急诊室患者滞留的影响因素

急诊室患者滞留时间是指患者从预检分诊开始到离开急诊室的时间段,包括急诊预检分诊时间(通常很短,可忽略不计)、抢救治疗时间、初步抢救后决定住院到实际离开急诊室的时间[1].患者的不合理滞留会带来严重的后果,包括增加患者的住院时间、医疗费用、不良事件发生率和病死率.所以,急诊室患者滞留时间是衡量急诊患者处置质量和效率的一个重要指标,被广泛运用于严重创伤、危急重症患者的急诊疾病处置中.     

标准作业流程在急性重症创伤救治中的应用研究

目的:总结标准作业流程(SOP)在急性重症创伤救治中的应用价值。方法:回顾性研究2017年1月-2017年12月三水区人民医院急诊科接诊的急性创伤患者212例的临床资料。结果:212急性创伤患者中重症创伤占130例(61.3%),急诊救治成功为81.2%,死亡率为19.8%。急性创伤SOP使创伤患者在急诊的滞留时间明显缩短,为患者的确定性治疗赢得相对充足的时间,急性创伤患者死亡率与急诊室滞留时间正相关。结论:在县区级医院建立创伤救治SOP,能够提高急性创伤患者的救治成功率和降低死亡率。     

全面提高严重创伤院内急诊救护水平的应对策略

严重创伤,特别是车祸伤救治是日常急诊急救所面临的最重要任务之一。创伤后1h被称为"黄金1h"[1],而这段时间恰恰是患者到达医院急诊抢救的时间。危重创伤患者在急诊室可尽快明确诊断,伤情评估并获得确定性治疗,大多数患者都可救治成功。故危重创伤患者在急诊科滞留时间一定程度上反映了急诊科的工作效能及医疗水平[2]。如何突出抢救的时效性,使创伤患者到达医院急诊     

整体护理在急诊严重创伤患者救治中的应用

严重创伤患者的抢救是急诊室工作的重要任务之一。为进一步提高救护质量及抢救成功率，提高急救护理满意度，江苏省苏北人民医院急诊室尝试将整体护理应用到急诊救护的全过程，在对2005年1～8月间190例严重创伤患者的急救护理中，紧紧围绕“以患者为中心”的整体护理模式，不断完善创伤急救的组织系统，使严重创伤急救的几个重要阶段即院前急救、急诊室急救、急危重症监护病房的监护治疗紧密相连，     

整体护理在急诊严重创伤患者救治中的应用

严重创伤患者的抢救是急诊室工作的重要任务之一.为进一步提高救护质量及抢救成功率,提高急救护理满意度,江苏省苏北人民医院急诊室尝试将整体护理应用到急诊救护的全过程,在对2005年1～8月间190例严重创伤患者的急救护理中,紧紧围绕“以患者为中心“的整体护理模式[1], 不断完善创伤急救的组织系统,使严重创伤急救的几个重要阶段即院前急救、急诊室急救、急危重症监护病房的监护治疗紧密相连,构成严重创伤急救的基本护理工作程序,从而为患者赢得了抢救的黄金时间[2], 大大提高了抢救成功率及护理质量,取得了满意效果.……     

综合性三甲医院急诊室抢救患者滞留状况的研究

目的调查某家综合性三甲医院抢救患者在急诊室的滞留状况,为进一步加快急诊抢救患者的分流,提高急诊服务质量提供依据。方法使用急诊预检分诊数据库,回顾性调查分析某综合性三甲医院2010年全年急诊室抢救患者的相关信息,包括不同月份、不同科室、不同去向抢救患者的滞留时间及可能的原因。结果①该院全年7966例抢救患者在急诊室滞留的时间为0.5～2998 h,中位数10 h（四分位数3～23 h）;②不同月份抢救患者的滞留时间比较差异有统计学意义（χ2=22.869,P=0.018）,其中2月份最短,5月份最长;③患者对急诊抢救室床位占用时间最长的4个科室依次为急诊内科、神经外科、神经内科和急诊科,合计达91.8%的总床位占用时间。患者在急诊抢救室滞留时间最长的4位科室依次为急诊内科、神经内科、神经外科和胸外科;④不同去向的抢救患者滞留时间比较差异有统计学意义（χ2=731.471,P〈0.0001）,其中以直接住院和自动出院患者的滞留时间最长;⑤滞留时间24 h以上的抢救患者中,83.4%与相应的专科病房无床有关。结论该家医院急诊室抢救患者的滞留状况比较严重,其中急诊内科、神经内科、神经外科3个科室尤为严重,主要与相应专科的病房床位供应不足有关,医院有必要采取相应的对策。     

