Prognostic value of noninvasive measures of contractility in emergency department patients with severe sepsis and septic shock undergoing early goal-directed therapy

Purpose

Reversible ventricular dysfunction is common in sepsis. Impedance cardiography allows for noninvasive measurement of contractility through time interval or amplitude-based measures. This study evaluates the prognostic capacity of these measures in patients with severe sepsis or septic shock in the emergency department.

Methods

This is a prospective observational cohort study of 56 patients older than 18 years meeting criteria for early goal-directed therapy (lactate level >4 mmol/L or systolic blood pressure <90 mm Hg after 2-L isotonic sodium chloride solution). Continuous collections of contractility measures were performed, and patients were followed until discharge or in-hospital death.

Results

A significant 57% reduction in the accelerated contractility index (ACI) in nonsurvivors (71 1/s² [41-102]) compared with survivors (123 1/s² [98-147]) existed. Only ACI predicted in-hospital mortality (area under the receiver operating characteristic curve = 0.70, P < .01). Accelerated contractility index did not correlate with amount of prior fluid administration, central venous pressure, number of cardiac risk factors, or troponin I value. An ACI of less than 40 1/s² is 95% (84-99) specific with a positive likelihood ratio of 8.8 for predicting in-hospital mortality.

Conclusions

A reduced ACI is associated with mortality in critically ill emergency department patients presenting with severe sepsis and septic shock meeting criteria for early goal-directed therapy. This association appears to be independent of clinical or laboratory predictors of cardiac dysfunction or preload.     

EPISEPSIS: a reappraisal of the epidemiology and outcome of severe sepsis in French intensive care units

Objective Ten years ago 8.4% of patients in French intensive care units (ICUs) were found to have severe sepsis or shock and 56% died in the hospital. As novel therapies for severe sepsis are emerging, updated epidemiological information is required.Design and setting An inception cohort study conducted in 206 ICUs of randomly selected hospitals over a 2-week period in 2001, including all patients meeting criteria for clinically or microbiologically documented severe sepsis (with 1 organ dysfunction).Measurements and results Among 3738 admissions, 546 (14.6%) patients experienced severe sepsis or shock, of which 30% were ICU-acquired. The median age of patients was 65 years, and 54.1% had at least one chronic organ system dysfunction. The median (range) Simplified Acute Physiology Score (SAPS II) and Sequential Organ Failure Assessment (SOFA) at onset of severe sepsis were 48 (2–129) and 9 (1–24), respectively. Mortality was 35% at 30 days; at 2 months the mortality rate was 41.9%, and 11.4% of patients remained hospitalized. The median (range) hospital stay was 25 (0–112) days in survivors and 7 (0–90) days in non-survivors. Chronic liver and heart failure, acute renal failure and shock, SAPS II at onset of severe sepsis and 24-h total SOFA scores were the independent risk factors most strongly associated with death.Conclusions Although the attack rate of severe sepsis in French ICUs appears to have increased over the past decade, its associated mortality has decreased, suggesting improved management of patients. Severe sepsis incurs considerable resources use, and implementation of effective management strategies and continued research efforts are needed.Electronic Supplementary Material Supplementary material is available in the online version of this article at The EPISEPSIS Study Group included:Writing Committee: C. Brun-Buisson, MD, P. Meshaka, MD, P. Pinton, MD, B. Vallet, MDSteering Committee: C. Brun-Buisson, MD, P. Meshaka, MD, P. Pinton, MD, P. Rodie-Talbere, MD, B. Vallet, MD, J.R. Zahar MDInvestigators participating in the EPISEPSIS study are listed in the Appendix (see the ESM)Presented in part at the 15^th Congress of the European Society of Intensive Care Medicine, Barcelona, September 2002 (Intensive Care Med 28 (Suppl 1):S142, 548).     

