基于倾向性评分匹配法急诊院前救护（EMS）与病情危重程度及相关影响因素的研究

目的:通过分析急诊院前救护（emergency medical services ,EMS）与患者病情严重程度相关性,评价EMS资源的合理使用情况;分析EMS送入急诊抢救室患者的相关特征,构建相关预测模型并为进一步优化EMS资源使用提供循证医学证据。方法:利用中国急诊专科医联体多中心急诊分诊数据相关数据库(CETAT数据库)抽取2020年1月至2021年7月间中国科学技术大学附属第一医院急诊抢救室收住患者的相关信息,根据就诊时是否呼叫EMS送诊将患者分为EMS送入组（AB+组）和自行就诊组（AB-组）。记录患者入急诊抢救室后的一般情况、生命体征、化验室检查结果等数据。根据最终是否收住重症医学科、专科监护室、接受急诊手术和/或急诊介入手术等处理判断患者的病情危重程度。分别建立不需要化验室检查的9变量模型和需要化验室检查的22变量模型进行倾向性评分校正,分析呼叫EMS转运是否与患者危重程度相关。亚组分析中按患者就诊原因分析EMS与患者危重程度的相关性。结果:本研究纳入期间抢救室收住患者16 489名,经相关标准筛选后最终纳入患者6 975名,其中AB+组患者2 768名（39.7%）,AB-组患者4 207名（60.3%）。AB+组中的高危患者522名（18.9%）,AB-组中高危患者563名（13.4%）。与AB-组相比,AB+组患者年龄更大,昏迷患者的比例更高,就诊时自主心率更快,而舒张压和血氧饱和度更低。9变量模型中,性别,意识水平,体温,心率以及舒张压是患者呼叫EMS的相关因素,22变量模型中,意识水平,血氧,中性粒细胞绝对值,白蛋白等是患者呼叫EMS的相关因素。倾向性评分校正前,呼叫EMS送诊是患者病情危重的独立危险因素（ OR=1.5,95% CI:1.32~1.72, P<0.001）,倾向性评分9变量模型校正后,EMS送诊比值比较未校正时减小（ OR=1.24,95% CI: 1.08~1.42, P<0.001）但仍有统计学意义,倾向性评分22变量模型校正后EMS送诊与患者病情危重程度无相关性（ OR=1.10,95% CI:0.95~1.28, P=0.195）。亚组分析中,中枢神经系统疾病就诊,心血管系统疾病就诊和外伤是就诊的前三位原因。未经倾向性评分校正前,中枢神经系统疾病、消化系统疾病、外伤就诊的患者EMS送诊与患者危重程度有关。9变量模型校正后,仅外伤亚组中EMS送诊与病情危重程度相关。22变量校正后,3个亚组中呼叫EMS送诊均与患者危重程度无显著相关性。 结论:呼叫EMS送诊在急诊抢救室收住患者中较为常见。与患者危重程度相关性随模型校正变量的增加而降低,提示EMS送诊并不意味着患者病情危重,多参数联合预测模型对于准确区分危重患者、优化院前EMS使用、避免不合理呼叫至关重要,未来的EMS资源或应当基于预测模型进行分层使用。     

Improvement of the Identification of Seniors at Risk scale for predicting adverse health outcomes of elderly patients in the emergency department

ObjectivesTo explore the validity of the Chinese version of the Identification of Seniors at Risk (ISAR) screening tool in emergency rooms (ERs) to identify elderly patients prone to adverse outcomes after being discharged from the ER.MethodsA prospective single-center observational study design was adopted and included 497 elderly (aged ≥65 years) ER patients of a medical center in northern Taiwan. Before discharge from the ER, baseline sociodemographic and clinic data were collected by researchers and the ISAR was administered. Adverse health outcomes (ER revisits, readmissions, and mortality) at 30 days were evaluated by medical records and follow-up telephone interviews.ResultsISAR screening showed that 334 (67.2%) elderly patients in the ER were at high risk after discharge. Higher-risk patients were older, had had a fall within the previous 6 months, and had complex comorbidities. The ISAR had good sensitivity (0.77∼1.00) for screening adverse health outcomes in these elderly patients. The discrimination of the ISAR for adverse health outcomes was 0.60∼0.77, and it increased to 0.64∼0.80 when the age-adjusted Charlson comorbidity index (ACCI) was simultaneously considered.ConclusionsThe ISAR exhibited good sensitivity for screening adverse outcomes for elderly patients at risk. The ACCI is recommended to simultaneously be considered to improve the prognostic performance of the ISAR.     

