新型冠状病毒感染肺炎疫情期间综合医院门诊发热预检分诊管理实践

综合医院门诊严格落实所有进入门诊的患者进行发热预检分诊，对传染源的早期发现和早期隔离治疗、切断传播途径、保护易感人群至关重要，是传染病有效防控的基础。对门诊发热预检分诊工作从流程制度、人力资源、环境设施、知识培训、消毒防护、质控督查等实施全面管理，促进发热预检分诊质量和效率提升的同时也有利于疫情期间门诊整体医疗服务工作的有序开展。     

传染病定点医院新冠肺炎疫情期间发热门诊分区分级接诊策略

新冠肺炎疫情期间发热门诊是筛查疑似或确诊病例的的主战场,也是高危患者聚集的区域,如管理不到位,极易发生医院内传播,严重威胁患者和工作人员生命安全,因此发热门诊是医院管理防控工作的重点和难点。四川绵阳四○四医院采取分区分级接诊策略,对发热患者实行3级预检分诊;设置高危、普通、儿童发热门诊及湖北人员快速接诊中心;建立观察等待区等防控措施,有效避免了高危发热患者与普通发热患者及普通就诊患者的接触,阻断了病原体在医院内传播,有效控制新冠肺炎疫情。从2020-01-17以来接诊3 068名发热患者,患者和医务人员均无交叉感染。     

《新冠肺炎流行期间胸痛中心常态化运行专家共识》节选(一):自行来院患者的分诊、接诊

分诊:各单位应按照国家卫健委防疫要求,新型冠状病毒(2019-nCoV)感染的肺炎(以下简称新冠肺炎)流行期间应重新布局预检分诊台及发热门诊,预检分诊台应与胸痛中心分诊台分开。对所有疑似新冠肺炎合并胸痛的患者,首先判断患者生命体征是否稳定,如果生命体征不稳定,应判断是因胸痛引起还是因肺炎引起的可能性大,如果判断为肺炎引起,应立即送往发热门诊隔离病房进行后续抢救和治疗,并逐级上报;如因胸痛引起或暂时无法判断具体原因,建议立即在急诊科隔离区就地抢救,维持生命体征。     

甲型H1N1流感预分发热门诊护士防控要点初探

甲型H1N1流感是由变异后的新型甲型H1N1流感病毒所引起的急性呼吸道传染病。预防控制工作十分重要。我院于2009年5月4习设立了发热预检分诊点和初诊发热门诊,作为首批医疗救治定点医院的“哨点门诊”,护士实行24小时值班制,采取了积极的预防控制应对措施。现将防控要点作一介绍探讨。     

基层医疗集团体系下社区健康服务机构防控新型冠状病毒肺炎疫情实践

背景随着新型冠状病毒肺炎疫情的蔓延,社区成为疫情联防联控的第一线,社区健康服务机构是落实社区防控的重要实践者。目的探讨基层医疗集团体系下社区健康服务机构防控新型冠状病毒肺炎疫情的做法。方法某基层医疗集团现设置1家综合性医院(院本部),下设24家社康中心。2020-01-24疫情防控以来,24家社康中心与院本部开通了发热患者双向转诊路径,24家社康中心分别与21个社区工作站和警区组建21个“三位一体”工作小组,开展社区联防联控,加强发热患者管理,掌握疫区返深人员名单,实施居家医学隔离,发现异常情况及时转运至院本部。结果2020-01-24至2020-02-20,社康中心上转发热患者807例,接收下转发热患者226例。2020-02-01至2020-02-20,累计登记疫区返深人员8704人,累计入户随访27268人次,累计居家隔离10319人,累计解除隔离7412人,累计电话随访72997人次,累计发现确诊病例9例,转运密切接触者12例。结论社区健康服务机构通过加强预检分诊、管理来自疫区人员,在防控新型冠状病毒肺炎疫情中起到“早发现、早报告、早隔离”的网底作用,能够有效遏制疫情的扩散和蔓延。     

