急诊Ⅰ期手术和控制性手术治疗肝胆外科损伤的临床效果比较

目的比较急诊Ⅰ期手术和控制性手术治疗肝胆外科损伤的临床效果。方法以2017年5月至2018年5月我院接收的68例肝胆外科损伤患者作为研究对象,根据治疗方法的不同将其分为参照组和控制性手术组,各34例。参照组采用常规急诊Ⅰ期手术治疗,控制性手术组采用控制性手术治疗。观察两组治疗前及治疗1周后的pH值、体温、血浆凝血酶原时间(PT)、手术时间、住院时间、治疗1周后的并发症发生情况及治疗2周后的死亡率。结果治疗1周后,两组pH值、体温明显高于治疗前,PT明显短于治疗前,且控制性手术组优于参照组(P<0.05)。控制性手术组的手术时间明显短于参照组,住院时间明显长于参照组(P<0.05)。治疗1周后,控制性手术组的并发症总发生率明显低于参照组(P<0.05)。治疗2周后,控制性手术组的死亡率明显低于参照组(P<0.05)。结论相比于常规急诊Ⅰ期手术,肝胆外科损伤患者通过控制性手术治疗的临床价值显著,值得在临床上推广应用。     

The Effect of Homelessness on Patient Wait Times in the Emergency Department

BackgroundProlonged emergency department (ED) wait times could potentially lead to increased morbidity and mortality. While previous work has demonstrated disparities in wait times associated with race, information about the relationship between experiencing homelessness and ED wait times is lacking.ObjectivesThe purpose of this study was to explore the relationship between residence status (undomiciled vs. domiciled) and ED wait times. We hypothesized that being undomiciled would be associated with longer wait times.MethodsWe obtained data from the National Hospital Ambulatory Medical Care Survey from 2014 to 2017. We compared wait times in each triage category using t tests. We used multivariate linear regression to explore associations between residence status and wait times while controlling for other patient- and hospital-level variables.ResultsOn average, undomiciled patients experienced significantly longer mean ED wait times than domiciled patients (53.4 vs. 38.9 min; p < 0.0001). In the multivariate model, undomiciled patients experienced significantly different wait times by 15.5 min (p = 0.0002). Undomiciled patients experienced increasingly longer waits vs. domiciled patients for the emergent and urgent triage categories (+33.5 min, p < 0.0001, and +22.7 min, p < 0.0001, respectively).ConclusionsUndomiciled patients experience longer ED wait times when compared with domiciled patients. This disparity is not explained by undomiciled patients seeking care in the ED for minor illness, because the disparity is more pronounced for urgent and emergent triage categories.     

应用PDCA循环法提高急诊检验项目全程TAT达标率

目的应用PDCA循环法缩短急诊项目的全程结果回报时间(TAT)。方法回顾性分析2017年1-12月(PDCA循环法实施前)深圳市罗湖医院集团妇科、产科急诊项目[血常规、凝血、离子七项、血人绒毛膜促性腺激素(HCG)+孕酮]的TAT未达标率。2018年应用PDCA管理工具,绘制鱼骨图分析原因、柏拉图真因确定、甘特图制订计划,利用5W1H法制订对策,并进行对策实施。同时,购置仪器、人员培训、规范化工作流程、加强临床沟通协调。对2017年1-12月(实施前)与2018年1-6月(实施后)的急诊报告时间达标率进行比较。结果2018年1—6月,急诊项目血常规、凝血、离子七项、血HCG+孕酮申请至采样时间达标率较2017年1—12月分别上升了4.89%、4.53%、6.94%、3.63%;采样至核收时间达标率分别上升了13.33%、13.57%、37.1%、13.95%;核收至发送时间达标率分别上升了20.85%、5.96%、5.01%、6.31%。应用PDCA前后申请至采样时间、采样至核收时间、核收至发送时间,差异均有统计学意义(χ2=11.325、19.569、5.301,P<0.001)。结论应用PDCA循环法对急诊检验项目TAT达标率进行质量改进、人员培训、标准化交接班制度制订,优化标本送检流程,标本高峰期增加运送人员,保障检测仪器的质量,进一步完善了信息系统,加强了与临床的沟通、协调,可以提高急诊项目全程TAT达标率,有效缩短结果TAT。     