综合医院急诊危重患者流行病学分析

目的研究急诊科抢救区危重患者的流行病学特点。方法对2011年急诊科抢救区2987例危重患者的年龄、性别、入科及转归时间分布、疾病谱和病死率等进行回顾性分析。结果循环系统、神经系统、呼吸系统疾病是急诊科的前3位危重病;男性多于女性;60～79岁老年组抢救人数最多;病死率由高到低前3位疾病是院前猝死、血液系统疾病和呼吸系统疾病;急诊抢救患者全年出现2个就诊高峰,分别为4月及12月,全天就诊高峰在16：00～20：00。结论危重患者的抢救工作是急诊工作的重中之重,应及时解除危及生命的紧急情况并尽快分流;抢救对象主要为老年心脑血管及呼吸系统疾病;应根据急诊抢救患者的分布特点合理安排人员及物资;建立病死率较高的几种急性单病种的绿色通道,建立院内合作团队,提高抢救成功率;做好相关的健康宣教工作,普及高危人群的急救知识。     

Effect of nurse staffing on rehospitalizations and emergency department visits among short-stay nursing home residents: A Cross-sectional study using the US Nursing Home Compare database

The aim of this study was to examine the effect of nurse staffing on both rehospitalizations and emergency department emergency department visits among short-stay nursing home residents in the United States. Data for 11,132 US nursing homes were drawn from the 2016 Nursing Home Compare. We found that the Five-Star Quality Rating System's staffing rating is a significant predictor for the rates of rehospitalization and emergency department visit among short-stay nursing home residents. The results also showed the importance of registered nurse staffing in nursing home caring for short-stay residents. Administrators and policy-makers can employ the findings to formulate management strategies that will reduce rehospitalizations and emergency department visits among nursing home residents.     

US practitioner opinions and prescribing practices regarding corticosteroid therapy for severe sepsis and septic shock

Purpose

The aim of this study was to examine opinions and practices of US critical care practitioners (USCCPs) toward corticosteroid therapy in adult patients with severe sepsis or septic shock.

Materials and Methods

A multicenter, electronic survey of USCCP members of the Society of Critical Care Medicine was conducted between March 18 and July 31, 2009.

Results

A total of 542 USCCPs responded to the survey. The majority (83%) do not commonly use corticosteroids in adult patients with severe sepsis; however, up to 81% report use of corticosteroids for septic shock. Twenty-eight percent believe that corticosteroids reduce mortality in septic shock, whereas 27% do not and 45% are unsure. The decision to initiate therapy is based, more often, on a patient's clinical status (65%) vs serum cortisol analysis (35%). Hydrocortisone is the most common corticosteroid prescribed (93%), with a median dosage of 200 mg/d and administration via intermittent intravenous injection. The Corticosteroid Therapy of Septic Shock trial had a large impact on survey respondents, with 62% reporting a practice change. Among the 19% of practitioners who do not prescribe corticosteroids, the most common reason was lack of proven survival benefit.

Conclusions

Corticosteroids are commonly used by USCCPs in adult patients with septic shock; however, criteria used to initiate therapy and opinions regarding their impact vary.     

The role of nurses in the recognition and treatment of patients with sepsis in the emergency department: A prospective before-and-after intervention study

Background

In 2004, the Surviving Sepsis Campaign (SSC), a global initiative to reduce mortality from sepsis, was launched. Although the SSC supplies tools to measure and improve the quality of care for patients with sepsis, effective implementation remains troublesome and no recommendations concerning the role of nurses are given.

Objectives

To determine the effects of a multifaceted implementation program including the introduction of a nurse-driven, care bundle based, sepsis protocol followed by training and performance feedback.

Design and setting

A prospective before-and-after intervention study conducted in the emergency department (ED) of a university hospital in the Netherlands.

Participants

Adult patients (≥16 years old) visiting the ED because of a known or suspected infection to whom two or more of the extended systemic inflammatory response syndrome (SIRS) criteria apply.

Methods

We measured compliance with six bundled SSC recommendations for early recognition and treatment of patients with sepsis: measure serum lactate within 6 h, obtain two blood cultures before starting antibiotics, take a chest radiograph, take urine for urinalysis and culture, start antibiotics within 3 h, and hospitalize or discharge the patient within 3 h.

Results

A total of 825 patients were included in the study. Compliance with the complete bundle significantly improved from 3.5% at baseline to 12.4% after our entire implementation program was put in place. The completion of four of six individual elements improved significantly, namely: measure serum lactate (improved from 23% to 80%), take a chest radiograph (from 67% to 83%), take urine for urinalysis and culture (from 49% to 67%), and start antibiotics within 3 h (from 38% to 56%). The mean number of performed bundle elements improved significantly from 3.0 elements at baseline to 4.2 elements after intervention [1.2; 95% confidence interval = 0.9–1.5].