应用思维导图在急诊预检分诊岗位培训的应用和临床观察

目的探究急诊预检分诊岗位培训引入思维导图的应用效果观察。方法针对本院急诊科2016年12月-2017年12月科室内的64名分诊护士进行研究,按照随机数表法分为两组,研究组给予以思维导图为基础的岗位培训,参照组给予一般的培训,观察两组急诊护士的预检分诊效果。结果(1)对护士预检分诊的决策能力影响较大的有是否专职的预检分诊护士、是否进行过预检分诊培训、是否取得急诊相关证书、是否参加过病例讨论、病例讨论频率(T/F=7.79、7.82、9.93、11.97、15.42,P<0.05);(2)进行岗位培训后,两组护士的预检分诊能力得分显著高于培训前;而一般岗位培训与思维导图基础的急诊预诊分诊岗位培训后对比,研究组护士预检分诊能力总得分及各维度认知行为、直觉、经验及技术信心、评判性思维显著高于参照组,差异明显t=15.88、5.72、5.84、6.22、7.19,P<0.05。结论急诊预检分诊岗位培训应用思维导图能有效提高医护人员的决策能力,提高分诊时效。     

解读《全国流行性感冒防控工作方案(2020年版)》

为进一步做好2020-2021年流行季全国流行性感冒防控工作,国务院应对新型冠状病毒肺炎疫情联防联控机制综合组制定了《全国流行性感冒防控工作方案(2020年版)》(以下简称《方案》)。《方案》从加强工作统筹、密切部门协作、推进中西医协同、强化疫情监测预警及分析研判、推动秋冬季多病共防、鼓励重点人群流感疫苗接种、提高疫苗接种便利化、加强对重点机构及人群密集场所疫情防控、及时处置聚集性疫情、提高医务人员流感防治水平、严格预检分诊、全力做好救治工作、统筹做好中医药防治流感工作、做好院内感染控制、加强国际交流、狠抓防控工作落实、切实保障防治物资供应等17个方面,对全国流感防控工作提出更加精准、细致的要求。     

精细化管理在急诊非创伤性胸痛患者分诊中的效果评价

目的探讨精细化管理对急诊非创伤性胸痛患者的分诊效果以提高急诊预检分诊的准确率。方法采用精细化管理的分诊模式对我院以非创伤性胸痛为主诉的1230例急诊患者,实施统一分诊标准提前分诊,分送不同急诊区域进行诊疗,并与上一年度非精细化管理分诊模式的同类患者进行比较,观察诊疗效果。结果急诊非创伤性胸痛患者的分诊准确率由实施前的90.00%提高到96.42%,其中急性冠状动脉综合征、肺栓塞、主动脉夹层等高危胸痛的分诊检出率由实施前的83.07%提高到97.18%,差异有统计学意义(P0.05)。结论对非创伤性胸痛患者的分诊实施精细化管理,有利于提高急诊预检分诊的准确性及高危胸痛患者的分诊检出率,从而减少高危胸痛的漏诊以及对中、低危胸痛患者的过度医疗。     

发热门诊的护理管理

目的成立并完善发热门诊的管理,对待排的传染病病例进行隔离医学观察,控制传染病传播。方法从发热门诊的布局、分区、功能;护理人员管理;工作制度和工作流程管理及患者管理等方面阐述了发热门诊的管理现状。结果严格并完善发热门诊的管理,对传染病特排的病例进行隔离,医学观察是控制传染病传播的重要措施之一。结论发热门诊科的设立是防控SARS疫情等烈性传染病、控制传染源至关重要的环节。     

察布查尔县一起炭疽疫情处置及疫情分析

目的了解炭疽在新疆察布查尔锡伯自治县的流行情况、发生原因,为制定炭疽防控措施提供科学依据。方法核实2013年8月2日察布查尔县托布中心托海村报告的炭疽疫情信息,对报告的5例炭疽患者通过流行病学调查、采样检测、疫源地处置、疫情上报等方式进行处置。结果 5例疑似患者的血液样本涂片和病原分离鉴定,3例疑似皮肤炭疽患者的样本直接分离出炭疽杆菌,2例患者临床使用抗生素3天以上,未分离出炭疽杆菌。结论 5例疑似患者经流行病学史、个案调查和临床表现初步诊断为皮肤炭疽。     

Real-world evaluation of a computed tomography-first triage strategy for suspected Coronavirus disease 2019 in outpatients in Japan: An observational cohort study

