糖尿病足患者三级甲等医院专业诊疗中心就诊前的诊治状况及影响因素分析

背景与目的:糖尿病足(DF)是糖尿病患者致残、致死的主要原因之一,而早期诊断和规范治疗不仅可提高疗效、促进溃疡愈合,也是保肢和节省医疗费用的有效途径。本研究探讨DF患者在具有专业DF多学科诊疗团队的三级甲等医院就诊前的诊治现状及相关因素,为DF的规范化诊疗提供相关依据。方法:于2017年10月-11月期间,采用随机整群抽样法,抽取湖南、浙江、上海、四川、广东、河北、黑龙江、澳门的13家具有专业DF诊疗中心的三级甲等医院共326例Wagner 1~5级DF患者行问卷调查与足部检查,以患者就诊于三级甲等医院前伤口清洗液的选择和伤口用药情况为指标评估治疗的规范性,分析可能影响其治疗规范性的因素。结果:在326例DF患者中,误诊率为25.8%,治疗不规范率为72.7%。单因素分析结果显示,患者治疗的规范性与清创人、就诊医院级别、敷料应用人、院前诊治地点、并发症个数和清创地点有关(均P<0.05);Logistic多元回归分析结果表明,医院分级和敷料应用人是DF治疗规范率的独立影响因素(均P<0.05),其中三级医院DF治疗规范率是一级医院的6.707倍,且明显优于二级医院,敷料应用人为伤口/造口治疗师的DF治疗规范率是敷料应用人为患者本人的24.117倍,且明显优于敷料应用人为医生和护士。结论:DF患者在进入具有专业DF多学科诊疗团队的三级甲等医院前存在较多的误诊和治疗不规范的现象。因此,需进一步加强对基层医院医务人员DF多学科规范化诊治的培训,尤其应重视伤口/造口治疗师的培养;完善基层医疗机构和三级医院DF患者双向转诊的标准;鼓励患者主动就医,以减少误诊和不规范诊治现象的发生。

Current situation of diagnosis and treatment of diabetic foot patients before entering grade A tertiary hospitals with specialized services and the influential factors

Background and Aims:Diabetic foot(DF)is one of the major causes of disability and death among patients with diabetes.Early diagnosis and standardized treatment of DF can not only increase the efficacy of treatment and accelerate ulcer healing,but also are the effective means for limb salvage and reducing medical costs.This study was conducted to investigate the current status of diagnosis and treatment of DF and the associated factors for the DF patients before referral to a grade A tertiary hospital with specialized multidisciplinary team for dealing with DF,so as to provide the relevant basis for the standardized diagnosis and treatment of this condition.Methods:Using a random cluster sampling method design,a total of 326 patients with Wagner’s grade 1-5 DF were selected during October to November 2017 from 13 grade A tertiary hospitals with specialized DF treatment center in Hunan,Zhejiang,Shanghai,Sichuan,Guangdong,Hebei,Heilongjiang and Macao,respectively,on whom,the questionnaire survey and foot examination were performed.The selection of wound cleaning fluid and the type of wound medication were used as the assessment criteria to evaluate the normalization of treatment before admission to grade A tertiary hospitals,and the factors that affect the standardization of treatment were analyzed.Results:Among the 236 DF patients,the misdiagnosis rate was 22.7%,and the rate of non-standard treatment was 72.7%.The results of univariate analysis showed that the degree of treatment standardization was significantly related to the person who performed the debridement,the level of the hospital where the patients were admitted,the person who changed the dressing,the location of the prehospital diagnosis and treatment,the number of complications and the site where the debridement was performed(all P<0.05).The results of Logistic regression analysis revealed that the hospital level and wound dressing person were independent influential factors for the standard treatment rate of DF(both P<0.05),in which,the standard treatment rate of DF in tertiary hospital was 6.707 times higher than that in primary hospital,and was also significantly better than that in secondary hospital;the standard treatment rate of DF with wound dressing performed by wound/ostomy therapists was 24.117 times higher than that performed by patient’s patients themselves,and was also superior to those performed by doctors and nurses.Conclusion:There are many misdiagnosis and non-standard treatment in DF patients before entering a grade A tertiary hospital with a specialized multidisciplinary team for DF.Therefore,the training on the standardized diagnosis and treatment of DF among medical staff in primary hospitals should be further strengthened and particularly,more attention should be paid to the training of the wound/ostomy therapists;the two-way referral system for DF patients in primary medical institutions and tertiary hospitals should be improved;the patients should be encouraged to seek medical assistance to reduce the occurrence of misdiagnosis and non-standard diagnosis and treatment.