543	<0.01
Preoperative D-dimer (μg/ml)	225.63 ± 56.38	223.43 ± 60.21	0.851	>0.05
D-dimer on postoperative day 7 (μg/ml)	501.32 ± 98.65	420.54 ± 41.65	24.046	<0.01

Note: P < 0.05 represents statistical difference.

The occurrence of DVT and PE in the experimental group was better than that in the control group, and the difference was statistically significant, as shown in Table 2

Table 2

Comparison of the results of color ultrasound examination of the lower extremities and the occurrence of DVT and PE between the two groups (cases (%)).

Group	Number of cases	Color ultrasound of lower limbs		DVT occurs	PE occurs
		Have	None
Control group	1015	61	954	61 (6.01)	35 (3.45)
Test group	1022	15	1007	15 (1.48)	3 (0.29)
χ 2 value				29.251	27.685
P value				<0.01	<0.01

Note: P < 0.05 represents statistical difference.

The satisfaction survey results of patients in the experimental group at discharge were better than those in the control group, and the difference was statistically significant, as shown in Table 3

Table 3

Comparison of patient satisfaction survey results between the two groups (cases (%)).

Group	Number of cases	Very satisfied	Satisfied	Dissatisfied	Satisfaction (%)
Control group	1015	365 (35.96)	495 (48.77)	155 (15.27)	84.73
Test group	1022	552 (54.01)	453 (44.32)	17 (1.66)	98.34
χ 2 value					121.971
P value					<0.01

Note: P < 0.05 represents statistical difference.

3. Discussion

In global cancer, lung cancer morbidity and mortality rank first [10]. In recent years, the incidence of lung cancer in China has been increasing continuously, with an average annual growth rate of 1.63% [11]. Tumor factors and surgical factors are essential factors for PE in lung cancer patients. Li et al. [12] conducted a Meta-analysis of 41 research results and showed that the total incidence of lung cancer-related PE was 3.7%. PE was missed and misdiagnosed due to its nonspecific clinical manifestations. At present, the diagnosis of fatal PE is only 1/3 [13], and the 30-day mortality of untreated PE is about 30% [14]. However, studies have shown [15] that aggressive treatment can reduce the 30-day mortality of PE to 4%. The 1-year mortality rate dropped to 13%, making PE one of the leading causes of preventable disease. Therefore, this study's dynamic step-by-step diagnosis and treatment of pulmonary embolism risk prediction, early warning, and precontrol based on the Smith model to form a multidisciplinary team are of great practical significance.

By integrating multidisciplinary medical resources, MDT can effectively prevent the occurrence of undertreatment, overtreatment, repeated treatment, and ineffective treatment while saving time and economic costs [16]. In the Smith model [17], there is a cyclic relationship between policy formulation and implementation. In this study, in the MDT policy formulation model, the four elements of implementing agency, target group, environment, and idealized policy are closely linked so that MDT forms effective interaction with surgical patients, obtains feedback information, and continuously improves the policy content, so that the implementation model changes from tense to coordination to stability and strives to achieve an idealized policy.

We invited multidisciplinary thrombosis prevention experts to develop a simplified PE prediction method, a personalized PE early warning method, and a rapid PE precontrol method, which have the following benefits: (1) the use of the D-dimer test results combined with the YEARS score table for PE prediction is a simple, safe, and effective clinical decision-making method, which has fewer evaluation items and is easier to remember, and is more suitable for clinical promotion [18]. Using an adjusted D-dimer positive threshold, the simplified PE prediction method reduces unnecessary CTPA examinations in more patients. CTPA examinations are the gold standard for PE diagnosis. However, suppose CTPA examinations are performed on all suspected PE patients. In that case, It will not only cause excessive exposure of patients to the radiation environment but also lead to the waste of medical resources and an increase in medical expenses [19]. (2) The multidisciplinary personalized PE early warning method means that when encountering complex cases in actual work, the nurses pass the timely diagnosis. Maintaining communication with various experts, nurses continue to improve their professional quality and ability under the guidance of experts and better provide nutrition, exercise, and psychological and hemodynamic monitoring services for patients undergoing perioperative thoracic surgery, which can maximize and improve the patient's ability to live activities and quality of life [20]. (3) The rapid PE precontrol method is a comprehensive emergency service including 24-hour emergency, imaging, ultrasound, and surgery provided by a multidisciplinary expert team for acute PE patients [21]. It can help to collect more reliable PE diagnoses and treatments. In this study, the experimental group adopted the MDT to prevent and treat pulmonary embolism based on the Smith model, and the postoperative extubation time, hospitalization time, and D-dimer test results on the seventh day were better than those of the control group. The occurrence of DVT and PE was slightly different. Improvement is as follows: patients are more satisfied when discharged from the hospital, which has better clinical promotion significance.

4. Summary

Lung cancer is the disease with the highest morbidity and mortality in the world. Tumors and surgery are also important causes of sudden PE in patients. Once PE occurs, it will increase the difficulty of clinical treatment and nursing and increase hospitalization time and hospitalization costs for patients. Based on the Smith policy management model, this study constructed an MDT collaborative nursing model for PE risk prediction, early warning, and precontrol in thoracic surgery by mobilizing multidisciplinary forces. However, this study was only carried out in patients undergoing thoracic surgery, and the scale of multidisciplinary cooperation was small. In the future, it is still necessary to continue strengthening to build an extensive DVT and PE dynamic prevention and control management system in the hospital and strive to achieve PE in high-risk departments in the hospital. Homogeneous management.