The emergency nurse responses to triage interruptions and how these responses are perceived by patients: An observational,prospective study

BackgroundHealthcare providers’ responses to triage interruptions in the emergency department affect quality of care. The purposes for this study were to (1) Examine the relationship between nurses’ response to triage interruption and each of, patients’ perceived confidence in nurses’ technical skills, perceived competence of triage nurse, and satisfaction with the triage experience, (2) Examine the relationship between nurses’ response to triage interruption and nurse demographics.MethodsUsing an observational, prospective design, this study was conducted in an adult academic level 1 trauma center. Data collection tools were: The Triage Interruptions Assessment Tool, Triage and Provider Satisfaction and Confidence Survey, and Demographic Questionnaire.ResultsThe number of observed triage interviews is 93. Of them, 66 interviews were interrupted. No significant relationships were found between nurses’ response to the interruption and patients’ perceived confidence in nurses’ technical skills, competence of triage nurse, or satisfaction with triage experience. There were no significant relationships between nurses’ response to triage interruptions and nurses’ demographics.ConclusionsTriage interruptions in the emergency environment are common and most often result in delays in care. In the current study, this has not been shown to affect patients’ satisfaction. Nurses’ individual characteristics did not affect their responses to triage interruptions.     

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.

Poor performance of the modified early warning score for predicting mortality in critically ill patients presenting to an emergency department

BACKGROUND:

This study was undertaken to validate the use of the modified early warning score (MEWS) as a predictor of patient mortality and intensive care unit (ICU)/ high dependency (HD) admission in an Asian population.

METHODS:

The MEWS was applied to a retrospective cohort of 1 024 critically ill patients presenting to a large Asian tertiary emergency department (ED) between November 2006 and December 2007. Individual MEWS was calculated based on vital signs parameters on arrival at ED. Outcomes of mortality and ICU/HD admission were obtained from hospital records. The ability of the composite MEWS and its individual components to predict mortality within 30 days from ED visit was assessed. Sensitivity, specificity, positive and negative predictive values were derived and compared with values from other cohorts. A MEWS of !4 was chosen as the cut-off value for poor prognosis based on previous studies.

RESULTS:

A total of 311 (30.4%) critically ill patients were presented with a MEWS !4. Their mean age was 61.4 years (SD 18.1) with a male to female ratio of 1.10. Of the 311 patients, 53 (17%) died within 30 days, 64 (20.6%) were admitted to ICU and 86 (27.7%) were admitted to HD. The area under the receiver operating characteristic curve was 0.71 with a sensitivity of 53.0% and a specificity of 72.1% in addition to a positive predictive value (PPV) of 17.0% and a negative predictive value (NPV) of 93.4% (MEWS cut-off of !4) for predicting mortality.

CONCLUSION:

The composite MEWS did not perform well in predicting poor patient outcomes for critically ill patients presenting to an ED.KEY WORDS: Modified early warning score, Emergency department, Outcomes, Triage     

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.     

急诊脓毒症病死率评分在急诊脓毒症患者中的应用

目的 验证急诊脓毒症病死率评分(mortality in emergency department sepsis score,MEDS)对于急诊脓毒症患者病情评估的应用价值,并将其对患者28 d病死率的预测效果进行比较。方法 对2009年9月至2010年9月首都医科大学附属北京朝阳医院急诊抢救室救治的613例脓毒症患者进行前瞻性研究。记录患者的证急诊脓毒症病死率评分(MEDS)、急性生理学与慢性健康情况评价系统Ⅱ（acute physiology and chronic health evaluation,APACHEⅡ）、简化急性生理学评分Ⅱ（simplified acute physiology score,SAPSⅡ）和改良早期预警评分(modified early warning score,MEWS)。随访28 d转归。根据患者MEDS评分分值将死亡风险分级：极低危险组(0 ～4分)、低度危险组（5～7分）、中度危险组（8～12分）、高度危险组（13 ～ 15分）、极高危险组（大于15分）,各组间实际病死率采用X2检验比较。再对生存组和死亡组进行比较,通过logistic 回归分析确定预测死亡的独立因素,应用受试者工作特征曲线（ROC曲线）比较MEDS与APACHEⅡ,SAPSⅡ和MEWS评分对预后的预测能力。结果 失访10例,完整记录603例。MEDS评分患者各组实际病死率分别为0％,7.7％,18.5％,46.7％,63％,各组间实际病死率有显著区别。生存组（440例）与死亡组（163例）之间年龄和四种评分差异均具有统计学意义(P＜0.01)。MEDS,APACHEⅡ,SAPSⅡ、MEWS评分均是预测死亡的独立因素,ROC曲线下的面积(AUC)分别为0.767,0.743,0.741和0.636。结论 MEDS评分可以对脓毒症患者死亡风险进行分级,在患者28 d病死率方面有较好的预测能力,适用于急诊脓毒症患者。     

