高效与人性化——从约翰梅尔医院急诊部看美国急诊部设计

文章通过对美国加州约翰梅尔医院急诊部为期5天的实地考察,分析和总结了美国急诊部设计的基本方法、技巧以及对中国急诊部建设的启示。     

走动式管理在小儿急诊分诊护理质量管理中的应用效果观察

目的观察走动式管理应用于小儿急诊分诊护理质量管理后的实际效果。方法将采用了走动式管理模式下的护理方法所护理的小儿急诊患者,设置为试验组;对照组则为仅接受常规护理的同等例数小儿急诊患者,对比两组患儿的临床护理质量,并比较两组患方的满意度。结果走动式管理组患者的护理质量评分和满意度均优于对照组患者。结论走动式管理模式下的护理方式,能够更方便、快捷地缓解小儿病患的临床症状,更大程度上减轻家属的紧张情绪,较常规护理措施质量更佳,具有较高的应用和推广价值。     

The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients

Background and objectiveThe National Emergency X-Radiography Utilization Study (NEXUS) criteria are used to assess the need for imaging to evaluate cervical spine integrity after injury. The aim of this study was to assess the sensitivity of the NEXUS criteria in older blunt trauma patients.MethodsPatients aged 65 years or older presenting between 1st July 2010 and 30th June 2014 and diagnosed with cervical spine fractures were identified from the institutional trauma registry. Clinical examination findings were extracted from electronic medical records. Data on the NEXUS criteria were collected and sensitivity of the rule to exclude a fracture was calculated.ResultsOver the study period 231,018 patients presented to The Alfred Emergency & Trauma Centre, of whom 14,340 met the institutional trauma registry inclusion criteria and 4035 were aged ≥65 years old. Among these, 468 patients were diagnosed with cervical spine fractures, of whom 21 were determined to be NEXUS negative. The NEXUS criteria performed with a sensitivity of 94.8% [95% CI: 92.1%–96.7%] on complete case analysis in older blunt trauma patients. One-way sensitivity analysis resulted in a maximum sensitivity limit of 95.5% [95% CI: 93.2%–97.2%].ConclusionCompared with the general adult blunt trauma population, the NEXUS criteria are less sensitive in excluding cervical spine fractures in older blunt trauma patients. We therefore suggest that liberal imaging be considered for older patients regardless of history or examination findings and that the addition of an age criterion to the NEXUS criteria be investigated in future studies.     

Individual and county level predictors of asthma related emergency department visits among children on Medicaid: A multilevel approach

Objective: Disparities in asthma outcomes are well documented in the United States. Interventions to promote equity in asthma outcomes could target factors at the individual and community levels. The objective of this analysis was to understand the effect of individual (race, gender, age, and preventive inhaler use) and county-level factors (demographic, socioeconomic, health care, air-quality) on asthma emergency department (ED) visits among Medicaid-enrolled children. This was a retrospective cohort study of Medicaid-enrolled children with asthma in 29 states in 2009. Multilevel regression models of asthma ED visits were constructed utilizing individual-level variables (race, gender, age, and preventive inhaler use) from the Medicaid enrollment file and county-level variables reflecting population and health system characteristics from the Area Resource File (ARF). County-level measures of air quality were obtained from Environmental Protection Agency (EPA) data. Results: The primary modifiable risk factor at the individual level was found to be the ratio of long-term controller medications to total asthma medications. County-level factors accounted for roughly 6% of the variance in the asthma ED visit risk. Increasing county-level racial segregation (OR=1.04, 95% CI=1.01-1.08) was associated with increasing risk of asthma ED visits. Greater supply of pulmonary physicians at the county level (OR=0.81, 95% CI=0.68-0.97) was associated with a reduction in risk of asthma ED visits. Conclusions: At the patient care level, proper use of controller medications is the factor most amenable to intervention. There is also a societal imperative to address negative social determinants, such as residential segregation.     