Improving triage accuracy through a modified nurse-administered emergency department assessment of chest pain score on patients with chest pain at triage (EDACT): A prospective observational study

BackgroundChest pain triage in our emergency department (ED) prioritize patients for consultation based on unstructured nursing gestalt. The Emergency Department Assessment of Chest Pain Score (EDACS) identifies patients at low-risk for major adverse cardiac events and may provide standardization for chest pain triage in ED.MethodsWe conducted a prospective observational study, including adult patients with chief complaint of chest pain who were self-conveyed. We aimed to evaluate the overall diagnostic performance of a modified EDACS in triaging these patients.ResultsData was collected over 6 weeks, with 284 patients included in the final analysis. Nursing gestalt had higher sensitivity (97.6%, 95% confidence interval [CI] 87.4% to 99.9% versus EDACS 45.2%, 95% CI 29.8% to 61.3%), while modified EDACS provided higher specificity (76.4%, 95% CI 70.6% to 81.6%, versus nursing gestalt 29.8%, 95% CI 24.1% to 35.9%). EDACS with electrocardiogram had significantly better area under the receiver operating characteristic curve statistic (0.712; 95% CI 0.631 to 0.793) than EDACS alone (0.608; 95% CI 0.528 to 0.689) and nursing gestalt (0.637; 95% CI 0.600 to 0.674) (p = 0.0324).ConclusionsFurther studies should explore if modified EDACS, together with nursing gestalt, can improve triage accuracy for ED patients with chest pain.     

Injuries occurring in hospital staff attending medical emergency team (MET) calls—A prospective,observational study

Background

Clinical emergency response systems such as medical emergency teams (MET) have been implemented in many hospitals worldwide, but the effect that these systems have on injuries to hospital staff is unknown. The objective of this study was to determine the rate and nature of injuries occurring in hospital staff attending MET calls.

Methods

This study was a prospective, observational study, using a structured interview, of 1265 MET call participants, in a 650 bed urban, teaching hospital. Data was collected on the number and the nature of injuries occurring in hospital staff attending MET calls.

Results

Over 131 days, 248 MET calls were made. An average of 8.1 staff participated in each MET call. The overall injury rate was 13 (95% confidence interval (CI) 7–20) per 1000 MET participant attendances, and 70 (95% CI 38–102) per 1000 MET calls. One injured participant required time off-work, an injury requiring time off-work rate of 1 (95% CI 0–4) per 1000 MET participant attendances, or 4 (95% CI 0–27) per 1000 MET calls. The relative risk of sustaining an injury if the MET participant performed chest compressions, contacted patient body fluids on clothing or protective equipment, without direct contact to skin or mucosa, or lifted the patient or a patient body part was 11.0 (95% CI 4.2–28.6), 8.7 (95% CI 3.4–22.0) and 5.5 (95% CI 2.1–14.2), respectively.

Conclusion

The rate of injuries occurring to hospital staff attending MET calls is relatively low, and many injuries could be considered relatively minor.     

The accuracy of adult limb radiograph interpretation by emergency nurse practitioners: A prospective comparative study

Background

One of the extensions to practice for the emergency nurse practitioner role is to appropriately order and interpret radiographs in the emergency department.

Objective

The aim of the study was to compare the accuracy in interpreting isolated adult limb radiographs between emergency nurse practitioners and emergency physicians.

Design

A prospective comparative study was undertaken.

Setting

Emergency department in a large metropolitan hospital.

Participants

200 adult patients with isolated limb injuries were consented.

Methods

Six emergency nurse practitioners and ten emergency physicians participated. One emergency physician and emergency nurse practitioner independently clinically assessed each patient, determined the need for radiograph and separately recorded their interpretation of the radiograph as either definite fracture, no fracture or possible fracture. A single consultant radiologist reviewed each radiograph and their interpretation was seen as the gold standard. The sensitivity and specificity of emergency physicians and emergency nurse practitioners were calculated. To measure the level of agreement between the two-clinician groups, the weighted Kappa statistic was used.

Results

The sensitivity for the emergency nurse practitioners was 91% and 88% for the emergency physicians. The specificity for the emergency nurse practitioners was 85% and for the emergency physicians 91%. The weighted Kappa on the presence of a fracture between the emergency nurse practitioners and emergency physicians was 0.83.

Conclusions

This study validates the clinical and diagnostic skills of emergency nurse practitioners assessed in the interpretation of isolated adult limb injury radiographs.     