"绿色通道"'模式护理救治546例严重手外伤患者分析

目的:探索"绿色通道"模式对严重手外伤患者急诊室处理的护理流程,以缩短患者受伤至确定性治疗的处理时间.方法:回顾性分析我院创伤抢救室2010年7月~2011年2月间人手术室治疗的严重手外伤患者546例的临床救护资料.结果:除常规包扎、止血、固定外,505例拍X线、496例行血液检验、17例做心电图:189例建立浅静脉留置针、372例肌注止痛剂;18例上气压止血带;56例离断肢体保存.手外伤患者来诊时间多在15:00~22:59,急诊室平均滞留时间为(46.5±14.3) min.结论:我院的严重手外伤患者抢救护理流程模式是创伤急救的有效模式.     

588例急诊死亡病例的回顾性分析

目的:对我院近年急诊死亡的病例资料进行回顾性分析,探讨急诊死亡患者的特点,以提升急诊危重疾病的救治能力,提高抢救成功率,减少不良预后,为提升类似老龄化城市的健康水平提供参考建议。方法:对2016-01—2019-12期间在我院急诊死亡的588例患者资料进行分析,包括性别、年龄、死亡的原因、季节分布、到急诊室的抢救时间等。结果:男性(419例)死亡人数明显多于女性(169例),男女比例2.48∶1,46～65岁是急诊死亡的高发年龄。患者达到医院高峰时间段为6:00～10:00和16:00～20:00。到达急诊时诊断为到院前死亡的病例占61.90%。急诊死亡原因中,排名前3位的依次是心源性猝死、脑血管性疾病、各种严重创伤,其中创伤疾病死因以车祸和坠落伤为主,高龄患者的主要死亡原因是内科系统疾病。结论:人口老龄化的城市,急诊死亡的特点需要引起重视,加强院前急救、院内急危重病患者的救治,有助于提高抢救成功率。同时应注重慢性病的健康管理,给予高龄患者必要的监护,有助于减少不良预后的发生。     

应用急诊信息化管理系统分析急诊患者滞留状况

目的根据急诊信息化管理系统数据,分析沈阳军区总医院急诊患者滞留状况,为加强急诊患者分流,改善急诊拥挤现象,提高急诊医疗服务质量提供依据。方法采用急诊信息化管理系统数据库,对2014年11月至2015年2月急诊滞留时间超过48 h的患者进行回顾性分析。结果 2014年11月至2015年2月我院急诊滞留超过48 h的患者231例。滞留患者以神经系统、心血管系统、消化系统等疾病为主,主要为神经内科、神经外科、心血管内科、消化内科等科室患者。患者滞留原因主要与逐步完善检查明确疾病诊断和病房床位紧张等因素有关。结论急诊滞留情况较严重,需要急诊医务人员、患者与家属、各专科病房、医院等各方面努力。     

急诊室过度拥挤的现状与对策

急诊室过度拥挤是近二十年全球医院普遍面临的难题,其核心问题是急诊患者不合理地滞留于急诊室.医院床位长期利用率高,床位不足是关键原因.此外,急诊就诊量的增加,急诊室内检查量增多等也是重要原因.患者在急诊室内的滞留时间延长,预后将变差.缓解过度拥挤的对策主要集中在合理利用现有的医疗资源,适当增加医院床位,调整住院患者的出院模式等方面.但直到目前为止,仍然没有有效的缓解措施.急诊室过度拥挤问题还需进一步的研究.     

