危重病人床边评估指引在ICU中的应用

[目的]探讨危重病人床边评估指引在重症监护病房(ICU)中的应用效果.[方法]制订危重病人床边评估指引,规范护士对危重病人的评估顺序,掌握评估时机,提高护理体检技能.[结果]实施危重病人床边评估指引2年后,护理文书书写合格率、基础护理合格率、危重病人抢救成功率明显提高,不良事件发生率明显降低.[结论]应用危重病人床边评估指引可有效提高ICU临床护理质量.     

校正MEWS评分在急危重病人筛选中的应用研究

目的：探讨校正MEWS评分在危重病人筛选中的应用效果。方法：将2012年7月至2012年12月来急诊就诊的患者随机分为对照组和实验组,分别按常规方法筛选和处理危重病人;实验组在患者来急诊就诊时应用校正MEWS评分表对患者进行危重病人的筛选和风险评估,并按病情分级指引进行相应的干预措施。结果：使用校正MEWS评分筛选急危重病人快捷、准确,提高了医生对护理人员的满意度、患者和家属对护理工作的满意度。结论：校正MEWS评分将病人病情分值化,使医护人员在筛选病人时依据更充分,具有识别潜在危重病人的作用。使危重病人能及时得到优先救治,保证了病人的安全,值得在筛选危重病人中推广应用。     

急危重病人家属需求的研究现状

急危重病人住入监护室 ,其家属因焦虑和压力会产生多种需求 ,如果得不到合理满足会影响病人及家属的应对和调适。本文回顾了急危重病人家属需求的概念、来源、家属对需求的认知以及与护士对急危重病人家属需求认知的比较、需求的满足与满意度、影响需求的相关因素的研究现状 ,借以为临床急重症病人及家庭的护理提供一定的借鉴和依据。     

有创动脉测压在急危重病人监测中的应用

目的：评价有创动脉测压对急危重病人进行监护的可行性和可靠性。方法：选择103例急危重患者进行直接动脉穿刺，连接弹簧压力表或压力换能器进行血压监测，并根据监测指导麻醉和治疗。结果：103例患者都顺利接受和成功完成有创动脉监测，其中穿刺桡动脉82例，足背动脉15例，肱动脉6例，全部患者都在有创动脉测压监测下维持循环稳定。结论：在急危重患者中进行有创动脉测压能及时、准确、可靠和连续地反映患者的血流动力学状况并能指导治疗。     

《急危重病人交接单》在急诊科护理风险管理中的应用

[目的]在急危重病人院内转运中应用《急危重病人交接单》,以减少意外事故,保障病人安全,降低和防止医疗纠纷的发生。[方法]选取2013年1月—2013年12月在我院由急诊科转入各科室的1231例病人作为观察组,将2012年1月—2012年12月在我院急诊科院内转运的1050例病人设为对照组。对照组按常规对病人进行治疗、护理和转运病人,交班时用口头交接班。观察组在急诊科与手术室、重症监护室(ICU)、内科和外科转运病人时要求严格遵守转运流程,必须使用《急危重病人交接单》。比较《急危重病人交接单》干预前后的差异。[结果]观察组护理风险发生率明显低于对照组,差异有统计学意义(P <0.05)。[结论]对急诊危重病人院内转运应用《急危重病人交接单》可提高危重病人院内转运的安全性,在护理风险管理过程中起到了预防控制的作用。     

QT离散度对急危重病人预后的评估

目的　研究QT离散度对急危重病人预后的预测价值。方法　死亡组 4 7例、疾病组 4 0例和正常组 4 3例。记录 12导联心电图 ,人工测量各导联R -R间期和QT间期 ,计算R -R、QTc、QTd和QTcd。结果　死亡组的R -R、QTc、QTd和QTcd分别为 0 5 6 2± 0 2 2 0ms、0 35 6± 0 0 6 9ms、0 0 5 6± 0 0 33ms和 0 0 79± 0 0 4 6ms ;疾病组的R -R、QTc、QTd和QTcd分别为0 80± 0 134ms、0 4 16± 0 0 3ms、0 0 34± 0 0 14ms和 0 0 39± 0 0 16ms;正常组的R -R、QTc、QTd和QTcd分别为 0 82 5± 0 0 88ms、0 4 0 2± 0 0 3ms、0 0 2 7± 0 0 15ms和 0 0 31± 0 0 15ms。比较死亡组、疾病组和正常组发现 ,死亡组和疾病组的R -R、QTc、QTd和QTcd存在显著差异 (P分别 <0 0 0 1、<0 0 0 2 5、<0 0 0 1和 <0 0 0 1)。死亡组和正常组的R -R、QTc、QTd和QTcd存在显著差异 (P分别 <0 0 0 1、<0 0 0 2 5、<0 0 0 1和 <0 0 0 1)。结论　QTd对急危重病人的预后有一定的预测价值 ;但其它临床应用价值存在局限性 ,有待进一步探索。     

