一体化急诊创伤外科运作模式初期实践的可行性分析

目的：评价以普外科为基础的初期一体化急诊创伤外科运作模式在诊疗相关患者方面的效用和所收治患者的主要特点,并与以往分科共诊模式进行比较。方法：采集急诊创伤外科成立之前和之后各2年半收治入院的155名急诊外科创伤患者,对其伤情特点、收治效率、转归情况等方面进行比较。结果：所有收入院患者中以男性患者为主,平均年龄47．92岁,交通事故伤为致创首因,腹部、颅面部、前胸部为易伤部位。就诊和入院的高峰时间分布为8点至24点及12点至20点。创伤组手术患者入院前滞留时间（t=2．115,P〈O．05）、入院至手术时间（t=2．381,P〈O．05）、投诉纠纷事件（x^2=7．232,P〈O．01）均短于或少于传统组。结论：以普外科为基础的初期一体化急诊创伤外科运作模式能够缩短患者入院或至急诊手术时间,提高伤员救治的及时性和连贯性,有利于减轻目前三级医院普遍较为严重的急诊患者的滞留问题及降低医疗投诉纠纷等隐患。可能对改善患者预后及缩短住院时间有所帮助,具有可行性。     

芦山地震震后2周应急医学救援时效与绩效评估

目的评价震后1～14天芦山地震应急医学救援的时效与绩效,验证和完善汶川经验,为全球类似地震应急医学救援提供有益参考。方法收集整理震后14天内官方信息通报、公开文件资料、新闻发布、网站信息等数据,并检索国内外地震医学救援相关文献,系统回顾、描述性分析芦山地震应急医学救援的时效和绩效。结果基于汶川经验,芦山地震应急医学救援的特点为：①科学评估灾情与伤情,合理调度人力、资金与物资,以省内区域力量救援为主;②“四集中”治疗危重伤员,创造了震后14天集中治疗0死亡的新记录;③检验、丰富和完善汶川、玉树与彝良地震应急医学救援经验,为全球地震医学救援提供循证决策的一手证据。     

芦山地震灾区急救日记

2013年4月20日8时02分四川省雅安市芦山县龙门山沟发生7．0级地震。截至24日14时30分,地震共计造成196人死亡,失踪21人,11470人受伤。地震发生后,四川大学华西医院立即派遣医疗救援队赶赴灾区,本文为一名普通的医疗救援队成员在灾区救援工作中所记的日记,反映了地震现场救援的危险与困难,以及救援队员们的大无畏精神。     

Caring for older people in prehospital emergency care: can nurses make a difference?

Aims and objectives. The aim of this paper is to explore older people's experiences in prehospital emergency care, and identify benefits and difficulties associated with developing a nurse‐led ambulance service. Data were collected at sites in Sweden and Norway. Focus group interviews were conducted to enable the collection of data from paramedics, ambulance nurses and nursing students, while individual interviews were utilized to gather data from older people. Background. There is little research on the quality of care older people over 65 years old receive in prehospital emergency care. Older people often present with multiple pathology and diverse needs that nurses are well equipped to deal with, but presently there is no clearly defined role for nurses in prehospital emergency care in the United Kingdom, although other countries such as Sweden and Norway are developing an ambulance nurse role. Conclusions. If the multiple needs of older people were addressed in the prehospital field, a reduction in readmissions and increased functional ability might be achieved. Comprehensive training is required for ambulance staff to enable them to meet such needs. While nurses have a great foundation for this care, additional specialist ambulance training is required alongside a need for education on older people's needs and attitudes to older people. Relevance to clinical practice. The introduction of ambulance nurses will result in role differentiation between paramedics and ambulance nurses, which has the potential for creating role conflict. To ensure a smooth transition appropriate training and education for nurses and paramedics should be provided. The end result is a potentially greatly enhanced ambulance care provision, enabling high quality care to all patients.     

Patient delay and use of ambulance by patients with chest pain

Objective: To identify the reasons why patients with chest pain delay in seeking hospital medical care and do or do not use an ambulance. Methods: One hundred and fifty‐one patients with an ED diagnosis of acute myocardial infarction or angina were interviewed about demographic characteristics, medical history, symptom onset, time taken before deciding to call an ambulance or go to hospital (delay time) and transport used. Multiple logistic regression determined independent predictors of late presentation (delay time >30 min) and ambulance use. Results: One hundred and twelve (74.2%, 95% CI 67.0–81.0%) patients delayed more than 30 min. Independent predictors of late presentation were: seeing a general practitioner (GP) (P = 0.001), having prior heart problems (P = 0.009) and symptoms occurring at night (P = 0.036). Eighty‐one (54.7%, 95% CI 47.0–63.0%) patients used an ambulance. Predictors of ambulance use were increased age (P = 0.025) and having ambulance insurance (P = 0.018), although there was interaction between these variables. Conclusions: Education programmes should continue to emphasize that chest pain is a potential medical emergency and an ambulance should be called. GPs should consider developing an action plan to manage patients presenting with chest pain.     