Do parents understand the medical information provided in paediatric emergency departments? A prospective multicenter study

Aim: We evaluated the extent to which parents understood the medical information about hospitalization of their child in an emergency department and looked for characteristics likely to increase the risk of poor comprehension. Methods: Prospective multicenter study in thirteen paediatric emergency departments. The parents and doctors completed questionnaires based on closed‐ended questions with a common core of four items: reasons of hospitalization, diagnosis, treatment and seriousness of child condition. We evaluated concordance between parents and doctor answers for these items by comparing their responses. Results: This study included 380 parents. Percentage of concordance was 55% for the reason of hospitalization, 78% for the diagnosis, 92% for the treatment, 48% for the seriousness of the condition and 19% for all four items. The mean number of concordant items was 2.76 (CI 95%, 2.66–2.86). Parents whose children seemed not in pain and parents who received additional information from the nurse showed significantly slightly higher levels of concordance with doctor’s answers (2.98 vs 2.66, p = 0.006 and 2.89 vs 2.60, p = 0.004, respectively). Conclusion: This study shows that improvements are required in the clarity of the information delivered to the parents. The assistance of nurses and optimal pain management may help to improve communication.     

Effects of Emergency Medical Services Agency Ownership Status on Patient Transport

Objectives: Medical insurers have clearly defined which ambulance services will be reimbursed and which will not. Thus, ambulance agencies that provide emergency 9-1-1 services must be highly cognizant of their organization's revenue needs. This presents a distinction between publicly funded and privately funded organizations. This study seeks to identify any differences in the transport decision among agency ownership types. Methods: This retrospective study captured all 9-1-1 ambulance requests in the state of Virginia for the years 2009 through 2013. Each request was answered by either a publicly funded ambulance service or a privately funded ambulance service. The outcome variable of interest was patient disposition and the key explanatory variable was organizational ownership type. Multivariate logistic regression was utilized for data analysis. Results: Of the 4.6 million 9-1-1 requests, approximately 30% were attended to by a private ambulance service. After controlling for potential confounders, ownership type was found to have a statistically significant effect on the transport decision. Private for-profit ambulance services were 4.5 times more likely to transport a patient than were their publicly funded counterparts (OR: 4.56, 95% CI: 4.47–4.65). Private non-profit organizations were twice as likely to engage in patient transport (OR: 2.12, 95% CI: 2.09–2.14). Private for-profit ambulance organizations were also found to be less likely to allow for patient refusal (OR: 0.54, 95% CI: 0.53–0.55) or to medically treat on-scene without subsequent transport (OR: 0.48, 95% CI: 0.45–0.50). Conclusions: Given the reimbursement practices of medical insurers, private ambulance services are incentivized towards patient transport. Operational revenue for these services is not generated through public budgeting processes but through user fees. Thus, private agencies are more reliant on billable services than are their publicly funded counterparts.     

急诊一体化救治护理急危重症患者中临床路径的应用

目的探讨危急重症患者实施护理过程中通过对患者进行急诊一体化救治护理方法的临床疗效。方法选取我院2014年10月~2015年10月收治的危急重症患者800例,将患者分为观察组以及对照组,对比两组患者护理效果、死亡率及满意度。结果观察组临床护理效果高于对照组,患者的死亡率以及患者的临床满意程度有差异,P0.05,差异具有统计学意义。结论实施急诊一体化救治护理,能够提升临床护理效果,是一种安全有效的救治方法 .     

Like an ace up the sleeve: an interview study of nurses’ experiences of the contact with relatives in a somatic emergency ward

Research indicates that active involvement of patients′ relatives generally has a positive impact on patients′ hospitalisation, including patient safety. Campaigns urge relatives to ask questions in relation to nursing care and treatment to enhance patient safety and to increase involvement of both patient and relatives. The question is how nurses experience relatives who ask questions. The aim of this study was to explore how nurses experienced contact with patients′ relatives during admissions to a somatic emergency ward including nurses′ experience of relatives asking questions related to nursing care and treatment. Six nurses were interviewed. The participants gave written consent to participate after receiving both oral and written information about the study. Data were analysed using combined theory and data‐driven qualitative content analysis. The findings formed three main themes: (i) relatives’ involvement as a means to efficiency during hospitalisation, (ii) relatives welcomed on the terms of the system and (iii) tension between high ideals and frustrating realities. The six interviews answered the research questions. However, more interviews could have broadened the study and contributed with further details. The nurses experienced relatives as an important resource – ‘an ace up the sleeve’, while reality seemed to challenge the relationship between nurses and relatives. The study contributes to discussions before development and implementation of specific initiatives aiming at increasing involvement of relatives of patients in a somatic emergency ward.