构建门诊急危重病人的抢救和护送体系

门诊病人多、就医环节多、病人的病情复杂，在就医过程中，由于病情的变化和各种治疗的反应，门诊经常是“险象环生”。另外，综合性医院的急诊部大多独立于门诊之外，但一些急诊病人常常误送入门诊部。如何使这些急危重病人得到及时抢救和护送，我院自1999年先后建立并完善了门诊急危重病人的抢救和护送体系，共抢救、护送急危重病人近千例，未发生一起因抢救不及时或不满意而引发的医疗纠纷，在提高患者抢救成功率的同时，也确保了门诊的医疗安全，收到良好效果。     

急危重病人血流动力学最佳化状态治疗研究的Meta分析

目的　探讨有关急危重病人血流动力学状态达到最佳化治疗研究中肺动脉导管 (Swan -Ganz)与复苏治疗的关系 ,评估生理、临床、治疗等方面因素对复苏治疗效果的影响。方法　从MEDLINE(英文医学文献资料网库 )中搜集所有与Swan -Ganz和血流动力学状态有关的 71篇研究文献。按照限定条件进行筛选 :①病人类型 :急性病 ,高危外科手术病人 ,创伤 ;②达到血流动力学指标正常值或超常值标准 ;③控制组死亡率 >2 0 % (危重组 )或 <15 % (一般组 ) ;④治疗后达到血流动力学指标的早晚 ;其中 2 1项研究接受Meta分析。结果　在危重组 ,早期达到血流动力学超常值治疗 ,2 1项研究中的 7项显示在控制组与治疗组之间死亡率有显著性的差别 (P <0 0 5 ) ;而晚期达到血流动力学超常值治疗的 6项研究 ,两组之间死亡率无显著性的差别 (P >0 0 5 )。在一般组 ,达到血流动力学正常值治疗的 5项研究和超常值治疗的 3项研究显示 ,控制组与治疗组之间死亡率无显著性的差别。结论　经Swan -Ganz引导早期达到血流动力学超常值治疗 ,能降低重病组的死亡率。     

连续性血液净化疗法在急危重病人的应用及护理

目的：观察分析连续性血液净化疗法应用于急危重伴急性肾功能衰竭（ARF）的患者在ICU应用的疗效。方法：32例病人中，均行CVVH，采用BAXTERD生产的BM 25与金宝生产的ACCURA牌机器，血液滤过器HF-1200置换液量2000-4000ml／h，血流量120—180ml／min。结果：治愈好转23例，占72％；死亡5例，占16％；因经济等原因自动出院4例，占13％。结论：连续血液净化疗法能迅速清除炎症介质，阻断炎症介质造成的损伤。有改善预后的作用，患者耐受性好，不受年龄限制，操作简单，可床旁实施，是ICU抢救危重病人的有效手段之一。     

Reliability and Validity of Scores on the Emergency Severity Index Version 3

OBJECTIVES: No widely used triage instrument accurately assesses patient acuity. The Emergency Severity Index (ESI) promises to facilitate reliable acuity assessment and possibly predict patient disposition. However, reliability and validity of ESI scores have not been established in emergency departments (EDs) outside the original research sites, and version 3 (v.3) of the ESI has not been evaluated. The study hypothesis was that scores on the ESI v.3 show good interrater reliability and predict hospital admission, admission site, and death. METHODS: The authors conducted an ED-based cross-sectional retrospective study of 403 systematically selected ED records of patients who presented to an academic medical center. Twenty-seven variables were abstracted, including triage level assigned, admission status, site, and death. Using a standard process, the researchers determined the true triage level. Weighted kappa and Pearson correlation were used to calculate interrater reliability between true triage level and triage score assigned by the registered nurse (RN). The relationships between the true ESI level and admission, admission site, and death were assessed. RESULTS: Interrater reliability between RN ESI level and the true ESI level was kappa = 0.89; Pearson r = 0.83 (p < 0.001). Hospital admission by ESI level was as follows: 1 (80%), 2 (73%), 3 (51%), 4 (6%), and 5 (5%). A higher percentage of ESI level-1 and level-2 patients (40%, 12%) were admitted to the intensive care unit than ESI levels 3-5 (2%, 0%, 0%). Admission to telemetry for ESI levels 1-5 was 20%, 19%, 7%, 1%, and 0%, respectively. Three of four patients who died were ESI level 1 or 2. CONCLUSIONS: Scores on the ESI assigned by nurses have excellent interrater reliability and predict hospital admission and location of admission.     