急诊危重患者急性肾损伤发生的危险因素分析

目的:调查急诊抢救室患者急性肾损伤（acute kindey injury,AKI）的发生率并探讨相关危险因素。方法:采用回顾性队列研究方法,纳入2018年9~12月经由本院抢救室收治的患者,根据患者入院后7 d内是否发生AKI,将患者分为AKI组和非AKI组。收集患者入抢救室时的人口学特征、APACHE Ⅱ评分、是否使用肾脏毒性药物、24 h液体出入量及院内生存时间等相关指标。使用多因素Logistic回归分析AKI发生的危险因素。使用COX回归研究AKI的发生对患者住院生存率的影响,并分析AKI严重程度对患者死亡风险的影响。结果:纳入急诊抢救室的患者238例,其中108例发生AKI（45.4%）,AKI 1期83例（34.9%）,AKI 2~3期25例（10.5%）。APACHE Ⅱ评分>13分[ OR=1.11,95% CI（1.07~1.16）, P<0.01],应用血管活性药[ OR=2.20,95% CI（1.08~4.49）, P=0.03],糖尿病（ OR=2.33,95% CI（1.23~4.42）, P=0.01）,24 h入量>3 L（ OR=3.10,95% CI（1.17~8.25）, P=0.02）是发生AKI的独立危险因素。多因素COX回归校正APACHE Ⅱ评分和年龄后,AKI仍是急诊抢救室患者死亡的独立危险因素,且AKI严重程度显著增加急诊患者死亡风险[AKI1期 HR=1.45,95% CI（1.08~2.03）, P=0.04; AKI2-3期 HR=3.15,95% CI（1.49~4.81）, P=0.03]。 结论:急诊抢救室患者中AKI的发生较常见。APACHE Ⅱ评分>13分,应用血管活性药,糖尿病,24 h入量>3 L是发生AKI的独立危险因素。随着AKI严重程度的增加,死亡风险增加。     

急诊危重患者急性肾损伤发生的危险因素分析

目的:调查急诊抢救室患者急性肾损伤（acute kindey injury,AKI）的发生率并探讨相关危险因素。方法:采用回顾性队列研究方法,纳入2018年9~12月经由本院抢救室收治的患者,根据患者入院后7 d内是否发生AKI,将患者分为AKI组和非AKI组。收集患者入抢救室时的人口学特征、APACHE Ⅱ评分、是否使用肾脏毒性药物、24 h液体出入量及院内生存时间等相关指标。使用多因素Logistic回归分析AKI发生的危险因素。使用COX回归研究AKI的发生对患者住院生存率的影响,并分析AKI严重程度对患者死亡风险的影响。结果:纳入急诊抢救室的患者238例,其中108例发生AKI（45.4%）,AKI 1期83例（34.9%）,AKI 2~3期25例（10.5%）。APACHE Ⅱ评分>13分[ OR=1.11,95% CI（1.07~1.16）, P<0.01],应用血管活性药[ OR=2.20,95% CI（1.08~4.49）, P=0.03],糖尿病（ OR=2.33,95% CI（1.23~4.42）, P=0.01）,24 h入量>3 L（ OR=3.10,95% CI（1.17~8.25）, P=0.02）是发生AKI的独立危险因素。多因素COX回归校正APACHE Ⅱ评分和年龄后,AKI仍是急诊抢救室患者死亡的独立危险因素,且AKI严重程度显著增加急诊患者死亡风险[AKI1期 HR=1.45,95% CI（1.08~2.03）, P=0.04; AKI2-3期 HR=3.15,95% CI（1.49~4.81）, P=0.03]。 结论:急诊抢救室患者中AKI的发生较常见。APACHE Ⅱ评分>13分,应用血管活性药,糖尿病,24 h入量>3 L是发生AKI的独立危险因素。随着AKI严重程度的增加,死亡风险增加。     

