杭州“7·5”公交纵火事件中血液资源管理与实践

目的采供血应急保障体系的有效运作对突发事件血液资源管理的管理的重要性。方法采供血应急保障体系的启动,掌握突发事件血液资源经历应急聚积、理性控制和平稳三个阶段特征分阶段进行有效的血液安全宣传,招募引导保留血液资源。结果 7·5事件发生后采供血应急保障体系的有效运作是应对此次事件的关键。通过本次血液资源应急管理的三阶段控制步骤,有效避免血液过期浪费的风险。回顾性分析血液报废率与同期相比无明显改变,说明此次事件中的血液安全可控。结论血站应进一步锻炼以血源和血液保障预案为核心,以后勤、信息、新闻应对等预案为辅的应急保障体系。     

极端气候事件对重庆市传染病流行影响

目的探讨极端气候事件对重庆市传染病流行的影响及相关因素。 方法对重庆市灾害前后的传染病疫情及突发公共卫生事件进行分析。结果2006年旱灾年重庆市甲、乙类传染病的年发病率比2005年上升了3.86%,2007年洪灾年比2005年上升了2.74%。2006年比2005年的肠道和自然疫源及虫媒传染病分别上升了14.91%和49.23%,而2007年比2005年和2006年的呼吸道传染病分别上升了1.28%和8.07%。旱灾受灾季节乙脑发病率比2005年同期上升最高,洪灾受灾季节比2006年同期上升较多的是麻疹、伤寒/副伤寒、钩端螺旋体病、流脑等疾病。灾害期间甲、乙类传染病突发事件数比2005年上升。 结论极端气候事件对重庆市传染病的流行和暴发产生了一定的影响,部分传染病的发病有不同程度的上升。     

Emergency medicine in a developing country: experience from Kilimanjaro Christian Medical Centre, Tanzania, East Africa

Tanzania in East Africa has a population of over 36 million and is one of the poorest countries in the world. Life expectancy has declined and infant mortality rates are increasing. Four consultant specialist hospitals and 17 regional hospitals service the mainland. Kilimanjaro Christian Medical Centre is a major specialist teaching hospital with 500 beds, serving the entire north-west of the country. There is a small 'casualty' ward with three cubicles and one resuscitation room. Malaria, HIV, respiratory infections and gastroenteritis are the chief causes of death in children. Changing lifestyle and Western influences have increased diabetes and vascular disease in adults, and large numbers of trauma deaths are increasingly encountered. Kilimanjaro Christian Medical Centre 'Casualty' admission data are presented, as well as an insight into the challenges of emergency medicine in this country.     

Unreliable post event report from an automated external defibrillator

Medical supervision of the use of automated external defibrillators (AEDs) is possible by the incorporation of a solid state memory system recording electrocardiography (ECG) tracings and information about the operation of the device. Since a post event report suggested inappropriate AED use erroneously, the information storage and printing processes of the Laerdal® AED system were investigated. This analysis strongly suggests (yet unpredictable) incompatibilities between the software built in the solid state memory modules and the different components of the printing system. Although no problems were encountered during the resuscitation attempts, these findings may be clinically relevant because an unreliable post event report from a solid state memory module may lead to erroneous criticism of an AED user.

Abstract

A supervisão médica do uso de desfibrilhadores automáticos externos (DAE) é possível através da incorporação de sistemas de memória permanente que gravam os traçados electrocardiográficos (ECG) e fornecem informação sobre o funcionamento do aparelho. Desde que um relato post-incidente sugeriu erradamente uma utilização inadequada do DAE, foram investigados os processos de impressão e armazenamento de informação do sistema DAE Laerdal. Esta análise sugere fortemente (mas não permite prever) a existência de incompatibilidades entre o software dos sistemas de memória e os componentes do sistema de impressão. Apesar de não terem sido detectados problemas em reanimações, estes achados podem vir a ter significado clínico relevantes já que relatos post-incidente de um módulo de memória, pouco fiáveis, podem provocar críticas erradas quanto á utilização de um DAE.     