Conclusions

Early recognition of sepsis in patients presenting to the ED and compliance with SSC recommendations significantly improved after the introduction of a predominantly nurse-driven, care bundle based, sepsis protocol followed by training and performance feedback.     

Comparisons of the cost-effectiveness among hospital chronic care, nursing home placement, home nursing care and family care for severe stroke patients

AIM: This study compared the cost and effectiveness of long-term institutional care and home care for stroke patients with severe physical disabilities. BACKGROUND: Whether home care is more economical or effective than institutional care for patients with chronic illnesses remains controversial when the cost of family labour is considered. Thus, decisions concerning the appropriate type of care setting for patients with severe chronic illness remain difficult. METHODS: From November 1995 to March 1996, 313 hospitalized stroke patients with severe physical disabilities treated at one of five hospitals in the Taipei metropolitan area were followed from the day of hospital discharge until the third month after discharge. These 313 patients were divided into four groups as follows: (1) 106 who were admitted to a chronic care unit in a hospital, (2) 60 who were admitted to nursing homes, (3) 60 who received professional home nursing care and (4) 87 who returned home without receiving professional care. The change of physical functional status in the patient was examined as the difference between activities of daily living (ADL) scores measured at discharge and at the end of the third month after discharge. RESULTS: Information on family costs for caregiving, including pay for long-term services utilized, labour costs for caregiving and out-of-pocket expenditures for miscellaneous materials was obtained during a weekly telephone interview. The results indicated that caring for patients in their own homes was not only more expensive but was also less effective in improving ADL scores than caring for patients in nursing homes and in chronic care units of hospitals. CONCLUSIONS: The results suggest that caring for patients with severe physical disabilities in institutions is more appropriate than caring of them at home.     

Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock

Objective To develop management guidelines for severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.Design The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. The modified Delphi methodology used for grading recommendations built upon a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along 5 levels to create recommendation grades from A–E, with A being the highest grade. Pediatric considerations were provided to contrast adult and pediatric management.Participants Participants included 44 critical care and infectious disease experts representing 11 international organizations.Results A total of 46 recommendations plus pediatric management considerations.Conclusions Evidence-based recommendations can be made regarding many aspects of the acute management of sepsis and septic shock that will hopefully translate into improved outcomes for the critically ill patient. The impact of these guidelines will be formally tested and guidelines updated annually, and even more rapidly when some important new knowledge becomes available.Electronic Supplementary Material Supplementary material is available in the online version of this articel at This article is published jointly with Critical Care MedicineChairs: R. Phillip Dellinger, MD*; Henry Masur, MD; Jean M. Carlet, MD; Herwig Gerlach, MD, PhD**. Committee members: Richard J. Beale, MD**; Marc Bonten, MD; Christian Brun-Buisson, MD; Thierry Calandra, MD; Joseph A. Carcillo, MD; Jonathan Cohen, MD**; Catherine Cordonnier, MD; E. Patchen Dellinger, MD; Jean-Francois Dhainaut, MD, PhD; Roger G. Finch, MD; Simon Finfer, MD; Francois A. Fourrier, MD; Juan Gea-Banacloche MD; Maurene A. Harvey, RN, MPH**; Jan A. Hazelzet, MD; Steven M. Hollenberg, MD; James H. Jorgensen, PhD; Didier Keh, MD; Mitchell M. Levy*, MD; Ronald V. Maier, MD; Dennis G. Maki, MD; John J. Marini, MD; John C. Marshall, MD; Steven M. Opal, MD; Tiffany M. Osborn, MD; Margaret M. Parker, MD**; Joseph E. Parrillo, MD; Graham Ramsay, MD*; Andrew Rhodes, MD; Jonathan E. Sevransky, MD; Charles L. Sprung, MD, JD**; Antoni Torres, MD; Jeffery S. Vender, MD; Jean-Louis Vincent, MD, PhD**; Janice L. Zimmerman, MD. Associate members: E. David Bennett, MD; Pierre-Yves Bochud, MD; Alain Cariou, MD; Glenn S. Murphy, MD; Martin Nitsun, MD; Joseph W. Szokol, MD; Stephen Trzeciak, MD; Christophe Vinsonneau, MD. *Executive Committee, Surviving Sepsis Campaign. **Steering Committee, Surviving Sepsis Campaign.Sponsoring organizations: American Association of Critical-Care Nurses; American College of Chest Physicians; American College of Emergency Physicians; American Thoracic Society; Australian and New Zealand Intensive Care Society; European Society of Clinical Microbiology and Infectious Diseases; European Society of Intensive Care Medicine; European Respiratory Society; International Sepsis Forum; Society of Critical Care Medicine; Surgical Infection Society.The Surviving Sepsis Campaign is administered jointly by the European Society of Intensive Care Medicine, International Sepsis Forum, and the Society of Critical Care Medicine, and is supported in part by unrestricted educational grants from Baxter Bioscience, Edwards Lifesciences, and Eli Lilly and Company (majority sponsor).The authors and the publisher have exercised great care to ensure that drug dosages, formulas, and other information presented in this book are accurate and in accord with the professional standards in effect at the time of publication. Readers are, however, advised to always check the manufacturers product information sheet that is packaged with the respective products to be fully informed of changes in recommended dosages, contraindications, and the like before prescribing or administering any drug.     