Contributing factors to chronic myofascial pain: a case-control study

This case-control study was designed to investigate the contributing factors for chronic masticatory myofascial pain (MFP). Eighty-three patients with MFP, selected from the dental clinics of the Jewish General and Montreal General Hospitals, Montreal, Canada, and 100 concurrent controls selected only at the first clinic, participated in this study. The association with MFP was evaluated for bruxism, head-neck trauma, psychological factors (symptom check list 90 revised questionnaire, SCL-90R) and sociodemographic characteristics by using unconditional logistic regression. Clenching-grinding was associated with chronic MFP in multiple models including anxiety (OR=8.48; 95% CI: 2.85; 25.25) and depression (OR=8.13; 95% CI: 2.76; 23.97). This association also remained for MFP, excluding all other temporomandibular disorders (TMD). Clenching-only (OR=2.54; 95% CI: 1.10; 5.87) and trauma (OR=2.10; 95% CI: 1.0; 4.50) were found to be associated with the chronic MFP, when the level of anxiety was adjusted in the model. No significant change was noted when the effects of clenching-only (2.76; 95% CI: 1.20; 6.35) and trauma (OR=2.08; 95% CI: 1.03; 4.40) were adjusted for depression. Clenching-only and clenching-grinding remained related to MFP regardless of patients being informed about these habits. A higher score of anxiety (OR=5.12; 95% CI: 1.36; 19.41) and depression (OR=3.51; 95% CI: 1.07; 11.54) were associated with MFP, as well as other psychological symptoms. In addition, female gender had almost three times the risk of chronic MFP than males when the model was also adjusted for psychological symptoms. Grinding-only, age, household income and education were not related with chronic MFP. Tooth clenching, trauma and female gender may contribute to MFP even when other psychological symptoms are similar between subjects.     

Effect of paraoxonase-1 polymorphism on clinical outcomes in patients treated with clopidogrel after an acute myocardial infarction

Paraoxonase-1 (PON1) Q192R polymorphism was recently suggested to determine per se clopidogrel response on major cardiovascular events (MACEs). We assessed the impact of PON1, CYP2C19, and ABCB1 polymorphisms on MACE in clopidogrel-treated acute myocardial infarction (AMI) patients (N = 2,210), including those undergoing percutaneous coronary intervention (PCI) (n = 1,538). PON1 polymorphism was not associated with increased risk of in-hospital death and MACEs at 1 year (adjusted hazard ratio (HR) 1.03, 95% confidence interval (CI) 0.66-1.61 and adjusted HR 0.77, 95% CI 0.42-1.41 for QQ versus RR in all and PCI patients, respectively). The presence of two CYP2C19 loss-of-function (LOF) alleles was associated with the risk of in-hospital death and MACEs at 1 year in the overall population (adjusted odds ratio (OR) 3.67, 95% CI 1.05-12.80 and adjusted HR 1.96, 95% CI 1.08-3.54) and in PCI patients (adjusted OR 6.87, 95% CI 2.52-18.72 and adjusted HR 3.06, 95% CI 1.47-6.41). Unlike CYP2C19 polymorphism, PON1 (Q192R) polymorphism is not a major pharmacogenetic contributor of clinical response to clopidogrel in AMI patients.     

Emergency Medicine Resident Scheduling and Patient Exposure

OBJECTIVES: As a result of increasing emergency department census and patient waiting times at the authors' institution, attending physician staffing was increased, followed by a change in resident shift schedule. A study was undertaken to ascertain any change in residents' exposure to patients during the times before and immediately following the staffing and scheduling changes. METHODS: The number and triage acuity of patients seen by residents were recorded and compared during four distinct time periods: two historical control periods with double attending coverage and two simultaneously scheduled residents; a period of triple attending coverage with two simultaneously scheduled residents; and a final period of triple attending coverage and staggered resident scheduling. RESULTS: Residents tend to see more patients per shift as the academic year progresses (mean increase of two per shift between fall and spring [95% CI = 1.5 to 2.4]). The increase to triple attending coverage during peak times did not alter the number or acuity of patients being seen by emergency medicine residents. However, a change in the resident's schedule from simultaneous day shifts to staggered day and night shifts was associated with a crude decrease in the number of patients seen by 0.7 per shift (95% CI = 0 to 1.3), and a decrease of 1.0 (95% CI = 0.4 to 1.2) when adjusted for patient census. CONCLUSIONS: After an increase in attending coverage, there was no change in the number or triage acuity of patients seen by residents. Staggered scheduling may decrease residents' exposure to patients compared with simultaneous scheduling.     

