客观结构化临床考试(OSCE)在麻醉科住院医师评估中的应用

目的针对麻醉学住院医师规范化培训的特点,建立客观结构化临床考试(OSCE)方案并予以实施,探寻评价麻醉学住院医师临床能力的新方案。方法设计OSCE站点(包括考核病例编写、标准化病人培训及各站点评分表编制等);组织2018年、2019年第3年住院医师进行OSCE;根据编制的评分表对住院医师的各站表现进行评分并对各站成绩进行比较。结果 OSCE共设置6个站点,分别为模拟口试、气管内插管术、椎管内麻醉穿刺术、深静脉置管术、心肺复苏术及麻醉访视,考试时间共70 min。共44名住院医师参加考试,平均成绩均合格。比较模拟口试、操作技能、麻醉访视3项成绩发现,住院医师的操作技能成绩显著高于模拟口试和麻醉访视成绩(P0.01),模拟口试显著低于麻醉访视成绩(P0.01)。3项成绩两两之间均存在中等程度的正相关关系。结论 OSCE能够多方面评价麻醉科住院医师的临床能力,是麻醉科住院医师临床能力考核的有效方式。     

术前访视对择期手术患者焦虑的影响

随着医学的不断发展,护理学从疾病的护理发展到以患者为中心的整体护理;通过术前访视,缓解了患者术前的不安和恐惧心理.同时可提高患者对手术室护理工作满意度,提高手术室护理质量.我院从2007年开始对手术患者进行术前访视,通过对300余名访视病人,仔细阅读病历,全面了解患者一般情况、术前诊断、手术名称及部位,根据不同病情、麻醉方式、患者的年龄、性别、文化程度、职业等,采取不同的交谈方式,使患者及家属能够明白和接受.     

手术室护士术前访视效果探讨

目的 探讨术前访视对手术病人及工作满意度的影响.方法 将80例择期行剖宫产手术病人随机分为访视组和未访视组,未访视组病人只常规发放手术须知,访视组病人在术前一日对其进行术前访视,对两组患者术日紧张度、血压和心率,及术后满意度进行调查、测评.结果 与未访视组比较,访视组患者的术前紧张度明显下降,术后满意度提高,差异具有统计学意义(P<0.05,P<0.01).结论 术前访视能有效减轻手术病人的紧张、焦虑情绪,增强患者战胜疾病的信心,提高手术质量满意度.     

浅谈术前访视在手术室整体护理中的重要性

目的 随着整体护理模式在全国各地大力推广,手术室的整体化护理也越来越显示了它独特的内涵,然而,人们大多更加关注手术中护理及术后随访,而术前访视往往被大家所忽视. 方法巡回护士在患者手术前一日下午到病房对患者进行访视,为了以病人的利益和需求为中心,保证整体护理模式在手术室得到全面广泛应用,由手术室护理人员在患者术前进行探访,让病人减轻恐惧,建立良好的信赖关系,收集到真实全面的病人心理社会的资料,从而使我们更好的开展工作.结果 通过手术前访视病人,护士可掌握患者的基本情况,缓解患者术前的焦虑恐惧心理,增强患者对手术的信心,同时也提高护理人员的观察能力以及专业知识水平,使患者能以轻松,愉快,充满信心的心情接受手术和治疗,与医务人员共同努力下达到最佳的健康状态.     

实施规范化术前访视质量管理的效果研究

目的 探讨术前访视规范化质量管理及实施效果.方法 成立术前访视质量控制管理小组,并对其进行访视技能培训,按规范化质量管理对术前患者进行访视,评估实施前、后访视效果.结果 保证了术前访视质量,解决了质量与效率产生的矛盾,提高了患者相关知识的掌握,手术配合率、医生满意度、访视单书写合格率、降低了并发症的发生.结论 实施规范化术前访视质量管理是一种科学、高效的管理模式,有利于提高访视质量.     