An exploration of the handover process of critically ill patients between nursing staff from the emergency department and the intensive care unit

The transfer of information between nurses from emergency departments (EDs) and critical care units is essential to achieve a continuity of effective, individualized and safe patient care. There has been much written in the nursing literature pertaining to the function and process of patient handover in general nursing practice; however, no studies were found pertaining to this handover process between nurses in the ED environment and those in the critical care environment. The aim was to explore the process of patient handover between ED and intensive care unit (ICU) nurses when transferring a patient from ED to the ICU. This study used a multi-method design that combined documentation review, semistructured individual interviews and focus group interviews. A multi-method approach combining individual interviews, focus group interviews and documentation review was used in this study. The respondents were selected from the ED and ICU of two acute hospitals within Northern Ireland. A total of 12 respondents were selected for individual interviews, three nurses from ED and ICU, respectively, from each acute hospital. Two focus groups interviews were carried out, each consisting of four ED and four ICU nurses, respectively. Qualitative analysis of the data revealed that there was no structured and consistent approach to how handovers actually occurred. Nurses from both ED and ICU lacked clarity as to when the actual handover process began. Nurses from both settings recognized the importance of the information given and received during handover and deemed it to have an important role in influencing quality and continuity of care. Nurses from both departments would benefit from a structured framework or aide memoir to guide the handover process. Collaborative work between the nursing teams in both departments would further enhance understanding of each others' roles and expectations.     

亲情护理对急诊患儿诊治时间及家长健康知识知晓率的影响

目的 探讨亲情护理对急诊患儿诊治时间及家长健康知识知晓率的影响.方法 将我院80例急诊发热的患儿分为观察组和对照组各40例,对照组采用常规护理,观察组在对照组的基础上采用亲情护理,比较两组患儿的护理效果.结果 观察组在急诊停留时间显著短于对照组,治疗时的配合程度、降温效果、家长健康知识的知晓率、护理满意度显著高于对照组(P＜0.05),观察组的家长心理状况显著好于对照组(P＜0.05).结论 亲情护理有利于提高护理质量,增加急诊患儿的配合度,减轻家长的焦虑感.     

Factors related to the acceptance of home care and nursing homes among older Egyptians: A cross-sectional study

Background

Socio-demographic changes may deprive older Egyptians from receiving care by family members and raise the question of how they react if they become dependent on help.

Objective

The objective of this study was to determine factors related to the acceptance of home care and nursing homes among older Egyptians.

Design

A two group comparative design based on self-reports.

Participants

The sample was composed of 344 older persons receiving home care or staying in a nursing home and 267 non-care recipients.

Setting

The study was conducted in Greater Cairo.

Methods

Factors related to the acceptance of home care and nursing homes were determined separately for each group by logistic regression.

Results

Lesser feelings of shame while receiving care from non-family members were related to an increased acceptance of both kinds of care. For non-care recipients disagreement to the traditional idea of family care had a similar effect. For care recipients the experience made with a particular kind of care was strongly related to its acceptance.

Discussion

Home care is a new phenomenon in Cairo and in contrast to nursing homes it was unknown to most study participants. For this reason any conclusion about which kind of service is preferred by older Egyptians would be a premature one.

Conclusion

Feelings of shame while receiving care from a non-family member are more important than functional limitations when older Egyptians are considering the options of home care and nursing homes.     