D-二聚体对急诊脓毒症患者预后价值的前瞻性研究

目的 探讨D-二聚体浓度能否预测急诊脓毒症患者28 d病死率,以及D-二聚体浓度对于脓毒症患者预后的意义.方法 采用前瞻性研究方法,选取2009年10月至2010年7月首都医科大学附属北京朝阳医院急诊科766例脓毒症患者,检测患者入院时的血中D-二聚体浓度(固相免疫层析法),并记录各项实验室检测指标和临床生理指标.以28 d为终点比较存活组与死亡组患者的D-二聚体水平、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分和简化急性生理学评分系统Ⅱ(SAPSⅡ)评分;分析D-二聚体水平与28 d病死率的关系.结果 766例脓毒症患者28 d内共有233例死亡,死亡组血中D-二聚体浓度(μg/L)明显高于存活组[1220.0(789.0,1835.0)比323.0(158.0,642.0),P＜0.01].D-二聚体水平与APACHEⅡ评分和SAPSⅡ评分均呈显著正相关(r1=0.643,r2=0.632,均P＜0.01).D-二聚体水平预测28 d病死率的受试者工作特征曲线(ROC曲线)下面积为0.880,95％可信区间(95％CI)为0.855～0.904,P＜0.001,预测28 d病死率的最佳界值为663.5 μg/L.血中D-二聚体＞663.5μg/L、APACHEⅡ评分＞19.5分和SAPSⅡ评分＞39.5分是预测患者28 d病死率的独立危险因素[优势比(OR值)分别为17.5、15.7、19.6,均P＜0.001].D-二聚体＜ 250.0、250.0～663.5、＞663.5 μg/L 3组间28 d病死率(1.4％、12.3％、64.2％)、APACHEⅡ评分[分:11(9,13)、13(11,16)、19(15,22)]、SAPSⅡ评分[分:24(18,29)、31(24,36)、40(33,49)]比较差异均有统计学意义(均P＜0.01).结论 D-二聚体水平是预测急诊脓毒症患者28 d病死率的独立指标.其预测能力与APACHEⅡ评分和SAPSⅡ评分十分相近;检测D-二聚体水平有助于脓毒症患者的危险分层.     

NEWS评分、qSOFA评分、SIRS评分对急诊感染性疾病患者预后评估价值的对比研究

目的 比较早期预警评分（NEWS）、快速脓毒症相关器官功能障碍评分(qSOFA)和全身炎症反应综合征（SIRS）评分对感染性疾病患者预后的评估价值。方法 选择2016年6月至2017年6月就诊于我院急诊的412例感染性疾病患者作为研究对象。收集患者的一般临床资料,记录就诊后生命体征,进行NEWS评分、qSOFA评分和SIRS评分,根据患者28天预后情况分为死亡组和存活组,分析3种评分与患者预后的相关性,应用受试者工作特征曲线（ROC）评估3种评分对预后的评估价值,并进行比较。结果 NEWS评分、qSOFA评分和SIRS评分分值越高,死亡危险越高;NEWS评分、qSOFA评分和SIRS评分的ROC曲下面积分别为0.750、0.792和0.723。结论 NEWS评分、qSOFA评分和SIRS评分对急诊感染性疾病预后评估存在临床价值,且3种评分中qSOFA评分的评估价值最高。     

Effect of triage on physicians' clinical decision: A prospective,observational, single-center and cross-sectional study

Objective: To investigate the effect of the use of color codes for patient triage on physicians' clinical decision. Methods: This prospective study was conducted among female patients aged 18-65 years who visited the emergency department (ED) with complaints of acute abdominal pain. A 3-level of triage system [red (very urgent), yellow (urgent) and green (less urgent)] was used in our ED. All patients were green level. Half of these patients remained at the green level (the green group), and the remaining patients were re-labeled as false yellow (the false yellow group) in the order of ED visits. Ordering tests, consultation requests, intravenous treatment, length of hospital stay, and cost were compared between the two groups of patients. Results: In total 393 patients were included with 198 patients in the green group and 195 in the false yellow group. There was no statistically significant difference between the two groups in age, temperature, systolic blood pressure, diastolic blood pressure, pulse and oxygen saturation (P>0.05). It was observed that more tests (P=0.001), consultations (P<0.001), and intravenous treatment were requested (P<0.001), and the duration of stay in the ED was longer (P<0.001) and cost (P<0.001) was higher in the false yellow group. Conclusions: Triage do affect the decisions of physicians on female patients with acute abdominal pain.     

