新型预约诊疗服务模式在大型综合医院中的应用

目的探讨大型综合医院新型预约诊疗服务模式的实施效果。方法选择2011年7—8月接受新型诊疗预约服务的门诊患者6000例作为观察组,2011年5—6月接受传统诊疗模式的门诊患者6000例作为对照组。对两组患者在预约检查时间、无效预约及患者满意度方面进行比较分析,以评价新型预约诊疗模式的效果。结果观察组在放射科预约检查时间≤1d者占68.8%、≥2d者占31.2%,在超声科预约检查时间≤1d者占67.2%、≥2d者占32.8%,在内镜室预约检查时间≤2d者占85.6%、≥3d者占14.4%,在心血管彩超室预约检查时间≤2d者占75.9%、≥3d者占24.1%,与对照组相比差异有统计学意义（χ2值分别为4.838,9.199,28.355,10.359;P＜0.05）。观察组在放射科、超声科、内镜室和心血管彩超室的无效预约分别占1.9%,2.4%,4.1%,2.5%,明显低于对照组,差异有统计学意义（χ2值分别为9.982,19.687,8.684,7.623;P＜0.05）。观察组对放射科、超声科、内镜室和心血管彩超室预约诊疗的满意度分别为94.9%,93.6%,96.3%,95.8%,均明显优于对照组,差异有统计学意义（χ2值分别为30.623,4.120,15.640,19.231;P＜0.05）。结论新型诊疗预约服务的实施,缩短了患者诊疗检查的预约时间,减少了无效预约、反复改约等现象,提高了诊疗效率和患者的满意度。     

持续质量改进在口腔科诊间预约挂号中的应用

目的探讨持续质量改进在口腔科诊间预约挂号中的应用。方法由门诊部组织成立口腔科诊间预约挂号持续质量改进小组,寻找焦点问题,分析原因,制订改进计划并实施。结果经过6个月的持续改进,口腔科复诊病人诊间预约挂号率由原来0.3%提高到90%。结论经过持续改进口腔科诊间预约挂号流程,发挥医生的主观能动性,使诊间预约挂号率逐步提高,进一步方便了复诊病人,明显缩短了等候时间,有利于医生合理安排初、复诊病人。     

Why do child contacts of multidrug-resistant tuberculosis not come to the assessment clinic?

Background:

Local policy advises that children exposed to multidrug-resistant tuberculosis (MDR-TB) should be assessed in a specialist clinic. Many children, however, are not brought for assessment.

Methods:

Focus group discussion was used to design appropriate questionnaires. From 1 September 2011, the first 50 children referred to the specialist paediatric MDR-TB clinic, Cape Town, South Africa, and who attended their clinic appointment, were recruited. The first 50 children who were referred but who did not attend were concurrently identified, traced and recruited. Differences in group characteristics were compared.

Results:

The median age of the children was 35 months: 48 (48%) were boys, 4 (4%) were human immunodeficiency virus infected and 47 (47%) were of coloured ethnicity. Factors significantly associated with non-attendance at the MDR-TB clinic were: Coloured ethnicity (OR 2.82, 95%CI 1.21–6.59, P = 0.01), the mother being the source case (OR 3.78, 95%CI 1.29–11.1, P = 0.02), having a smoker resident in the house (OR 2.37, 95%CI 1.01–5.57, P = 0.04), the time (P = 0.002) and cost (P = 0.03) required to get to the specialist clinic, and fear of infection whilst waiting to be seen (OR 2.45, 95%CI 1.07–5.60, P = 0.03).

Conclusions:

Reasons for non-attendance at paediatric MDR-TB clinic appointments are complex and are influenced by demographic, social, logistical and cultural factors.     

Most Patients with Colorectal Tumors at Young Age Do Not Visit a Cancer Genetics Clinic

Purpose  This study examined the referral process for genetic counseling at a cancer genetics clinic in patients with colorectal cancer and to search for determinants of variation in this referral process. Methods  Patients who were recently diagnosed with colorectal cancer at a young age or multiple cancers associated with Lynch syndrome, hereditary nonpolyposis colorectal cancer, (N = 119) were selected from PALGA, the nationwide network and registry of histopathology and cytopathology in the Netherlands. In a retrospective analysis, we examined whether these patients visited a cancer genetics clinic and identified determinants for referral to such a clinic. Factors of patients, professional practice, and hospital setting were explored with logistic regression modeling. Results  Thirty-six (30 percent) patients visited a cancer genetics clinic. Seventy percent of patients whom the surgeon referred to a cancer genetics clinic decided to visit such a clinic. Analysis of determinants showed that patients with whom the surgeon discussed referral and that were treated in a teaching hospital were more likely to visit a cancer genetics clinic. Conclusion  The referral process is not optimally carried out. To deliver optimal care for patients suspected of hereditary colorectal cancer, this process must be improved with interventions focusing on patient referral by surgeons and raising awareness in nonteaching hospitals. This work was supported by ZonMw, the Netherlands Organization for Health Research and Development.     