The risk stratification and prognostic evaluation of soluble programmed death-1 on patients with sepsis in emergency department

Objective

To evaluate the efficacy of soluble programmed death-1 (sPD-1) for risk stratification and prediction of 28-day mortality in patients with sepsis, we compared serum sPD-1 with procalcitonin (PCT), C-reactive protein (CRP), and the Mortality in Emergency Department Sepsis (MEDS) score.

Impact of Ramadan on demographics and frequencies of disease-related visits in the emergency department

Summary The objective of this study was to determine whether Ramadan is changing frequencies and demographics of visits due to certain diseases. Data obtained from the charts of the adult patients admitted into the emergency department (ED) due to 10 predetermined entities between 2000 and 2004 were analysed. Demographic variables analysed separately for certain entities visiting the ED in Ramadan were not found to be different from visits in other times of year. Visit frequencies for hypertension and uncomplicated headache in Ramadan were significantly higher than in non-Ramadan months (chi(2) test, p = 0.015 for hypertension, p < 0.001 for uncomplicated headache). Mean age of the patients admitted to the ED due to diabetes-related conditions in Ramadan was significantly lower than in pre- and post-Ramadan months (59.91 +/- 14.60 and 62.11 +/- 14.61, respectively) (Mann-Whitney U-test, p = 0.032). The patients with diabetes presenting in Ramadan were found significantly younger than their peers in the rest of the year. For other diseases, Ramadan does not appear to be a risk factor.     

Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

Objective To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, “Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock,” published in 2004. Design Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding. Methods We used the GRADE system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation [1] indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost), or clearly do not. Weak recommendations [2] indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations. Results Key recommendations, listed by category, include: early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures prior to antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7–10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure ≥ 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for post-operative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7–9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B) targeting a blood glucose < 150 mg/dL after initial stabilization ( 2C ); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper GI bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include: greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); a recommendation against the use of recombinant activated protein C in children (1B). Conclusion There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients. Sponsoring Organizations: American Association of Critical-Care Nurses*, American College of Chest Physicians*, American College of Emergency Physicians*, Canadian Critical Care Society, European Society of Clinical Microbiology and Infectious Diseases*, European Society of Intensive Care Medicine*, European Respiratory Society*, International Sepsis Forum*, Japanese Association for Acute Medicine, Japanese Society of Intensive Care Medicine, Society of Critical Care Medicine*, Society of Hospital Medicine**, Surgical Infection Society*, World Federation of Societies of Intensive and Critical Care Medicine**. Participation and endorsement by the German Sepsis Society and the Latin American Sepsis Institute. for the International Surviving Sepsis Campaign Guidelines Committee***, **** * Sponsor of 2004 guidelines; ** Sponsor of 2008 guidelines but did not participate formally in revision process; *** Members of the 2007 SSC Guidelines Committee are listed in Appendix I.; **** Please see Appendix J for author disclosure information. The article will also be published in Critical Care Medicine. An erratum to this article can be found at     

Effects of seasonality and daylight savings time on emergency department visits for mental health disorders

ObjectivesEmergency Department (ED) utilization accounts for a large portion of healthcare services in the US. Disturbance of circadian rhythms may affect mental and behavioral health (MBH) conditions, which could result in increased ED visits and subsequent hospitalizations, thus potentially inducing staffing shortages and increasing ED wait time. Predicting the burden of ED admissions helps to better plan care at the EDs and provides significant benefits. This study investigates if increased ED visits for MBH conditions are associated with seasonality and changes in daylight savings time.MethodsUsing ED encounter data from a large academic medical center, we have examined univariate and multivariate associations between ED visits for MBH conditions and the annual time periods during which MBH conditions are more elevated due to changes in the seasons. We hypothesize that ED visits for MBH conditions increase within the 2-week period following the daylight savings time changes.ResultsIncreased MBH ED visits were observed in certain seasons. This was especially true for non-bipolar depressive illness. We saw no significant changes in MBH visits as associated with changes in the daylight savings time.ConclusionsData do not provide conclusive evidence of a uniform seasonal increase in ED visits for MBH conditions. Variation in ED MBH visits may be due to secular trends, such as socioeconomic factors. Future research should explore contemporaneous associations between time-driven events and MBH ED visits. It will allow for greater understanding of challenges regarding psychiatric patients and opportunities for improvement.     