Predicting Asthma Morbidity in Harlem Emergency Department Patients

OBJECTIVES: To determine predictors of asthma morbidity in African American patients with asthma. Proxies for asthma morbidity were emergency department (ED) visits for asthma and hospitalizations for asthma. METHODS: This was a prospective observational study that evaluated baseline predictors of asthma morbidity in adults in an urban, predominantly African American community in New York City. Potential predictors of asthma morbidity evaluated were education, gender, employment status, current smoking status, asthma severity, duration of asthma, daily use of a peak flow meter, presence or absence of pets at home, presence or absence of a significant other, presence or absence of medical insurance, and previous hospitalization for asthma in the past year. Follow-up consisted of a repeat questionnaire obtained between nine and 15 months after the baseline questionnaire. Follow-up data collection was limited to the last three-month history of ED visits or hospitalizations before the follow-up visit. At follow-up, the baseline predictors were related to the presence or absence of ED visits for asthma or hospitalizations for asthma. All predictors were evaluated individually (crude odds ratio [OR]) and simultaneously (adjusted OR) in a logistic regression model with the dichotomous outcome variable ED visits or hospitalization. RESULTS: Return ED visits on follow-up were more likely to occur in asthma patients hospitalized in the previous year (adjusted OR, 3.9; 95% confidence interval [CI] = 1.7 to 9.0) and were less likely to occur in asthma patients with pets (OR, 0.4; 95% CI = 0.2 to 0.9). Patients with moderate/severe asthma, relative to patients with mild asthma, were more likely to be seen in the ED on follow-up on initial analysis (crude OR, 2.4; 95% CI = 1.1 to 1.5), but the adjusted OR was not significant. Follow-up hospitalizations were significantly more likely to occur only in subjects reporting daily use of a peak flow meter (OR, 6.8; 95% CI = 1.3 to 34.5). Subjects hospitalized for asthma in the previous year were more likely to be hospitalized subsequently on initial analysis (crude OR, 2.9; 95% CI = 1.0 to 8.1), but the adjusted OR was not significant. CONCLUSIONS: It appears that African American patients with asthma who had previous hospitalizations for asthma within the past year or use a peak flow meter daily (a marker for more severe asthma) are more likely to visit the ED in the future or to be hospitalized for asthma, respectively. These patients need to be targeted and treated more aggressively to improve asthma care and decrease morbidity. The apparent protective effect of the presence of pets on reducing ED visits is unclear at this time, and the findings need to be replicated and evaluated further.     

危险性上消化道出血患者病情严重程度危险因素分析及预警评估模型构建北大核心CSCD

目的探讨影响上消化道出血(upper gastrointestinal bleeding,UGIB)病情严重程度的影响因素,构建预警评估模型,以列线图的形式呈现,为急诊护士预检分诊提供可行依据。方法回顾性分析2019年1月至2020年1月温州医科大学附属第一医院急诊科收治的680例UGIB患者,采用随机数字表法分为建模组(510例)和验证组(170例),依据《2020急性上消化道出血急诊诊治流程专家共识》的标准分为高危组和低危组,比较组间各指标差异,多因素Logistic回归分析影响病情严重程度的因素,绘制列线图并验证。结果呕血(OR:3.875,95%CI:2.212~6.79)、糖尿病(OR:2.64,95%CI:1.184~5.883)、晕厥(OR:10.57,95%CI:3.675~30.403)、心率(OR:3.262,95%CI:1.753~6.068)、红细胞分布宽度(OR:3.904,95%CI:2.176~7.007)、凝血酶原时间(OR:3.665,95%CI:1.625~8.269)、乳酸(OR:3.498,95%CI:1.926~6.354)、血红蛋白(OR:4.984,95%CI:2.78~8.938)可准确预测UGIB病情严重程度(P<0.05)。列线图表现出良好的一致性和区分度(C-index=0.903,95%CI:0.875~0.931),并经内部验证(C-index=0.895)和Hosmer-Lemeshow拟合优度检验(P=0.7936)。外部验证C-index为0.899(95%CI:0.846~0.952),校准曲线提示预警评估模型具有良好稳定性,预测效能优于改良早期预警评分系统(P<0.05)。结论预警评估模型具有可靠的预测价值,可为急诊医务人员筛查高危患者和制定针对性护理干预措施提供参考依据。     