手术室护士实施术前访视及术后随访的探讨

探讨手术室护士在术前访视及术后随访中护患沟通存在的问题,来提高访视质量,防止和减少不良事件的发生。随着护理医学模式的转变,,术前访视及术后随访是手术室护士的一项重要的常规工作。手术室的护理工作不仅仅是配合手术医生完成手术,手术室护士到病房访视,进行面对面的沟通以交流,对患者进行心里疏导,帮助患者平稳安全的度过围手术期。我院手术室从2013年1月~2014年6月对2956例手术患者实施术前访视及术后随访后发现在工作中加强手术室专科护士的培训,教导手术室护士多学习法律知识。提高访视的质量。规范访视的流程,及时制定、修订实施相关的措施,使手术患者能够顺利的的进行手术,取得了良好的效果。     

外科住院医师规范化培训需求的调查分析及对策

目的调查外科住院医师规范化培训中临床技能及科研技能的教学需求,指导教学改革方向。方法采取自填式问卷调查法,于2018年7月集中开会形式,召集在培第二年和第三年的北京协和医院外科住院医师,在阶梯教室隔位就座,统一讲解填写方法与注意事项,学员们“背靠背”式不记名自行填写。到场收取问卷85份,有效问卷83份。主要调查了培训的临床诊疗与操作技能学习需求、科研技能学习需求两方面共5道多项选择题。结果临床技能方面需求最多的为外科常见病的诊疗和手术教学,其中手术教学较多需求是有更多的动手机会。科研技能方面主要需求是数据资料收集、统计学方法(Meta分析)、科研设计与立项、标书的书写与投标,论文的写作与发表。结论外科住院医师对常见病诊疗、临床动手操作能力、科研能力的欠缺。对此外科教研室提出了“导师制”“动物模型”“全要素模拟手术”“增加科研培训课程”等改革方案。     

手术患者术前访视需求和满意度调查分析

目的 了解手术病人的术前需求与病人对手术室术前访视的效果评价.方法 通过自制<术前访视问卷调查表>、<术后问卷调查表>,对300例择期手术患者进行术前和术后问卷调查,并进行了围手术期的全程护理.结果 与结论患者对术前访视需求率100%,对术前访视满意度达98%.提高手术室护士的素质和手术室护理质量,真正体现了"以人为本"的人性化护理服务模式,收到了良好的社会效益.     

术前访视对择期手术患者的心理影响

目的本文通过对择期手术患者术前访视的实施,与传统的只是医师与患者进行术前谈话效果对照,阐明了术前访视的实施.能够进一步促使护理人员掌握手术患者的心理变化,帮助患者做好自我心理调整,缓解各种心理疾病和社会因素的影响,使手术患者以最佳的心理状态,顺利度过手术期.方法将2009年1月～2009年6月我院160例择期手术患者,随机分成观察组和对照组,每组80例.观察组实施术前访视,对照组实施传统的只是医师与患者进行术前谈话.然后对其结果进行对照.结果发现实施术前访视后,手术患者存在的心理问题的百分率明显下降.结论术前访视能减轻择期手术患者的心理反应,效果显著,意义重大.     

术前访视及术后随访单的综合设计与应用

我院手术室于1999年开始使用术前访视、术后随访单,并不断完善和改进,通过这几年万例多择期手术病人的术前访视、术后随访,收到了较好效果。手术室护士走出手术室,直接与手术病人接触,在术前消除了病人对手术室陌生感,缓解了不安与恐惧,并帮助其维持最佳的手术状态。在术后及时看望他们,带去手术全体人员的祝福,有助于手术病人尽快康复,同时通过及时了解他们对整个手术服务的意见,亦有助于我们改进工作,提高手术室护理质量。     