The Coronavirus disease 2019 pandemic continues to spread worldwide. Because of the absence of reliable rapid diagnostic systems, patients with symptoms of Coronavirus disease 2019 are treated as suspected of the disease. Use of computed tomography findings in Coronavirus disease 2019 are expected to be a reasonable method for triaging patients, and computed tomography-first triage strategies have been proposed. However, clinical evaluation of a computed tomography-first triage protocol is lacking.The aim of this study is to investigate the real-world efficacy and limitations of a computed tomography-first triage strategy in patients with suspected Coronavirus disease 2019.This was a single-center cohort study evaluating outpatients with fever who received medical examination at Yokohama City University Hospital, prospectively registered between 9 February and 5 May 2020. We treated according to the computed tomography-first triage protocol. The primary outcome was efficacy of the computed tomography-first triage protocol for patients with fever in an outpatient clinic. Efficacy of the computed tomography-first triage protocol for outpatients with fever was evaluated using sensitivity, specificity, positive predictive value, and negative predictive value. We conducted additional analyses of the isolation time of feverish outpatients and final diagnoses.In total, 108 consecutive outpatients with fever were examined at our hospital. Using the computed tomography-first triage protocol, 48 (44.9%) patients were classified as suspected Coronavirus disease 2019. Nine patients (18.8%) in this group were positive for severe acute respiratory syndrome coronavirus 2 using polymerase chain reaction; no patients in the group considered less likely to have Coronavirus disease 2019 tested positive for the virus. The protocol significantly shortened the duration of isolation for the not-suspected versus the suspected group (70.5 vs 1037.0 minutes, P < .001).Our computed tomography-first triage protocol was acceptable for screening patients with suspected Coronavirus disease 2019. This protocol will be helpful for appropriate triage, especially in areas where polymerase chain reaction is inadequate.     

Triage clinics: a way forward in genitourinary medicine

Our objective was to evaluate the effectiveness of a nurse-led triage clinic in genitourinary medicine (GUM). A prospective study was made of 200 consecutive patients attending the triage clinic in the GUM Department, Portsmouth. These patients were seen by the triage nurse and treated according to clinic guidelines. The consultants reviewed the case notes to assess the appropriateness of management. During the 6-week study period, 3009 patients were seen in the department. Of the 200 patients seen in the triage clinic, 38 were referred to a doctor during the initial visit. One or more sexually transmitted or associated infections were found in 61 female and 58 male patients. Six female and 4 male patients were not treated according to the clinic guidelines. Given appropriate education and training and working within a supportive framework the nurse undertaking a triage role in GUM can provide a highly effective and high-quality service to patients.     

Computerized algorithm-directed triage in the emergency department

A retrospective audit was conducted evaluating the effectiveness of the computerized algorithm-directed triage at Brooke Army Medical Center. A total of 98,086 charts were reviewed. From this, 58,282 patients were given dispositions to our acute care clinic and the remainder to the emergency department. Of these, 733 patients (1.2%) were retriaged from the acute care clinic to the ED. Based on these data, we conclude that the computerized algorithm-directed triage, using minimally trained personnel, appears to be an effective system.     

Reliability of Subjective Fever in Triage of Adult Patients

Study objective: To determine whether a historical complaint of fever is predictive of fever on emergency department triage. Methods: We prospectively questioned 651 ambulatory adult patients in a military tertiary care emergency department as to whether they had fever before oral temperature was taken. Fever was defined as a temperature of 38°C (100.4°F) or greater. Results: Sensitivity and specificity were 83% (95% confidence interval [CI], 71% to 95%) and 83% (95% CI, 80% to 86%), respectively. The prevalence of objective fever was 6.4%, yielding positive and negative predictive values of 25% (95% CI, 18% to 32%) and 99% (95% CI, 93% to 100%), respectively. Overall accuracy was 83% (95% CI, 80% to 86%). Conclusion: In this study, outpatients were fairly accurate in predicting fever. However, in an outpatient population with a low overall prevalence of objective fever, the predictive value of a complaint of fever representing an objective fever remained low. Therefore the complaint of subjective fever should be interpreted with caution when it is used to support a given diagnosis in an ambulatory care setting. [Buckley RG, Conine M: Reliability of subjective fever in triage of adult patients. Ann Emerg Med June 1996;27:693-695.]     

