病人日志在神经内科护患沟通中的作用

目的:探讨病人在住院期间记录日志的真实体验,研究病人日志在护患沟通中的作用。方法:以质性研究中的现象学方法为指导,采用目的抽样方法,对北京市某一三甲医院的研究对象进行录音半结构式个人深入访谈。样本包括 3 组人群:①记录病房日志大于 5 天的住院病人;②在某一病房工作大于半年的主管护士;③在某一病房工作大于半年的主治医生。访谈的内容全部录音,并使用原始笔记补充、分析研究和资料的收集同时进行,直至最后研究报告的完成。结果:病人日志在临床运用中可促进病人心理和情绪的稳定,能为护患沟通提供一种交流方式,并减少护患纠纷。结论:将病人日志与面对面的沟通有机结合,并加强对病人的随访可提高医疗护理质量。     

Communicating in the "Gray Zone": Perceptions about Emergency Physician–hospitalist Handoffs and Patient Safety

Objectives: To identify the perceptions of emergency physicians (EPs) and hospitalists regarding interservice handoff communication as patients are transferred from the emergency department to the inpatient setting.
Methods: Investigators conducted individual interviews with 12 physicians (six EPs and six hospitalists). Data evaluation consisted of using the steps of constant comparative, thematic analysis.
Results: Physicians perceived handoff communication as a gray zone characterized by ambiguity about patients' conditions and treatment. Two major themes emerged regarding the handoff gray zone. The first theme, poor communication practices and conflicting communication expectations, presented barriers that exacerbated physicians' information ambiguity. Specifically, handoffs consisting of insufficient information, incomplete data, omissions, and faulty information flow exacerbated gray zone problems and may negatively affect patient outcomes. EPs and hospitalists had different expectations about handoffs, and those expectations influenced their interactions in ways that may result in communication breakdowns. The second theme illustrated how poor handoff communication contributes to boarding-related patient safety threats for boarders and emergency department patients alike. Those interviewed talked about the systemic failures that lead to patient boarding and how poor handoffs exacerbated system flaws.
Conclusions: Handoffs between EPs and hospitalists both reflect and contribute to the ambiguity inherent in emergency medicine. Poor handoffs, consisting of faulty communication behaviors and conflicting expectations for information, contribute to patient boarding conditions that can pose safety threats. Pragmatic conclusions are drawn regarding physician–physician communication in patient transfers, and recommendations are offered for medical education.     

早期目标导向性治疗在中型颅脑损伤中的应用效果及对患者血流动力学指标的影响

目的探讨早期目标导向性治疗(EGDT)在中型颅脑损伤中的应用效果及对患者血流动力学指标的影响。方法将我院2016年3月至2019年3月收治的86例中型颅脑损伤合并创伤性休克患者,按随机数表单、双号将其分为观察组(43例,EGDT)和对照组(43例,常规液体复苏)。比较两组患者的临床疗效。结果观察组的24 h输液量少于对照组,复苏开始时间早于对照组,病死率低于对照组(P<0.05)。复苏后,观察组的收缩峰血流速度(Vs)、平均血流速度(Vm)大于对照组,血管搏动指数(PI)小于对照组(P<0.05)。结论 EGDT对中型颅脑损伤患者的临床效果显著,可提高液体复苏效果,改善脑血流动力学指标,降低病死率。     

Differences in Nurse and Surgeon Perceptions of Teamwork: Implications for Use of a Briefing Checklist in the OR

The quality of teamwork among health care professionals is known to affect patient outcomes. In the OR, surgeons report more favorable perceptions of communication during procedures and of teamwork effectiveness than do nurses. We undertook a quality improvement project in the Veterans Health Administration to confirm reported teamwork differences between perioperative nurses and surgeons and to examine the implications of these differences for improving practice patterns in the OR. The Safety Attitudes Questionnaire, which measures safety culture, including the quality of communication and collaboration among health care providers who routinely work together, was administered in 34 hospitals. Perioperative nurses who participated in the survey rated teamwork higher with other nurses than with surgeons, but surgeons rated teamwork high with each other and with nurses. On five of six communication and collaboration items, surgeons had a significantly more favorable perception than did perioperative nurses. To increase the likelihood of success when implementing the use of checklist-based crew resource management tools, such as the World Health Organization's Surgical Safety Checklist, project leaders should anticipate differences in perception between members of the different professions that must be overcome if teamwork is to be improved.     