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.     

The significance of non-sustained hypotension in emergency department patients with sepsis

Objective  Few studies have documented the incidence and significance of non-sustained hypotension in emergency department (ED) patients with sepsis. We hypothesized that ED non-sustained hypotension increases risk of in-hospital mortality in patients with sepsis. Methods  Secondary analysis of a prospective cohort study. ED patients aged >17 years admitted to the hospital with explicitly defined sepsis were prospectively identified. Inclusion criteria  Evidence of systemic inflammation (>1 criteria) and suspicion for infection. Patients with overt shock were excluded. The primary outcome was in-hospital mortality. Results  Seven hundred patients with sepsis were enrolled, including 150 (21%) with non-sustained hypotension. The primary outcome of in-hospital mortality was present in 10% (15/150) of patients with non-sustained hypotension compared with 3.6% (20/550) of patients with no hypotension. The presence of non-sustained hypotension resulted in three times the risk of mortality than no hypotension (risk ratio = 2.8, 95% CI 1.5–5.2). Patients with a lowest systolic blood pressure <80 mmHg had a threefold increase in mortality rate compared with patients with a lowest systolic blood pressure ≥80 mmHg (5 vs. 16%). In logistic regression analysis, non-sustained hypotension was an independent predictor of in-hospital mortality. Conclusion  Non-sustained hypotension in the ED confers a significantly increased risk of death during hospitalization in patients admitted with sepsis. These data should impart reluctance to dismiss non-sustained hypotension, including a single measurement, as not clinically significant or meaningful. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

急性胃肠损伤分级联合qSOFA评分在脓毒症诊断中的价值

目的:构建急性胃肠损伤（acute gastrointestinal injury,AGI）分级联合qSOFA评分诊断脓毒症的预测模型,并评价其价值。方法:为前瞻性观察性研究,纳入2018年9月至2019年9月入住常熟市第一人民医院普通病房的感染或疑似感染患者,排除年龄小于18岁、妊娠、中途放弃治疗、入院后3 d内死亡患者。记录感染前48 h内至发病后24 h的基本生命体征、实验室化验结果、AGI分级情况,根据患者是否诊断为脓毒症分为脓毒症组和非脓毒症组。将研究对象按7∶3比例随机分为建模组和验证组,在建模组中对单因素分析有统计学差异的因素进行多因素logistic回归分析。分别建立诊断模型A（qSOFA）、模型B（AGI分级联合qSOFA评分）以及模型C（多因素分析中有统计学差异的变量为参数）。在验证组进行验证,通过ROC曲线评价模型的诊断效果,绘制校准曲线评价一致性,使用决策曲线分析评价净效益,并绘制各预测模型诊断的列线图。结果:共2 553例患者纳入研究,建模组1 789例,验证组764例,两组患者基本情况差异无统计学意义,其中共326例患者发生了脓毒症。单因素分析显示年龄、性别、感染源、体温、心率、呼吸急促、意识改变、严重水肿、高血糖、白细胞数量、CRP、PCT、低血压、低氧、急性少尿、凝血功能异常、高乳酸血症、毛细血管充盈受损或皮肤花斑、AGI分级及qSOFA对脓毒症的发生有显著影响（均 P<0.01）。多因素Logistic回归分析,显示预测脓毒症的危险因素为年龄（ OR=1.027, P<0.01）,感染源（ OR=2.809, P=0.03）,低血压（ OR=35.449, P<0.01）、低氧血症（ OR=57.018, P<0.01）,AGI分级（ OR=19.313, P<0.01）。ROC分析显示建模组中模型A、B、C的曲线下面积（AUC）分别为0.784,0.944,0.971,敏感度分别为63.9%,89.5%,97.5%,特异度分别为90.8%,90.3%,88.1%,验证组中,模型A、B、C的AUC为0.832,0.975,0.980,敏感度分别为72.7%,90.9%,96.6%,特异度分别为92.2%,94.5%,92.8%。模型B、模型C的AUC明显大于模型A（ P<0.01）,而在验证组之间B、C（ P=0.684）。模型A在验证组中的校准度较差,精确性低,有漏诊脓毒症的风险（ P=0.044）。决策曲线分析显示模型B及模型C的净效益优于模型A。 结论:AGI分级联合qSOFA评分在脓毒症诊断中的具有较高的预测价值和准确性。     