Using a Discrete‐event Simulation to Balance Ambulance Availability and Demand in Static Deployment Systems

Objectives: To improve ambulance response time, matching ambulance availability with the emergency demand is crucial. To maintain the standard of 90% of response times within 9 minutes, the authors introduce a discrete‐event simulation method to estimate the threshold for expanding the ambulance fleet when demand increases and to find the optimal dispatching strategies when provisional events create temporary decreases in ambulance availability. Methods: The simulation model was developed with information from the literature. Although the development was theoretical, the model was validated on the emergency medical services (EMS) system of Tainan City. The data are divided: one part is for model development, and the other for validation. For increasing demand, the effect was modeled on response time when call arrival rates increased. For temporary availability decreases, the authors simulated all possible alternatives of ambulance deployment in accordance with the number of out‐of‐routine‐duty ambulances and the durations of three types of mass gatherings: marathon races (06:00–10:00 hr), rock concerts (18:00–22:00 hr), and New Year’s Eve parties (20:00–01:00 hr). Results: Statistical analysis confirmed that the model reasonably represented the actual Tainan EMS system. The response‐time standard could not be reached when the incremental ratio of call arrivals exceeded 56%, which is the threshold for the Tainan EMS system to expand its ambulance fleet. When provisional events created temporary availability decreases, the Tainan EMS system could spare at most two ambulances from the standard configuration, except between 20:00 and 01:00, when it could spare three. The model also demonstrated that the current Tainan EMS has two excess ambulances that could be dropped. The authors suggest dispatching strategies to minimize the response times in routine daily emergencies. Conclusions: Strategies of capacity management based on this model improved response times. The more ambulances that are out of routine duty, the better the performance of the optimal strategies that are based on this model.     

Field triage systems: Methodologies from the literature

The primary goal of the Neely Conference project is to work toward defining a set of research criteria for medical necessity in emergency medical services (EMS). This paper reviews the extant literature on triage and nontransport decisions made in the field by EMS personnel, with emphasis on the methodologies that have been used to date. Two types of medical necessity standards are considered. First, there are triage criteria for determining whether a given patient requires EMS transport to the hospital, or whether an alternative might be appropriate. These triage criteria might be incorporated into protocols that field personnel could apply on scene to determine the best disposition for a given patient. Second, there are the outcome measures against which the decisions made by the field personnel are judged. In some cases, the outcome measure is the judgment of a reviewing emergency physician or nurse, while in others specific outcome measures are used to judge the performance of the criteria and the decision making of the field providers. While review of the literature shows that no “standard” set of triage criteria have been generated or validated in determining medical necessity in EMS, there are certain themes that emerge from the literature, and these themes can likely form the basis of a consensus on elements of a medical necessity criteria that need to be validated and refined. These may include (for triage criteria) vital signs, chief complaints, and physical exam findings, and (for outcome measures) hospital admission, critical events, death, and diagnosis.     

COVID‐19‐another influential event impacts on laboratory medicine management

BackgroundBefore public health emergencies became a major challenge worldwide, the scope of laboratory management was only related to developing, maintaining, improving, and sustaining the quality of accurate laboratory results for improved clinical outcomes. Indeed, quality management is an especially important aspect and has achieved great milestones during the development of clinical laboratories.Current statusHowever, since the coronavirus disease 2019 (COVID‐19) pandemic continues to be a threat worldwide, previous management mode inside the separate laboratory could not cater to the demand of the COVID‐19 public health emergency. Among emerging new issues, the prominent challenges during the period of COVID‐19 pandemic are rapid‐launched laboratory‐developed tests (LDTs) for urgent clinical application, rapid expansion of testing capabilities, laboratory medicine resources, and personnel shortages. These related issues are now impacting on clinical laboratory and need to be effectively addressed.ConclusionDifferent from traditional views of laboratory medicine management that focus on separate laboratories, present clinical laboratory management must be multidimensional mode which should consider consolidation of the efficient network of regional clinical laboratories and reasonable planning of laboratories resources from the view of overall strategy. Based on relevant research and our experience, in this review, we retrospect the history trajectory of laboratory medicine management, and also, we provide existing and other feasible recommended management strategies for laboratory medicine in future.     