环氧化酶-2启动子变异与幽门螺杆菌感染交互和食管癌发病风险的关系

目的 探讨环氧化酶-2(COX-2)启动子区遗传变异与食管癌发病风险的关系,并评价幽门螺杆菌(Hp)感染对其相互作用的影响.方法 以PCR-限制性片断长度多态性方法 在119例食管癌患者和238例健康对照中进行基因分型.以Logistic回归计算比值比(OR)和95%可信区间(CI).结果 COX-2启动子区-1195 G>A遗传变异和食管癌发病风险相关.与1195GG基因型携带者相比,1195GA基因型和1195AA基因型罹患食管癌的发病风险增高,其OR(95%CI)值分别为2.69(1.46～5.14)和2.30(1.23～4.89).而且这种相关关系仅存在于Hp感染阳性的个体中,其OR(95%CI)值为2.74(1.35～5.96).结论 COX-2启动子区遗传变异对食管癌发病风险的影响和Hp感染的状态有关.

Abstract：

Objective To evaluate the association of COX2 genetic variants with the risk of esophageal cancer and the interaction of COX2 genetic variants with Hp infection. Methods A total of 119 patients with esophageal cancer and 238 frequency-matched controls were genotyped by polymerase chain reaction-restriction fragment length polymorphism method. Odds ratios (OR) and 95% confidence intervals ( CI) were estimated by logistic regression. Results Case-control analysis showed an increased risk of developing esophageal cancer for 1195 GA(OR =2.69,95% CI= 1. 46-5. 14) and 1195AA ( OR = 2. 30,95% CI = 1.23-4. 89) genotype carriers,respectively, compared with non 1195 GG carriers. When stratified by Hp status, the significantly increased risk of esophageal cancer was found among Hp carrier with OR (95%CI) =2.74 (1.35-5.96) ,but not among Hp non-carriers. Conclusion Genetic polymorphism in COX2 promoter region may play an important role in esophageal cancer by Hp infection.     

Cardiac arrest in public locations-An independent predictor for better outcome?

OBJECTIVE: Outcome after cardiac arrest is known to be influenced by immediate access to resuscitation. We aimed to analyse the location of arrest in relation to the prognostic value for outcome. DESIGN: Retrospective review from prospective databases (ambulance routine documentation database and emergency department database on patients treated for cardiac arrest). Setting: Vienna (1.7 million inhabitants) ambulance service and tertiary care facility (university clinics). Patients: Two independent cohorts: (1) a population-based cohort of patients who were treated for cardiac arrest by the municipal ambulance service outside the hospital. The endpoint in this group was survival to hospital admission with spontaneous circulation. (2) A cohort of patients who were admitted to the emergency department after successful out of hospital resuscitation. The endpoint in this group was survival to 6 months with good neurological status (best Cerebral Performance Category 1 or 2 within 6 months). MEASUREMENTS: We analysed whether the location of non-traumatic adult out-of-hospital cardiac arrest (public versus private place) was a predictor for good outcome. RESULTS: Patients who had cardiac arrest in a public location were more likely to arrive in hospital alive (39% versus 31%, crude OR 1.4, 95% CI 1.001-1.975, p=0.049) and were more likely to have a good neurological outcome after 6 months (35% versus 25%, crude OR 1.65, adjusted OR 1.59, 95% CI 1.07-2.36, p=0.023), compared to patients who had cardiac arrest in a non-public location. CONCLUSION: Cardiac arrest in a public location is independently associated with a better outcome.