Derivation of a prognostic score for identifying critically ill patients in an emergency department resuscitation room

Introduction

Several prognostic scores exist for critically ill patients, including APACHE II, Revised Trauma Score (RTS), Rapid Emergency Medicine Score (REMS) and Modified Early Warning Score (MEWS). However, there is no widely used score specifically designed to predict the likelihood of early intensive care unit (ICU) admission or death in undifferentiated emergency department (ED) resuscitation room patients. We aimed to derive such a score and compare it with other similar scores.

Methods

This was a single centre study of consecutive adult resuscitation room patients over one month. Physiological and blood test variables were compared according to the composite primary outcome: admission to ICU or death within 7 days of attendance. Multivariate logistic regression was used to derive a prediction score which was compared with other scores using ROC (receiver operating characteristic) analysis.

Results

330 patients were included in the study, of whom 77 were admitted to ICU or died within 7 days. A prediction score was derived using the following parameters: systolic blood pressure; Glasgow coma score; blood glucose; bicarbonate; white cell count; and a history of metastates. This score significantly out-performed APACHE II, RTS, REMS and MEWS with an area under the ROC curve of 0.909 (95% CI 0.872–0.938).

Conclusion

The Prince of Wales Emergency Department Score (PEDS) is a new prognostic score to predict the likelihood of early ICU admission or death in undifferentiated resuscitation room patients. Further studies are needed to validate and refine this potentially useful tool.     

A systematic review on the validity and reliability of an emergency department triage scale,the Manchester Triage System

Objective

To conduct a systematic review to check the level of validity and reliability of the Manchester Triage System and the quality of reporting of literature on this topic.

Design

This is a systematic review based on the PRISMA guideline on reporting systematic reviews.

Data sources

The systematic search of the international literature published from 1997 through 30 November 2012 in the PubMed, Embase, Cochrane Library, Cinahl, Web of Knowledge, and Scopus databases.

Review methods

This review included quantitative and qualitative research investigating the reliability and validity of the Manchester Triage System for the broad population of adults and children visiting the emergency department.After a systematic selection process, included studies were assessed on their quality by three researchers using the STARD guidelines.

Results

Twelve studies were included in the review. The studies investigated the inter- and intra-rater reliability using the “kappa” statistic; the validity was tested with many measures: validity in predicting mortality, hospital admission, under- and overtriage, used resources, and length of stay in the emergency department, as well as a reference standard rating.

Conclusions

In this review, the Manchester Triage System shows a wide inter-rater agreement range with a prevalence of good and very good agreement. Its safety was low because of the high rate of undertriage and the low sensitivity in predicting higher urgency levels. The high rate of overtriage could cause unnecessarily high use of resources in the emergency department. The quality of the reporting in studies of the reliability and validity of the Manchester Triage System is good.     

Factors related to under-triage of patients with acute coronary syndrome in the emergency department: A retrospective study

IntroductionThis study aimed to provide fundamental data to avoid under-triage in the initial severity classification of patients with suspected acute coronary syndrome (ACS) by analyzing factors associated with patients who visited the emergency department (ED).MethodsThis retrospective study identified factors related to under-triage by comparing the characteristics of participants diagnosed with ACS and appropriately classified those who were under-triaged.ResultsThe probability of under-triage increased 5.402 times in patients who visited the ED immediately than in those who visited the ED through an outpatient clinic. The probability of under-triage decreased in patients who visited the ED by ambulance rather than using their personal vehicle. Furthermore, when patients experienced chest pain, the tendency for under-triage decreased. The under-triage tendency increased 8.315 times in patients with dementia.ConclusionsMedical staff training on the classification of non-specific symptoms accompanying diseases is needed. Patients with ACS need to be aware of the symptoms that require visiting the ED and the appropriate route and method. Therefore, it is possible to avoid under-triage for possible ACS during the initial triage, and triage can be performed quickly and accurately.     