Complaints from emergency department patients largely result from treatment and communication problems

Objective: Emergency department patient complaints are often justified and may lead to apology, remedial action or compensation. The aim of the present study was to analyse emergency department patient complaints in order to identify procedures or practices that require change and to make recommendations for intervention strategies aimed at decreasing complaint rates. Methods: We undertook a retrospective analysis of patient complaints from 36 Victorian emergency departments during a 61 month period. Data were obtained from the Health Complaint Information Program (Health Services Commissioner). Results: In all, 2419 emergency department patients complained about a total of 3418 separate issues (15.4% of all issues from all hospital departments). Of these, 1157 complaints (47.8%) were received by telephone and 829 (34.3%) were received by letter; 1526 (63.1%) complaints were made by a person other than the patient. Highest complaint rates were received from patients who were female, born in non‐English‐speaking countries and very young or very old. One thousand one hundred and forty‐one issues (33.4%) related to patient treatment, including inadequate treatment (329 issues) and inadequate diagnosis (249 issues); 1079 (31.6%) issues related to communication, including poor staff attitude, discourtesy and rudeness (444 issues); 407 (11.9%) issues related to delay in treatment. Overall, 2516 issues (73.6%) were resolved satisfactorily, usually by explanation or apology. Only 59 issues (1.7%) resulted in a procedure or policy change. Remedial action was taken in 109 issues (3.2%) and compensation was paid to eight patients. Conclusions: Communication remains a significant factor in emergency department patient dissatisfaction. While patient complaints have resulted in major changes to policy and procedure, research and intervention strategies into communication problems are indicated. In the short term, focused staff training is recommended. See Commentary, page 9.     

Primary headache disorder in the emergency department: perspective from a general neurology outpatient clinic

Over a six month period, 22% of patients with headache seen in general neurology outpatient clinics reported prior attendance at an emergency department because of their headache; 9% of the headache cohort had been admitted to hospital. All had primary headache disorders according to International Headache Society diagnostic criteria. Improved primary care services for headache patients are required to reduce the burden of primary headache disorders seen in emergency departments.     

Adolescent access to emergency contraception in A and E departments: reviewing the literature from a feminist perspective

Recent moves in parts of UK to provide opportunities for 'over the counter' purchasing at pharmacies, has meant that access to emergency oral hormonal contraception for adolescents is undergoing something of a revolution. The provision of emergency contraception (EC) to adolescents in Accident and Emergency (A and E) departments, however, is nothing new and is now an established component of the current government objective to reduce teenage pregnancy rates in this country. The tensions apparent in A and E departments related to the provision of EC, particularly to adolescents, have recently been recognized, but little attention has been paid to analysing the reasons why such tensions might exist. This article is based on a literature review carried out as part of a study of nurses' encounters with adolescents accessing EC in A and E departments in the North-west of England. It is a reappraisal of the salient issues in this arena from a feminist perspective, aiming to provide an alternative with which to view the encounter between adolescents and service providers in A and E.     

Handover from paramedics: Observations and emergency department clinician perceptions

Objectives: 1. To evaluate emergency clinician attitudes towards handover from prehospital paramedics. 2. To determine the content and methods of paramedic handover delivery to emergency clinicians. Methods: Exploratory study comprising questionnaire of emergency clinicians and observation of paramedic‐to‐emergency clinician handover with associated survey at an adult tertiary referral hospital with approximately 12 000 ambulance arrivals of 37 000 annual attendances. Results: Emergency staff found handover from paramedics on patient conditions relevant, especially for altered consciousness (94%, 95% CI 83.5–98.6), trauma (90%, 95% CI 82.0–98.4) and chest pain (88%, 95% CI 79.0–97.0), but less so for behavioural disturbance (67%, 95% CI 53.7–79.5). A total of 621 handovers from 311 ambulance arrivals were observed. Most arrivals (81%, 95% CI 76.4–85.4) were not preceded by prehospital communication. Paramedics handed over twice 91% of the time (95% CI 88.2–94.4). Doctors received direct paramedic handover for 12% (95% CI 8.0–15.1) of ambulance arrivals, including 19 team handovers, whereas triage nurses took 97% (95% CI 95.6–99.2) and attending nurses, 91% (95% CI 87.5–93.9). Fifty per cent (95% CI 42.7–57.3) of emergency clinicians referred to ambulance sheets. Handover information was perceived to be useful and accurate in more than 80% of instances. Verbal handover occurred before ambulance sheet completion for 78% (95% CI 73.5–82.7). Conclusion: Although there is satisfaction in paramedic handover, prehospital notification and emergency physician contact with paramedics is uncommon for low acuity patients, who constitute the majority of ambulance attendances and hospital admissions. Scope for improved direct doctor–paramedic communication exists.     