Factors that impact upon the time to hospital presentation following the onset of chest pain

Introduction: Although morbidity and mortality associated with chest pain are related to time to intervention, many patients have delayed ED presentations. We aimed to assess the extent of and reasons for prehospital delay, and identify patient subgroups more at risk of delayed presentation. Methods: This was an analytical, cross‐sectional survey of patients with undifferentiated, potentially ischaemic chest pain, at a tertiary referral ED. Data were collected on the circumstances surrounding the chest pain incident (including components of total prehospital time) and the proportion of delayed presentations (defined as >3 h). Multiple linear regression determined variables significantly associated with prehospital time. Results: One hundred and fifty patients were enrolled. Mean age was 51.9 ± 15.9 years and 90 (60.0%, 95% CI 51.7–67.8) were male. The mean total prehospital time was 6.38 h (median 3.17). Seventy‐nine (52.7%, 95% CI 44.4–60.8) patients had a delayed presentation (>3 h) and those most at risk of this were those at home at pain onset and those with a history of AMI. The decision time (from onset of pain to decision to present) comprised the majority (82.8%) of total prehospital time. Factors positively associated with decision time were: waiting to see if symptoms resolved (P < 0.0001), seeking GP advice (P < 0.0001), fluctuating symptoms (P = 0.02), embarrassment (P = 0.01) and attributing symptoms to muscle problems (P = 0.04). Nine patients diagnosed with AMI had a mean total prehospital time of 10.2 h. Conclusion: Intensified efforts are required to promote awareness of the need to present directly to the ED upon the onset of chest pain. The factors associated with decision delay may help to inform revisions in public education initiatives.     

From the emergency department to home

Aim. The purpose of this study was to explore dimensions of the management of the older person following care in an emergency department in preparation for discharge home by identifying perceptions and attitudes of staff in both emergency department and primary care sectors. Background. It is recognized that older people discharged home directly from the emergency department are a vulnerable group. Effective communication and liaison are seen to be keys to the provision of high quality care for older people in the emergency department and in ensuring a seamless care between sectors. Design. A purposeful sample was collected that comprised the total population (n = 222) of all grades of medical and nursing staff in both the emergency department and all nursing (Public Health Nurses & Practice nurses) and medical staff (General Practitioners) in the primary care area. Methods. Methodology used was that of a survey approach of nursing and medical staff in both the emergency department and primary care services. Standardized questionnaires were employed which comprised both open and closed questioning style. Raw statistical data were analysed using SPSS for Windows while the qualitative data arising from the open‐ended questions were content analysed for themes. Results. Many staff in the primary care area reported the level of communication between the emergency department and the primary care area as unsatisfactory with confusion regarding follow‐up care and a lack of support for older people on discharge. Hospital staff reported the level of communication to be much greater than that perceived by their colleagues in primary care. There was agreement of staff in both sectors in relation to the perceived usefulness of a discharge liaison nurse in the emergency department. Conclusions. Previous research highlights communication difficulties when patients are discharged from hospital. Findings from this study indicate that this problem can also be applied to the emergency department. Relevance to clinical practice. Implications for practice include a need for a multidisciplinary approach to developing referral guidelines, staff training and a comprehensive dissemination of information between sectors ultimately to improve quality and continuity of care for the older person.     

Ambulance diversion is not associated with low acuity patients attending Perth metropolitan emergency departments

Objective: To examine the relationship between ambulance diversion and low acuity patient (LAP) attendances to EDs. Methods: Comparison of LAP attendance rates at inner metropolitan EDs and outer metropolitan EDs using a previously validated methodology. Results: The percentage of LAP attendances was lower at inner metropolitan EDs (11.4%, 95% CI 11.3–11.6) compared to outer metropolitan hospitals (22.9%, 95% CI 22.6–23.2, P < 0.001). The proportion of LAP attendances was slightly higher at both inner and outer metropolitan hospitals after‐hours compared to working hours. Average daily LAP attendances per inner metropolitan hospital (13.4 attendances, 95% CI 13.2–13.6) which averaged 89.2 min of diversion daily (95% CI 88.7–89.7) were lower than at outer metropolitan hospitals (19.3 attendances, 95% CI 19.0–19.6, P < 0.001), which averaged 12.4 min of diversion daily (95% CI 12.1–12.5, P < 0.001). Conclusions: Inner metropolitan hospitals experience low LAP attendance rates. Attempts to further reduce LAP attendance rates at Perth inner metropolitan hospitals have limited scope to reduce ambulance diversion.     

突发公共事件紧急医疗救援体系运行模式探讨

建立健全四川省突发公共事件紧急医疗救援指挥体系，建立省、市（州）紧急医疗救援中心及急救网络，制定紧急医疗救援预案，加强应急救援队伍建设及培训和演练，重视应急医疗救援设备装备和救援物资储备，与当地政府、公安、消防、军队等密切配合，能很好地完成交发公共事件的紧急医疗紧急救援。