Contraception and its ethical considerations

Access to appropriate contraception not only has direct benefits for women's health and wellbeing but also has a broader positive impact on society as a whole. Obstetricians and gynaecologists play a key role in counselling women. Decisions regarding contraceptive choices must take into account women's preferences, cultural and religious beliefs as well as any co-existing medical issues.This article outlines three commonly encountered scenarios and the ethical and legal issues that may affect the choice of contraceptive.     

Outcomes following emergency laparotomy in Australian public hospitals

Background

International studies reporting outcomes following emergency laparotomies have consistently demonstrated wide inter‐hospital variation and a 30‐day mortality in excess of 10%. The UK then prioritized the funding of the National Emergency Laparotomy Audit. In a prospective Western Australian audit there was minimal inter‐hospital variation and a 6.6% 30‐day mortality. In the absence of any multi‐hospital Australian data the aim of the present study was to compare national administrative data with that previously reported.

Methods

Data on emergency laparotomies performed in Australian public hospitals during 2013/2014 and 2014/2015 were extracted from admitted patient activity and costing data sets collated by the Independent Hospital Pricing Authority. The data sets, containing episode‐level data relating to admitted acute and sub‐acute care patients, included administrative, demographic and clinical information such as patient age, cost, length of stay, in‐hospital mortality, diagnosis and surgical procedure details.

Results

Ninety‐nine public hospitals undertaking at least 50 emergency laparotomies performed 20 388 procedures over the 2 years. The overall in‐hospital mortality was 5.2%. There was a wide interstate and inter‐hospital variation in risk‐adjusted in‐hospital mortality (4.8–6.6% and 0–9.3%, respectively), length of stay (12.5–16.8 days and 5.8–18.9 days, respectively) and intensive care unit admissions (24.5–40.2% and 0–75.7%, respectively).

Conclusion

This data suggest the wide variation in outcomes and care process observed overseas exist in Australia. However, administrative data has considerable limitations and is not a substitute for high quality prospective data. Minimizing variations through prospective quality improvement processes will improve patient outcomes.     

Factors Associated With Emergency Department Visits by People With Dementia Near the End of Life: A Systematic Review

ObjectivesEmergency department (ED) attendance is common among people with dementia and increases toward the end of life. The aim was to systematically review factors associated with ED attendance among people with dementia approaching the end of life.DesignSystematic search of 6 databases (MEDLINE, EMBASE, ASSIA, CINAHL, PsycINFO, and Web of Science) and gray literature. Quantitative studies of any design were eligible. Newcastle-Ottawa Scales and Cochrane risk-of-bias tools assessed study quality. Extracted data were reported narratively, using a theoretical model. Factors were synthesized based on strength of evidence using vote counting (PROSPERO registration: CRD42020193271).Setting and ParticipantsAdults with dementia of any subtype and severity, in the last year of life, or in receipt of services indicative of nearness to end of life.MeasurementsThe primary outcome was ED attendance, defined as attending a medical facility that provides 24-hour access to emergency care, with full resuscitation resources.ResultsAfter de-duplication, 18,204 titles and abstracts were screened, 367 were selected for full-text review and 23 studies were included. There was high-strength evidence that ethnic minority groups, increasing number of comorbidities, neuropsychiatric symptoms, previous hospital transfers, and rural living were positively associated with ED attendance, whereas higher socioeconomic position, being unmarried, and living in a care home were negatively associated with ED attendance. There was moderate-strength evidence that being a woman and receiving palliative care were negatively associated with ED attendance. There was only low-strength evidence for factors associated with repeat ED attendance.Conclusions and ImplicationsThe review highlights characteristics that could help identify patients at risk of ED attendance near the end of life and potential service-related factors to reduce risks. Better understanding of the mechanisms by which residential facilities and palliative care are associated with reduced ED attendance is needed.