Early symptoms of bone and soft tissue sarcomas: could they be diagnosed earlier?

INTRODUCTION

Delays in diagnosis are common for patients with bone and soft tissue sarcoma (STS) despite guidance produced by the National Institute for Health and Clinical Excellence. This study set out to identify early symptoms experienced by patients and reasons for delays in making a definitive diagnosis.

METHODS

Retrospective interviews were carried out with 107 patients (66 with an STS and 41 with a bone sarcoma) presenting to a specialist centre. Symptoms were determined prior to definitive diagnosis and the occurrence of patient and doctor delays in reaching specialist care.

RESULTS

The median patient delay was 1 month while the median doctor delay was 3.2 months from first symptoms to diagnosis for all sarcomas. Forty-nine patients with STS (74%) presented initially to their general practitioner with at least one guideline feature to prompt urgent referral. Only 2 patients (4%), however, were referred directly to a sarcoma unit, with 21 (43%) referred to secondary care for investigation. Patients with a lump increasing in size exhibited longer patient delays while doctor delay was shorter for deep lumps. Thirty-six patients with a bone sarcoma (88%) presented initially with symptoms to prompt further investigation. Nevertheless, significant delays (3.9 months) were seen in reaching specialist care. Only 4 patients (10%) were referred directly to a sarcoma unit at first presentation, with 21 (54%) referred for further investigation elsewhere.

CONCLUSIONS

It is evident that awareness and referral of sarcomas remain poor. We suggest specific amendments to current guidelines and clearer referral pathways for patients. Furthermore, the need for robust education strategies is indicated, predominantly among healthcare professionals.     

Senior triaging of ENT emergency clinic referrals alleviates pressures on the outpatient department

IntroductionThe ear, nose and throat (ENT) emergency clinic is managed by foundation year (FY) doctors from taking referrals to discharging patients, under the supervision of a registrar. FYs learn essential skills and knowledge on how to manage common ENT problems. The clinic is often overloaded because of a high patient demand, and this limits the opportunities for teaching. We hypothesised that the clinic bookings would be better managed if referrals from general practitioners (GPs) were triaged by registrars.MethodsTelephone referrals from GPs for the ENT emergency clinic were directed to the on-call ENT registrar, between 8am and 1pm from Monday to Friday, and to the FY outside of this period. Consecutive referrals to the emergency clinic were analysed in a baseline audit and a post-intervention cycle.ResultsA total of 646 and 611 patients were given clinic appointments in the first and second cycles, respectively. Clinic session overbookings decreased from 85% to 46.3%. Appointments for referrals that were deemed inappropriate had reduced from 22% to 12.1%.Discussion and ConclusionInvolvement of a registrar in taking referrals for the ENT emergency clinic was associated with a reduction in clinic overbookings. It is feasible and productive to involve a senior decision maker in the operational management of the emergency clinic, while preserving the delivery of this service by FYs for its training value.     

神经科总住院医师607例会诊病例分析

目的分析神经科总住院医师会诊病例的构成特点,从一个方面反映总住院医师的工作情况。方法统计北京协和医院神经科1名总住院医师在2003年8月1日至2004年1月31日会诊的病例。结果共新会诊患者607例,女性305例,男性302例,年龄5个月至92岁,平均年龄55·2岁,平均每周新会诊24例。急症会诊208例(34·3%),常规会诊399例(65·7%)。362例(59·6%)继发于系统性疾病;66例(10·9%)与医源性因素有关。急症会诊以代谢性脑病最多(92例),占急症会诊的44·2%,病因包括呼吸衰竭、肾功能衰竭、多器官功能衰竭等;其次为急性脑血管病51例;第三为癫发作23例。内科常规会诊病例以周围神经病最多(69例),占内科常规会诊的17·3%(69/398),病因包括糖尿病、血管炎/结缔组织病、肿瘤相关的周围神经病等。外科和妇科约请神经科常规会诊主要目的是围手术期的神经科疾病评估和预防。结论会诊工作具有特殊性和挑战性,神经科总住院医师应该了解会诊病例特点,在会诊中学习和积累经验。     

What women want: convenient appointment times for cervical screening tests

Little is known about women's preferred appointment times for cervical screening tests. Data from a postal questionnaire survey were used to compare preferred appointment times with those given. Although 33.4%[95% confidence intervals (CI) 31.8%-35.0%] of respondents received appointments between 10h00 and 11h55, only 17.0% (95% CI 15.3%-18.7%) wanted an appointment at that time. Nineteen per cent (95% CI 17.4%-21.0%) of respondents wanted appointments between 18h00 and 20h00, but only 4.4% (95% CI 3.7%-5.1%) received them. Saturday appointments for cervical screening are not given; however, overall approximately 13% of those surveyed would have preferred a Saturday appointment. Preferred times also varied significantly with age and deprivation category. Further research is required to determine whether appointment times for cervical screening can be tailored to meet these expressed needs, and the impact this has on service provision and uptake.