Tracheal intubation in an urban emergency department in Scotland: A prospective,observational study of 3738 intubations

AimThe emergency department (ED) is an area where major airway difficulties can occur, often as complications of rapid sequence induction (RSI). We undertook a prospective, observational study of tracheal intubation performed in a large, urban UK ED to study this further.MethodsWe reviewed data on every intubation attempt made in our ED between January 1999 and December 2011. We recorded techniques and drugs used, intubator details, success rate, and associated complications. Tracheal intubation in our ED is managed jointly by emergency physicians and anaesthetists; an anaesthetist is contacted to attend to support ED staff when RSI is being performed.ResultsWe included 3738 intubations in analysis. 2749 (74%) were RSIs, 361 (10%) were other drug combinations, and 628 (17%) received no drugs. Emergency physicians performed 78% and anaesthetists 22% of intubations. Tracheal intubation was successful in 3724 patients (99.6%). First time success rate was 85%; 98% of patients were successfully intubated with two or fewer attempts, and three patients (0.1%) had more than three attempts. Intubation failed in 14 patients; five (0.13%) had a surgical airway performed. Associated complications occurred in 286 (8%) patients. The incidence of complications was associated with the number of attempts made; 7% in one attempt, 15% in two attempts, and 32% in three attempts (p < 0.001).ConclusionA collaborative approach between emergency physicians and anaesthetists contributed to a high rate of successful intubation and a low rate of complications. Close collaboration in training and delivery of service models is essential to maintain these high standards and achieve further improvement where possible.     

Gestalt for shock and mortality in the emergency department: A prospective study

Objective

The diagnosis of shock in patients presenting to the emergency department (ED) is often challenging. We aimed to compare the accuracy of experienced emergency physician gestalt against Li's pragmatic shock (LiPS) tool for predicting the likelihood of shock in the emergency department, using 30-day mortality as an objective standard.

Violence toward emergency physicians: A prospective-descriptive study

BACKGROUND: The highest rate of workplace violence occurs in the health sector, although most cases remain unreported. Emergency services face the majority of these incidents for many reasons, such as the patient profile, long waiting time, and overcrowding. We aimed to determine the characteristics and causes of violence toward emergency physicians.     

Non-invasive mechanical ventilation in Australian emergency departments: A prospective observational cohort study

Objectives

Data describing use of non-invasive ventilation (NIV) in the emergency department (ED) setting consist primarily of physician surveys. Our objective was to conduct a prospective study to document the characteristics of patients receiving NIV, interfaces, mode, and parameters used as well as NIV duration and decision-making responsibility.

Methods

We conducted a 2-month prospective observational study of adult patients who received NIV in 24 EDs. Patient characteristics, delivery methods, and decision-making responsibility were documented for each ED presentation.

Results

Data were recorded on 245 patients; 185 patients received non-invasive positive pressure ventilation (NIPPV) and 60 received continuous positive airway pressure (CPAP). Acute cardiogenic pulmonary oedema (ACPO) (80/245, 33%) and exacerbation of chronic obstructive pulmonary disease (COPD) (75/245, 31%) were the two most frequent indications for NIV. Compared to patients with respiratory failure from other aetiologies, those with ACPO were more likely to receive CPAP (28/80 [35%] versus 32/165 [19%] P = 0.008). Initial NIV settings were selected by ED nurses for 118/245 (48%) patients, by ED physicians for 118/245 (48%) patients, and by ICU staff for 3/245 (1.5%) patients (not reported for 6 [2.5%] patients). The role of ED nurses in the selection of initial NIV settings was not influenced by ED location, patient type or triage category.

Conclusions

Acute exacerbations of CPO and COPD were the most common indications for NIV. Clinicians demonstrated a preference for NIPPV for all patient aetiologies except ACPO. Responsibility for NIV management was shared by ED nurses and physicians.     

Drug dependence and its risk factors in emergency department patients: A retrospective cross-sectional study

Objective: To determine the characteristics and risk factors of drug dependence among patients who were administered drugs with addictive potential (DAP) in an emergency department (ED).Methods: This retrospective cross-sectional study included patients who were administered DAP 3 or more times in the emergency room between September 1, 2019 and March 1, 2020. The demographic and baseline information were recorded. All the prescibed DAP, the reasons to use these drugs, secondary drug dependence, the department where DAP were first prescribed, types of doctors who preferred to prescribed DAP, and the risk factors for the development of drug dependence were determined. Results: A total of 3000 patients were screened from medical records, and among them, 80 patients developed drug dependence. Drug dependence only developed for tramadol (n=57, 71.3％), diazepam (n=11, 13.8％), and biperiden (n=12, 15.0％). Tramadol was the most frequently prescribed drug (n=57, 71.3％). The most common reason for drug dependence was psychiatric disorders (n=29, 36.3％). Drug dependence developed in renal colic patients due to the administration of tramadol (n=7, 100％). On the contrary, dependence to biperiden were mainly developed in patients with psychiatric complaints (n=12, 41.4％). The rate of secondary drug dependence was 15％ (n=12). Of the Biperiden users, 41.7％ developed secondary drug dependence on diazepam. Most DAP were first prescribed in the ED (n=52, 65％), and the specialist preferred to prescribe DAP (n=43, 53.8％). For the development of dependence, the presence of renal colic (OR: 3.387, 95％ confidence interval (CI): 1.473-7.788, P=0.004) and low back pain (OR: 5.778, 95％ CI: 2.779-12.014, P<0.001) were the risk factors. Conclusions: Most DAP were first prescribed in the ED compared to other departments, and specialist are preferred to use DAP. Tramadol is the most commonly used drugs caused drug dependence. Psychiatric disorder patients are easier to develope drug dependence. Furthermore, renal colic and low back pain patients needs more attention to avert drug dependence.     