Factors influencing emergency hospital admissions from nursing and residential homes: positive results from a practice‐based audit

Background and aims Emergency admissions of frail older people in care homes, many of whom have dementia, are critical events which should be avoided if possible. To identify and influence factors related to emergency admissions and place of death. Method Design of study: Completed audit cycle. Setting: Jenner Health Centre patients in six local care homes. Data collection over 12 months in 05/6, repeated in 08/9. Emergency admissions, admitting health professional, assessment prior to admission, length of hospital stay, annual visit workload and place of death. Results Admission numbers fell from 91 (194 patients) in 05/6 to 52 (183 patients) in 08/9, related to a fall in admissions by general practitioners (GPs) and out of hours (OOH). The proportion of admissions by care home staff doubled. There was a highly significant difference (P < 0.001), between GPs and OOH in patients visited prior to admission in 05/6 which persisted in 08/9 (P < 0.01). A hospital stay >72 hours was significantly more likely if patients were visited prior to admission. In 05/6, 55% of deaths occurred in the care home rising to 75.5% in 08/9 (total numbers deaths unchanged). There was a highly significant difference (P < 0.001 05/6 and 08/9), between deaths in nursing compared with residential homes. GP visits to nursing home patients rose by 10.3% but visits to residential home patients fell by 5.4%. Conclusions The aims of the audit were achieved with a 43% reduction in emergency admissions and a 45% reduction in deaths in hospital but at the expense of a 12% increase in visits. Improved anticipatory planning and increased medical and nursing support for patients and staff in residential homes may help to further reduce emergency admissions and deaths in hospital in future.     

International Emergency Medicine: A Review of the Literature from 2006

The field of international emergency medicine (IEM) has grown rapidly over the past several decades, with a rise in the number of IEM fellowship positions, sustained growth in the international sections of major emergency medicine organizations, and an increase in the range of topics included under its rubric. One of the greatest obstacles to the continued growth of IEM remains the lack of a high-quality, consolidated, and easily accessible evidence base of literature. In response to this perceived need, members of the Emergency Medicine Residents' Association IEM Committee, in conjunction with members of the Society for Academic Emergency Medicine International Health Interest Group, embarked on the task of creating a recurring review of IEM literature. This article reviews 25 IEM research articles published in 2006. Research articles were selected for the review according to explicit, predetermined criteria that included both methodological quality and perceived impact of the research. It is the authors' hope that this annual review will act as a forum for disseminating best practices while also stimulating further research in the field of IEM.     

Preventable deaths in patients admitted from emergency department

Background

There is limited data about how appropriate medical care is in the emergency department (ED).

Objectives

To investigate the rate and types of preventable deaths among patients with early mortality after emergency admission from the ED.

Methods

We retrospectively reviewed charts of early mortality (defined as mortality which occurred within 24 hours after admission from the ED ) over a 3 year period. Those patients with terminal cancer or out of hospital cardiac arrest (OHCA) at presentation were excluded. Two independent assessors reviewed each eligible chart and determined whether early mortality was preventable. Any disagreements were resolved through discussion between the investigators. A mortality event was considered preventable if actions or missed actions were identified that would have prevented the death. The types of preventability were categorised as misdiagnosis, delayed diagnosis, and inappropriate medical management. Interrater reliability in the initial determination was assessed using Cohen κ statistic.

Results

Over a 3 year period, 210 early mortality cases were identified. Excluding patients with terminal cancer or OHCA, the rate of preventable deaths was 25.8% (32/124). The types of preventability were inappropriate medical management (17 patients), delayed diagnosis (eight), and misdiagnosis (seven). There was good agreement between assessors with a Cohen κ statistic of 0.81.

Conclusions

Preventable deaths in emergency admitted patients with early mortality are not uncommon. Analysis and identification of preventability early mortality by using a chart based method may be used as a quality assurance index in emergency medical care.     

Significant event auditing

Significant event auditing has been described for 5 years and it is slowly gaining credibility as an effective method of quality assurance in British general practice. This paper describes what it is, what its background is, how it is done and whether it is effective. While it needs a positive team culture - and therefore may not suit every practice - where it is used it appears to be a useful adjunct to a clinical audit programme.