Impacts of the introduction of a triage system in Japan: A time series study

The aim of the present study was to measure and compare the effectiveness of nursing triage before and after introduction of the Japanese Triage and Acuity Scale (JTAS), the Japanese version of the Canadian Triage and Acuity Scale (CTAS), during emergency treatment. Surveys of triage nurses and emergency physicians were conducted before and after JTAS introduction. Respondents were triage nurses (before 112 cases, after 94 cases), emergency physicians (before 50, after 41), and triaged patients (before 1057, after 1025) from seven separate emergency medical facilities. The results showed that nursing triage using the JTAS shortened “time from registration to triage” by 3.8 min, “triage duration” by 1 min, “time from registration to physician” by 11.2 min, and “waiting time perceived by patients to see a physician” by 18.6 min (p < 0.001). The difference in assigned level of urgency between triage nurses and emergency physicians decreased from 34.2% to 12.2% (p < 0.001), over-triage decreased from 24.7% to 8.6% (p < 0.001), and under-triage decreased from 9.5% to 3.6% (p < 0.001). Furthermore, assessment agreement between triage nurses and emergency physicians increased significantly, from weighted κ = 0.486 to weighted κ = 0.820. These findings suggest that the introduction of the JTAS promoted more effective nursing triage and medical care.     

Comparison of different versions of the quick sequential organ failure assessment for predicting in-hospital mortality of sepsis patients:A retrospective observational study

BACKGROUND:The quick sequential organ failure assessment(qSOFA)is recommended to identify sepsis and predict sepsis mortality.However,some studies have recently shown its poor performance in sepsis mortality prediction.To enhance its effectiveness,researchers have developed various revised versions of the qSOFA by adding other parameters,such as the lactate-enhanced qSOFA(LqSOFA),the procalcitonin-enhanced qSOFA(PqSOFA),and the modified qSOFA(MqSOFA).This study aimed to compare the performance of these versions of the qSOFA in predicting sepsis mortality in the emergency department(ED).METHODS:This retrospective study analyzed data obtained from an electronic register system of adult patients with sepsis between January 1 and December 31,2019.Receiver operating characteristic(ROC)curve analyses were performed to determine the area under the curve(AUC),with sensitivity,specificity,and positive and negative predictive values calculated for the various scores.RESULTS:Among the 936 enrolled cases,there were 835 survivors and 101 deaths.The AUCs of the LqSOFA,MqSOFA,PqSOFA,and qSOFA were 0.740,0.731,0.712,and 0.705,respectively.The sensitivity of the LqSOFA,MqSOFA,PqSOFA,and qSOFA were 64.36%,51.40%,71.29%,and 39.60%,respectively.The specificity of the four scores were 70.78%,80.96%,61.68%,and 91.62%,respectively.The LqSOFA and MqSOFA were superior to the qSOFA in predicting in-hospital mortality.CONCLUSIONS:Among patients with sepsis in the ED,the performance of the PqSOFA was similar to that of the qSOFA and the values of the LqSOFA and MqSOFA in predicting in-hospital mortality were greater compared to qSOFA.As the added parameter of the MqSOFA was more convenient compared to the LqSOFA,the MqSOFA could be used as a candidate for the revised qSOFA to increase the performance of the early prediction of sepsis mortality.     

急诊脓毒症改良死亡风险评分对急诊脓毒症患者危险分层的应用

目的 探讨急诊脓毒症改良死亡风险评分(NMEDS)对急诊脓毒症患者危险分层的应用价值.方法 连续入选海南省农垦总医院急诊科2015年1月1日至2015年8月31日急诊就诊并且明确诊断为脓毒症患者164例,随访28 d按照患者预后分为死亡组(48例)和存活组(116例)两组,比较两组患者入院后24h内NMEDS与急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分;并描绘受试者工作特征曲线(ROC曲线),分析NMEDS与APACHEⅡ评分对急诊脓毒症患者死亡危险预后能力的比较.结果 死亡组患者在入院24h内NMEDS分值明显高于存活组(13.4±1.8)vs.(5.8±2.1),P ＜0.01;APACHEⅡ评分相比较,死亡组(27.4±3.6)分较存活组(17.6±4.1)分高,P=0.003;NMEDS评分不同分值28 d患者病死率:≤4分为4.5％,5～8分为10.0％,9～12分为19.4％,13～16分为42.4％,≥17分为66.7％.NMEDS对患者28 d死亡风险预测的ROC曲线下面积为0.788,数值上较APACHEⅡ评分曲线下面积为0.701高,但差异无统计学意义,P=0.056.结论 NMEDS对急诊脓毒症患者是可以应用的危险分层评分系统,在急诊临床工作中具有应用价值.     

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.