舒适护理运用于急诊科临时输液室的探讨

目的探讨急诊科临时输液室的舒适护理模式。方法采用自行设计调查表调查急诊输液患者运用舒适护理的前后各100例对输液环境、护士的技术操作及服务质量的满意度。结果通过改善输液环境、合理安排护士班次、规范操作流程、提高护理人员服务态度等,使病人的总体满意度由71．5％上升到95．5％。结论舒适护理运用于急诊科临时输液室,充实了“以人为本”的整体护理质量。     

急诊心肺复苏140例临床分析

目的分析因心跳骤停（CA）来院急救的140例患者行心肺复苏后的结果及影响心肺复苏的相关因素,为有效的心肺复苏提供临床参考资料。方法选择2009年1月至2010年1月四川省人民医院城东病区急救的140例心跳骤停患者,分析患者复苏的方式、急救时间及复苏的结果等,为临床心肺复苏提供有价值的参考材料。结果复苏失败122例,成功18例,其中3例痊愈出院。复苏的方式、时间等对心肺复苏结果有重要影响。结论心跳骤停是急诊医学中的常见情况,急诊工作者要在尽可能短的时间内进行正确的心肺复苏才能提高患者的存活率。     

预防性护理程序在急症手术中的应用研究

目的 :比较常规护理与预见性护理在急症手术中应用的效果。方法 :将 80例急症手术患者随机等分为两组 ,即常规护理组 (对照组 )与预见性护理程序组 (实验组 ) ,记录两组从接手术通知单到手术开始的时间。结果 :两组所用时间差异有显著性 (P <0 0 1)。结论 :预见性护理程序为急症患者减少了术前物品准备的时间 ,提高了手术成功率。     

102例急诊科非创伤性死亡病例分析

目的了解急诊科非创伤性死亡的病因构成和救治状况,为制定预防措施提供依据。方法对我院2009年全年急诊科非创伤性死亡病例进行回顾性分析,对以上患者的性别、年龄、病因、抢救时间、抢救措施等资料进行整理。结果平均死亡年龄为68．1岁,以70—80岁年龄段最多;23．5％的死亡病例小于60岁;非创伤性死亡原因依次为心脏病、脑血管病、呼吸系统疾病、猝死、恶性肿瘤,心脑血管病占58．8％;猝死、急性脑血管病患者在急诊抢救室滞留时间长。结论①心脑血管疾病占急诊非创伤性死亡病例的大部分;②应重视改善急诊危重抢救措施。     

126例严重多发伤的急诊救治

目的 探讨严重多发伤急诊科救治的重要性.方法 回顾性分析总结2003年3月至2007年6月4年多126例严重多发伤病人急诊救治的过程及要点.结果 本组126例抢救成功109例,成功率80.2%;死亡17例,死亡率19.8%.结论 多发伤在复苏、抗休克的同时尽可能的快速作出诊断,缩短中间环节,快速启动救命的手术程序,是提高抢救成功率的关键.     

A profile of the waiting room nurse in emergency departments: An online survey of Australian nurses exploring implementation and perceptions

BackgroundIn response to increasing waiting times, adverse patient outcomes and patient dissatisfaction, some emergency departments introduced a Waiting Room Nurse role. Despite implementation into routine practice, there remains limited formal evaluation of the role.AimTo explore the implementation of a Waiting Room Nurse role in Australian emergency departments and emergency nurses’ perceptions.MethodsSurvey design. A 40-item survey was developed, piloted and then distributed to members of a professional College for online completion. Responses for closed-ended and open-ended items were reported using frequencies or proportions, and quantitative content analysis, respectively.ResultsRespondents (n = 197) reported that 51 emergency departments allocated a Waiting Room Nurse, with varying hours of operation. Five key areas of responsibility were: patient care, patient safety, escalation of care, triage and communication. Role variations were identified in experience, preparation and supporting policies. Challenges, including workload and personal safety issues, were reported.ConclusionsThe role was perceived as vital, especially at times of high demand, in ensuring that patients were safe to wait, detecting deterioration and escalating care as needed. Communication and therapeutic relationships were key to effective performance. Challenges identified had clear implications for the welfare of nurses performing the role.