Evaluation of the Emergency Severity Index (version 3) Triage Algorithm in Pediatric Patients

Objectives: As demand for emergency services outpaces available allocated resources, emergency department (ED) triage systems face increasing scrutiny. Longer waits for care make the use of reliable, valid triage systems imperative to patient safety. Little is known about the reliability and validity of triage systems in children. The purpose of this study was to evaluate the reliability and validity of the Emergency Severity Index version 3 (ESIv.3) triage algorithm in a pediatric population. Methods: This two‐phase investigation used both retrospective chart review and prospective, observational designs. Interrater reliability was evaluated using ED triage scenarios, a prospective cohort of ED patients presenting to triage, and retrospective triage assignments using the original triage note. ED triage nurses, nurse investigators, and physician investigators performed retrospective blinded triages using only the original triage note to assess reproducibility. In the second phase, validity was assessed using a retrospective analysis of observed resource use, ED length of stay, and hospitalization compared with resource utilization estimated at triage by the ESI. Results: In the reliability phase, weighted κ for ED nurse triage of standard scenarios ranged from 0.84 to 1.00, representing excellent agreement. Twenty ED pediatric patients were triaged simultaneously by an ED triage nurse and the nurse investigator. Weighted κ was 0.82 (95% confidence interval = 0.66 to 0.98), also representing strong agreement between raters. When used for retrospective chart review, the weighted κ statistics ranged from 0.42 to 0.84, representing poor to good agreement among the different categories of reviewers. During the validity phase, 510 patients were included in the final data analysis. Hospitalization, ED length of stay, and resource utilization were strongly associated with ESIv.3 category. Conclusions: The ESI triage algorithm demonstrated reliability and validity between triage assignment and resource use in this group of ED pediatric patients.     

Assessment of Interrater Reliability of the Emergency Severity Index After Implementation in Emergency Departments in Jamaica Using a Learning Collaborative Approach

IntroductionIn 2016, the Ministry of Health in Jamaica selected the Emergency Severity Index as the triage tool to be used nationally. This study evaluated the effectiveness of this approach by assessing the interrater reliability among new users trained with minimal resources by 2 experienced trainers, 1 local and 1 international.MethodsA retrospective case series review was conducted within an online learning collaborative framework. After completion of the training, the participants from each of the 19 clinical sites were asked to submit 2 triage cases per month for blinded review by the expert trainers. The triage categories assigned by each reviewer were compared with those assigned by the newly trained Emergency Severity Index providers. A weighted kappa value was calculated to assess the degree of agreement between the sites and the expert trainers.ResultsA total of 166 cases were received over the study period. Participation in the learning collaborative was consistently below 50%. The interrater reliability between the expert trainers (κ = 0.48) as well as between each scorer and each accident and emergency department site (κ_SF = 0.33, κ_PT = 0.26) was low, although there was improvement over the study period. Incomplete triage documentation limited raters' ability to assign triage categories and assess interrater reliability.DiscussionDespite a rigorous implementation process, the interrater reliability of the Emergency Severity Index skills of Jamaican emergency nurses and doctors when compared with that of the 2 experts was poor. Several areas were identified for strengthening. Considerations for the implementation of the Emergency Severity Index in countries outside of the US were also discussed.     

Different triage categorization using Emergency Severity Index (ESI) method in emergency department

Objective

Triage is basically a categorization process to prioritize various treatments for patients based on the types of disease, severity, prognosis and resource availability. However, the term triage is more appropriate to be used in the context of natural disaster or mass casualties. Within the context of emergency situation in emergency department, the term triage refers to a method used to assess the severity of patients’ condition, determine the level of priority, and mobilize the patients to the suitable care unit. ESI is a new concept of triage using five scales in classifying the patients in emergency department. The real implementation of this concept demands nurses have to immediately make assessment about patients’ condition right away, besides they must give their final decision, whether to move the patients to the ward or to let them leave the hospital.