基于网络的培训方式在北京市放射科住院医师规范化培训中的应用

目的探讨网络培训平台在北京市放射科住院医师规范化培训中的应用效果。方法在北京市住院医师规范化培训Ⅰ阶段考试前约1年的时间针对全体北京市放射科住院医师进行网络培训,对网络培训平台访问量、访问人数、观看时长及受众情况进行分析和整理,并对考生培训平台的使用情况调查问卷结果进行分析,问题包含考生是否喜欢网络培训方式及网络培训平台是否可补充日常工作的病例病种等。结果对视频课程及PPT课程,课程访问量明显多于访问人数(P<0.001),课程时长与平均实际观看时长相比,无差异。几乎所有的课程均可看到放射科以外的其他科室成员访问。学生普遍喜欢网络培训平台这一授课方式,认为培训平台提高了学习效率,对一阶段考试有所帮助。2018年北京市放射科住院医师规范化培训Ⅰ阶段考试成绩为平均分86分、通过率为87.8%,高于2017年考试成绩84.5分及通过率85.3%(p=0.380)。结论网络培训平台在放射科住院医师规范化培训中认可度较高,对考生通过Ⅰ阶段考试有所帮助,在今后的放射科住院医师规范化培训中可进行推广。     

独立值班考核制度在内科住院医师规范化培训中的应用

目的介绍北京协和医院内科创立的独立值班考核制度,分析该考核制度在住院医师独立值班能力评价和分层中的作用。方法对北京协和医院内科2017年和2018年内科住院医师独立值班考核的结果进行统计,分析不同来源的住院医师在考试次数、通过考试所需时间和通过率方面的分布。结果内科临床医学博士后、专业型临床硕士研究生和北京市基地规培住院医师在通过独立值班考核所需次数方面无差异;内科临床博士后通过考核用时最短,专业型临床硕士研究生次之,北京市规培住院医师用时最长(χ^2=96.27,P<0.05),可以进行初步分层;通过临床带教,大部分住院医师都能在实习6个月内通过独立值班考核,承担独立值班工作。结论在内科住院医师规范化培训中,独立值班考核制度能够客观评价住院医师的值班能力,最大限度的保证临床安全。北京市基地规培住院医师通过考核时间较长,应注意加强临床教学、提高学员能力。     

Anesthetist to patient transmission of hepatitis C virus associated with non exposure-prone procedures

A 44-year-old lady was diagnosed with acute hepatitis C virus (HCV) infection 8 weeks after hysterectomy at which the attending anesthetist was known to be hepatitis C seropositive. Comparative nucleotide sequence analysis and phylogenetic comparison proved that transmission had occurred from the anesthetist to the patient. The patient had received general anesthesia with endotracheal intubation and peripheral intravenous cannulation. No exposure-prone anesthetic procedures had been performed. This is the first case described in UK involving transmission from an anesthetist to a patient during anesthesia where no exposure prone procedures were carried out. It is the first example in which the anesthetist was known to be seropositive for hepatitis C prior to the operation.     

生物医学工程学仿真在麻醉模拟教学中的应用进展

目前医学院学生和住院医师培训的主要方法仍然是课堂教学、死记硬背地学习和师带徒式传承.虽然这些教学方法均能很好地传授知识,但在技能的培训、复杂病情的管理和团队的决策方面显然存在着难以克服的缺陷.生物医学工程学仿真技术在模拟教学中的应用可以部分弥补这一不足,在医学教学,包括麻醉学教学方面取得良好效果,已经成为教育的趋势,就此课题作一综述.     

Residents' ability to identify patients with poor literacy skills.

PURPOSE: To determine whether residents could identify patients with poor literacy skills based on clinical interactions during a continuity clinic visit. The authors hypothesized residents would overestimate patients' literacy abilities and fail to recognize many patients at risk for poor literacy. METHOD: The Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) was administered to screen patients for potential literacy problems. Residents were asked "Do you feel this patient has a literacy problem?" and answered yes or no. Continuity adjusted chi-square was used to test for overestimation of literacy abilities by residents. RESULTS: REALM-R scores and residents' evaluations of literacy were available for 182 patients. The residents believed 10% of patients (18) had literacy problems based on their clinical interactions. Only three patients passing the literacy screen were incorrectly identified as at risk for literacy. Of the 90% of patients (164) the residents perceived to have no literacy problem, 36% (59) failed the literacy screen. CONCLUSION: Resident physicians overestimated the literacy abilities of their patients. A significant portion of these residents' patients may not have the skills to effectively interact with the health care system and are at increased risk for adverse outcomes.     