Implementing Early Goal-directed Therapy in the Emergency Setting: The Challenges and Experiences of Translating Research Innovations into Clinical Reality in Academic and Community Settings

Research knowledge translation into clinical practice pathways is a complex process that is often time-consuming and resource-intensive. Recent evidence suggests that the use of early goal-directed therapy (EGDT) in the emergency department care of patients with severe sepsis and septic shock results in a substantial mortality benefit; however, EGDT is a time- and resource-intensive intervention. The feasibility with which institutions may translate EGDT from a research protocol into routine clinical care, among settings with varying resources, staff, and training, is largely unknown. The authors report the individual experiences of EGDT protocol development, as well as preimplementation and postimplementation experiences, at three institutions with different emergency department, intensive care unit, and hospital organization schemes.     

Early Goal-directed Therapy, Corticosteroid, and Recombinant Human Activated Protein C for the Treatment of Severe Sepsis and Septic Shock in the Emergency Department

Objectives: To describe our experience with early goal‐directed therapy (EGDT), corticosteroid administration, and recombinant human activated protein C (rhAPC) administration in patients with severe sepsis or septic shock and an Acute Physiology and Chronic Health Evaluation (APACHE) II score ≥25 in the emergency department (ED). Methods: This was a retrospective case series of a prospectively maintained ED sepsis registry. Data are presented as median (25th, 75th percentile). The setting was an academic tertiary ED with approximately 60,000 annual patient visits. Patients with severe sepsis or septic shock and an APACHE II score ≥25 entered in an ED sepsis registry over a four‐month period were included. Patients who received rhAPC in the intensive care unit were excluded. Central venous catheterization for central venous pressure and central venous oxygen saturation monitoring, antibiotics, fluid resuscitation, mechanical ventilation, vasopressors, inotropes, corticosteroids, and rhAPC were initiated by the emergency physicians and continued in the intensive care unit by intensivists. Results: Twenty‐four patients were enrolled. Patient characteristics were as follows: age, 79.5 (68.0, 83.5) years; APACHE II score, 31.5 (29.8, 36.0); ED length of stay, 6.5 (4.0, 10.5) hours; predicted mortality, 76.7% (71.9, 86.4); and in‐hospital mortality, 45.8%. All patients received broad‐spectrum antibiotics, 54.2% completed EGDT, 33.3% received corticosteroids, and 33.3% received rhAPC. Time of antibiotic administration was 1.5 (1.0, 2.0) hours, time of central venous pressure/central venous oxygen saturation monitoring was 1.0 (0.5, 2.5) hour, and time of rhAPC administration was 9.5 (6.8, 10.5) hours after patients met criteria for severe sepsis or septic shock. In‐hospital mortality of patients who received rhAPC in addition to other therapies was 25.0%. Conclusions: EGDT, corticosteroid administration, and rhAPC administration are feasible in the ED setting. While these evidence‐based therapies individually have been shown to improve outcomes for patients with severe sepsis or septic shock, further studies are needed to examine their combined effectiveness during the early stages of this disease.     

Lost in translation: Maximizing handover effectiveness between paramedics and receiving staff in the emergency department

Objective: The purpose of the present study is to investigate perceptions by paramedics and hospital receiving staff about what enables and constrains handover in the ED. Methods: This is a qualitative study of interviews with 19 paramedics, 15 nurses and 16 doctors (n = 50) from ambulance services and ED in two states of Australia. Results: Three main themes emerged that were evident at both sites and in the three professional groups. These were: difficulties in creating a shared cognitive picture, tensions between ‘doing’ and ‘listening’ and fragmenting communication. Conclusion: Recommendations arising from the present study as to how handover could be improved are the need for a common language between paramedics and staff in the ED, for shared experiences and understanding between the members of the team and for the development of a standardized approach to handover from paramedics to ED receiving staff.