Improving ED Emergency Severity Index Acuity Assignment Using Machine Learning and Clinical Natural Language Processing

IntroductionTriage is critical to mitigating the effect of increased volume by determining patient acuity, need for resources, and establishing acuity-based patient prioritization. The purpose of this retrospective study was to determine whether historical EHR data can be used with clinical natural language processing and machine learning algorithms (KATE) to produce accurate ESI predictive models.MethodsThe KATE triage model was developed using 166,175 patient encounters from two participating hospitals. The model was tested against a random sample of encounters that were correctly assigned an acuity by study clinicians using the Emergency Severity Index (ESI) standard as a guide.ResultsAt the study sites, KATE predicted accurate ESI acuity assignments 75.7% of the time compared with nurses (59.8%) and the average of individual study clinicians (75.3%). KATE’s accuracy was 26.9% higher than the average nurse accuracy (P <.001). On the boundary between ESI 2 and ESI 3 acuity assignments, which relates to the risk of decompensation, KATE’s accuracy was 93.2% higher, with 80% accuracy compared with triage nurses 41.4% accuracy (P <.001).DiscussionKATE provides a triage acuity assignment more accurate than the triage nurses in this study sample. KATE operates independently of contextual factors, unaffected by the external pressures that can cause under triage and may mitigate biases that can negatively affect triage accuracy. Future research should focus on the impact of KATE providing feedback to triage nurses in real time, on mortality and morbidity, ED throughput, resource optimization, and nursing outcomes.     

Establishing Research Priorities for the Emergency Severity Index Using a Modified Delphi Approach

IntroductionThe accuracy of an initial ED triage decision has been reported to drive the clinical trajectory for ED patients, and, therefore, this assessment is critical to patient safety. The Emergency Severity Index—a 5-point score assigned by a triage nurse and based on disease acuity, patient potential for decompensation, and anticipated resource use—is used both in the United States and internationally. In the US, the Emergency Severity Index is used by up to 94% of the academic medical center emergency departments. In 2020, the Emergency Nurses Association acquired the intellectual property rights to the Emergency Severity Index and is responsible for its maintenance and improvement.ObjectiveThe purpose of this study was to establish a research agenda for the improvement of individual and institutional understanding and use of the Emergency Severity Index.MethodsModified Delphi process was used with 3 rounds of data collection.ResultsRound 1 yielded 112 issues, which were collapsed into 18 potential research questions in 4 general categories: education and training (6 questions), workplace environment (3 questions), emergency care services (7 questions), and special populations (2 questions). These questions were used in round 2 to establish importance. Round 3 yielded a rank ordering of both categories and research questions.DiscussionThe research priorities as set through the use of this modified Delphi process align well with current gaps in the literature. Research in these areas should be encouraged to improve the understanding of educational, environmental, and process challenges to emergency nurses’ triage decisions and accuracy of Emergency Severity Index assignments.     

Comparison between Emergency Severity Index and Heart Failure Triage Scale in heart failure patients: A randomized clinical trial

BACKGROUND: It is not clear whether Emergency Severity Index (ESI) is valid to triage heart failure (HF) patients and if HF patients benefit more from a customized triage scale or not. The aim of study is to compare the effect of Heart Failure Triage Scale (HFTS) and ESI on mistriage among patients with HF who present to the emergency department (ED).METHODS: A randomized clinical trial was conducted from April to June 2017. HF patients with dyspnea were randomly assigned to HFTS or ESI groups. Triage level, used resources and time to electrocardiogram (ECG) were compared between both groups among HF patients who were admitted to coronary care unit (CCU), cardiac unit (CU) and discharged patients from the ED. Content validity was examined using Kappa designating agreement on relevance (K*). Reliability of both scale was evaluated using inter-observer agreement (Kappa).RESULTS: Seventy-three and 74 HF patients were assigned to HFTS and ESI groups respectively. Time to ECG in HFTS group was significantly shorter than that of ESI group (2.05 vs. 16.82 minutes). Triage level between HFTS and ESI groups was significantly different among patients admitted to CCU (1.0 vs. 2.8), cardiac unit (2.26 vs. 3.06) and discharged patients from the ED (3.53 vs. 2.86). Used resources in HFTS group were significantly different among triage levels (H=25.89; df=3; P<0.001).CONCLUSION: HFTS is associated with less mistriage than ESI for triaging HF patients. It is recommended to make use of HFTS to triage HF patients in the ED.