Entitling the student doctor

Oscar Thompson, a third-year medical student on a shift in the emergency department, is eager to participate in as many procedures as possible. According to the triage nurse’s history, the next patient to be seen is a 58-year-old man who has had fever, headache, and neck stiffness. Anticipating his first lumbar puncture, Oscar approaches the room with enthusiasm. The nurse whispers that the patient is irritated and can’t wait to see the doctor. The student pauses, draws back the curtain, and says, “Hello, I’m Dr. Thompson, how can I help you today?”     

合肥市1例输入性卵形疟病例分析

目的　对合肥市1例输入性卵形疟病例进行流行病学调查和实验室诊断分析,为今后预防控制输入性疟疾提供参考依据。方法　对该例输入性卵形疟患者的流行病学史、诊疗经过等资料进行收集、整理和分析。结果　患者从非洲莫桑比克务工返乡,回国数月后因反复发热就医。快速诊断试纸条法（RDT）提示为非恶性疟原虫感染;镜检见被感染红细胞正常大小或略胀大、锯齿状不明显,大滋养体胞浆增多、形态不规则、基本无空泡。荧光定量PCR确诊该病例为卵形疟原虫感染。结论　临床医务人员应加强对有境外流行区生活及工作史人员的疟疾诊断意识,及时早期合理用药,防止疟疾疫情扩散。     

Refusing care to patients who present to an emergency department

In July 1988, our emergency department adopted a policy of refusing to treat patients in the ED if they failed to have what was considered an emergency condition. Screening examinations were performed by triage nurses to determine whether patients were eligible to be seen in the ED. Patients whose vital signs fell within specific categories and who had one of 50 minor chief complaints were refused care in the ED and referred to off-site clinics. The referral of these patients out of the ED after a screening examination falls within the scope of legislation governing ED care and transfer (federal COBRA, Cal SB-12, and Title 22) as determined by the University of California legal counsel. In the first six months of this new triage system, 4,186 patients were referred from the ED; this represented 19% of total ambulatory patients who presented to the triage area. Of the 4,186 patients refused care, 84% were referred to off-site nonuniversity clinics, and 15% were referred to a university-affiliated faculty-staffed clinic. Follow-up letters and telephone calls to their clinics identified no patients who needed retriage to an ED, and only 54 patients (1.3%) complained about their referral out of the ED. Only 42 patients returned to the ED within 48 hours of initial triage, and none had a deterioration of their condition. In conclusion, a selective triage system may be used to effectively decompress an ED, although further study is needed to identify potential rare adverse outcomes.     

Strategies for Optimizing Clinic Efficiency in a Community-Based Antiretroviral Treatment Programme in Uganda

We address a critical aspect of antiretroviral therapy (ART) scale-up: poor clinic organization leading to long waiting times and reduced patient retention. Using a before and after study design, time and motion studies and qualitative methods we evaluated the impact of triage and longer clinic appointment intervals (triage) on clinic efficiency in a community-based program in Uganda. We compared time waiting to see and time spent with providers for various patient categories and examined patient and provider satisfaction with the triage. Overall, median time spent at the clinic reduced from 206 to 83 min. Total median time waiting to see providers for stable-ART patients reduced from 102 to 20 min while that for patients undergoing ART preparation reduced 88–37 min. Improved patient flow, patient and provider satisfaction and reduced waiting times allowed for service delivery to more patients using the same staff following the implementation of triage.     

新型冠状病毒肺炎疫情下心血管外科疾病的诊治流程

2019年12月以来,湖北省武汉市陆续出现新型冠状病毒(2019-nCoV)感染病例,疫情持续蔓延至湖北省内乃至全国各地。新型冠状病毒肺炎(COVID-19)疫情,给心血管外科的临床诊疗工作带来了巨大挑战,门急诊需要加强对就诊患者特别是发热患者的筛查。疫情期间严格把握手术指征,推迟择期手术;急诊手术,术前完善术前准备的同时进行COVID-19标本留取,术中严密防护,术后隔离治疗,并严格开展手术消毒隔离措施。在住院患者中,积极排查发热及相关症状病例。通过制定相应流程,在心血管外科临床工作中提高警惕,规范操作,科学防治,阻断病毒传播,并发挥自身心肺重症治疗方面的优势,早日打赢这场疫情防控阻击战。