优化急诊护理流程对脑卒中患者抢救效果及满意度的影响

目的 观察并分析优化急诊护理流程对脑卒中患者抢救效果及满意度的影响.方法 随机选取2011年10月~2014年5月该院收诊的脑卒中患者82例,依照入院抢救时间顺序将其分为观察组42例和对照组40例.对照组患者给予常规急诊护理流程配合抢救,观察组患者给予根据本院实际情况(包括医疗水平与我院所在地的实际生活水平等)所制定的优化后的急诊护理流程进行抢救.观察并比较两组患者接诊到确诊的时间、确诊到专科诊治的时间,及患者接受治疗后的病死率、致残率及并发症的发生率,调查并分析患者对优化的急诊护理流程治疗脑卒中患者的满意度.结果 经诊断,观察组与对照组的脑卒中类型比较,差异无统计学意义(P>0.05);观察组患者的治疗情况,包括接诊-确诊时间、确诊-接受专科治疗时间及住院费用等均明显优于对照组,差异均有统计学意义(均P<0.05);且观察组患者的致死率与致残率明显低于对照组,差异均有统计学意义(均P<0.05);除此之外,观察组患者的抢救满意度明显优于对照组患者,差异有明显统计学意义(P<0.05).结论 优化急诊护理流程可有效缩短接诊及诊断时间,降低患者的病死率与致残率,减少患者相关并发症的发生率,提高脑卒中患者的抢救效果及满意度等,值得推广应用.     

护生临床实习期关键事件应激源及应对行为的调查研究

目的 探讨护生实习期常见关键事件应激源及其应对方式的现状。方法 采用自编护生实习期关键事件开放性调查问卷、护生临床实习压力感知量表(Perceived Stress Scale,PSS)、护生临床实习应对行为量表(Coping Behavior Inventory,CBI)对上海市三所三级甲等医院450名实习护生进行调查。结果 共收集到453件关键事件,析出五大主题,依次为人际关系、突发情况、护理操作、职业损伤、高工作负荷;护生临床实习期压力感知总均分为(40.43±7.04)分,应激源于照顾病人、与教师和其他护理人员的关系以及缺乏专业知识和技能;应对行为频率总均分为(41.50±7.40)分,应对行为效果总均分为(37.90±11.25)分,护生在面临应激时多采取解决问题、乐观应对等应对方式,且其效果最佳。结论 护生临床实习期经历的关键事件是护生应激的主要来源,在临床实习期应采取相应措施以减少应激源,提高护生关键事件应激的自我管理及应对行为效果,降低护生应激水平。     

急诊科拥挤度变化规律研究:昼夜节律和节假日效应

目的 通过分析急诊科患者流量和拥挤度变化规律,分析急诊科拥挤度影响因素,找寻客观评估急诊科拥挤度指标.方法 前瞻性队列观察研究,分析一家大型临床教学医院急诊科患者流量和拥挤度变化规律,观察患者流量的24h变化节律和节假日效应、政策效应.并对影响急诊科拥挤度的相关因素进行多因素回归分析.结果 工作日急诊患者流量24h变化规律特征明显,患者流量高峰在20:00-22:00,低谷则在4:00-6:00,而拥挤度评分高峰和低谷滞后2h.急诊患者流量有明显周末和长假日双峰效应,急诊患者流量也受政策性因素影响.多因素回归分析显示时间段内(2 h)急诊来诊人数(B=0.027,P＜0.01)、急诊床位占用率(B=5.25,P＜0.01)与下一个时段急诊科拥挤度显著相关.结论 急诊医疗资源需求具有波动性的,急诊患者流量呈现周期性变化和节假日效应,决策者在着手解决急诊科拥挤问题时需要考虑这一规律.当急诊系统内部和外部环境稳定时,患者流量和急诊床位占用率是预测急诊科拥挤度重要的客观指标.     

Impact of the stage of dementia on the time required for bathing-related care: a pilot study in a Japanese nursing home

Time required for bathing-related care for nursing home residents with various stages of severe dementia were observed. Time required for each resident, including guiding to the bathroom, undressing, and dressing were plotted in graphs in order to make comparisons. The situations and conversations observed for the instances when additional time was needed were analyzed. Stage of dementia affected the amount of time required for the task of guiding to the bathroom, but did not appear to affect time required for dressing or undressing. For dressing and undressing, additional time was required when caregivers failed to keep to a specific routine.