Impact of the Training on the Compliance and Persistence of Weekly Bisphosphonate Treatment in Postmenopausal Osteoporosis: A Randomized Controlled Study

Long-term patient adherence to osteoporosis treatment is poor despite proven efficacy. In this study, we aimed to assess the impact of active patient training on treatment compliance and persistence in patients with postmenopausal osteoporosis. In the present national, multicenter, randomized controlled study, postmenopausal osteoporosis patients (45-75 years) who were on weekly bisphosphonate treatment were randomized to active training (AT) and passive training (PT) groups and followed-up by 4 visits after the initial visit at 3 months interval during 12 months of the treatment. Both groups received a bisphosphonate usage guide and osteoporosis training booklets. Additionally, AT group received four phone calls (at 2^nd, 5^th, 8^th, and 11^th months) and participated to four interactive social/training meetings held in groups of 10 patients (at 3^rd, 6^th, 9^th, and 12^th months). The primary evaluation criteria were self-reported persistence and compliance to the treatment and the secondary evaluation criteria was quality life of the patients assessed by 41-item Quality of Life European Foundation for Osteoporosis (QUALEFFO-41) questionnaire.. Of 448 patients (mean age 62.4±7.7 years), 226 were randomized to AT group and 222 were randomized to PT group. Among the study visits, the most common reason for not receiving treatment regularly was forgetfulness (54.9% for visit 2, 44.3% for visit 3, 51.6% for visit 4, and 43.8% for visit 5), the majority of the patients always used their drugs regularly on recommended days and dosages (63.8% for visit 2, 60.9% for visit 3, 72.1% for visit 4, and 70.8% for visit 5), and most of the patients were highly satisfied with the treatment (63.4% for visit 2, 68.9% for visit 3, 72.4% for visit 4, and 65.2% for visit 5) and wanted to continue to the treatment (96.5% for visit 2, 96.5% for visit 3, 96.9% for visit 4, and 94.4% for visit 5). QUALEFFO scores of the patients in visit 1 significantly improved in visit 5 (37.7±25.4 vs. 34.0±14.6, p<0.001); however, the difference was not significant between AT and PT groups both in visit 1 and visit 5. In conclusion, in addition to active training, passive training provided at the 1^st visit did not improve the persistence and compliance of the patients for bisphosphonate treatment.     

OSCE在北京市放射科住院医师规范化培训Ⅰ阶段技能考试中应用的评价

本研究对客观结构化临床考试(OSCE)在北京市放射科住院医师规范化培训Ⅰ阶段技能考试中的应用效果进行了评估。研究对象为2014年至2016年参加北京市Ⅰ阶段考试的放射科住院医师,研究考生的学历组成、不同学历考生的平均分及通过率、考生对考试的调查问卷反馈进行了评价。考生组成中本科学历比例逐渐增高,博士生及硕士生考试通过率高于本科生,考试平均分整体趋势为博士生考试平均分高于硕士生和本科生;OSCE这一概念在考生中普及率逐年升高,考生赞同普及这种考试形式,对于胜任力的概念在培训过程中有待推广,尤其要加强沟通能力培训,对于考试的流程普遍反映良好。放射科住院医师未来培训应该将培训内容与学历相结合;考生对OSCE这一形式接受度很高;在日常培训内容应围绕临床胜任力进行,并注重沟通能力的培训,要继续普及应用OSCE。     

Effects of metoclopramide and ranitidine on preoperative gastric contents in day-case surgery

This prospective, randomized, double-blinded study was performed to evaluate the effects of intravenous metoclopramide and ranitidine on preoperative gastric contents in outpatients receiving intravenous anesthesia for laparoscopic gynecologic surgery. Fifteen minutes before the induction of anesthesia, the Z-M group (n=20) received 50 mg ranitidine and 10 mg metoclopramide intravenously and the control group (n=20) received the same volume of normal saline. Before the surgery, a 14-F multiorifice nasogastric tube was inserted to aspirate the gastric contents of patients under sedation with propofol and midazolam. The mean pH values of the gastric fluid were 2.7 +/- 2.0 (SD) [median 1.6 (range: 1.2-7.2)] in the control group, and 6.1 +/- 1.9 [median 6.8 (range 1.4-7.8)] in the Z-M group. The mean aspirated volumes (mL) were 15.3 +/- 10.4 (SD) [median 11.0 (range: 5.0-44.0)] in the control group, and 6.9 +/- 10.0 (SD) [median 4.5 (range: 0-38.0)] in the Z-M group. There were significantly more high-risk (gastric fluid volumes > 25 mL and pH < 2.5) patients in the control group (4/20, 20%) than in the Z-M group (1/20, 5%). In conclusion, intravenous prophylactic ranitidine and metoclopramide may be an easy and useful method to decrease the volume while increasing the pH of gastric contents, and therefore may reduce the number of patients at risk for aspiration pneumonitis in ambulatory laparoscopic procedures who receive an anesthesia.     

Oral rehydration therapy for preoperative fluid and electrolyte management

Aim: Preoperative fluid and electrolyte management is usually performed by intravenous therapy. We investigated the safety and effectiveness of oral rehydration therapy (ORT) for preoperative fluid and electrolyte management of surgical patients.Methods: The study consisted of two studies, designed as a prospective observational study. In a pilot study, 20 surgical patients consumed 1000 mL of an oral rehydration solution (ORS) until 2 h before induction of general anesthesia. Parameters such as serum electrolyte concentrations, fractional excretion of sodium (FENa) as an index of renal blood flow, volume of esophageal-pharyngeal fluid and gastric fluid (EPGF), and patient satisfaction with ORT were assessed. In a follow-up study to assess the safety of ORT, 1078 surgical patients, who consumed ORS until 2 h before induction of general anesthesia, were assessed.Results: In the pilot study, water, electrolytes, and carbohydrate were effectively and safely supplied by ORT. The FENa value was increased at 2 h following ORT. The volume of EPGF collected following the induction of anesthesia was 5.3±5.6 mL. In the follow-up study, a small amount of vomiting occurred in one patient, and no aspiration occurred in the patients.Conclusion: These results suggest that ORT is a safe and effective therapy for the preoperative fluid and electrolyte management of selected surgical patients.     

Resultados de la aplicación de un curso taller de distocia de hombros utilizando simulación en el programa de residentado médico de Obstetricia y Ginecología de la Universidad Peruana Cayetano Heredia

Introduction and objectiveDespite there being risk factors, shoulder dystocia is unpredictable. For this reason, general practitioners, and especially gynaecology and obstetrics residents, should receive training using modern didactic strategies, such as simulation. The aim of the present study was to determine the level of satisfaction and the effect on clinical practice of the first shoulder dystocia workshop held between May and July 2016 for obstetric and gynaecological residents of the medical residency program of the Peruvian University Cayetano Heredia.MethodologyA cross-sectional study was carried out, using a questionnaire to assess the satisfaction and application in clinical practice, completed by gynaecology and obstetrics residents 3 to 5 months after having finished the course. The variables studied were: year of residence, hospital location, level of satisfaction of the quality of the course, clinical experience in shoulder dystocia, ability to resolve dystocia, manoeuvres used, course usefulness in resolving dystocia, and recommendation of the course to colleague, as well as at what public should it be aimed. Of the 33 resident physicians who attended the course, 5 of them completed the residency program and were excluded from the study. Of the 28 remaining doctors, 24 completed the questionnaire, of whom 9 were residents from the third year, and 15 from the second year.ResultsThe majority (79%) rated the course as excellent, and 21% as good. Episodes of shoulder dystocia were attended to by 18 residents (75%) in their clinical practice, and in 100% of cases they were able to resolve it using the manoeuvres they had learned in the course. The most used manoeuvres were those of McRoberts and Mazzanti. All of them (100%) believed that the course helped them resolve the dystocia, and would recommend it to other colleagues. When asked who should be recommended, they referred to undergraduate doctors, first-year residents in first place, second and third year residents, as well as general practitioners.ConclusionsThe level of satisfaction of the shoulder dystocia course for the resident physicians who attended it was good, and led to a change of behaviour in their clinical practice.