急诊分诊标准的制定和实施进展

<正>急诊分诊是指急诊护士对每一位来诊病人进行简单迅速的评估,了解其医疗需求,判断就诊的紧急程度,使其在恰当的时机、恰当的治疗区域获得恰当的治疗与护理的过程[1]。急诊分诊是急救医疗服务体系中的重要环节,是抢救急危重症病人的关键环节。现代急诊分诊已不再是简单的"分科分诊",而是根据患者的病情为患者安排就诊的"病情分诊"[2]。1国外急诊分诊标准实施模式国外的急诊科有当地卫生机构统一制定的急诊分诊标     

急性腹痛急诊分诊流程及护理

目的总结急性腹痛急诊分诊流程和护理措施。方法根据我院急诊科急性腹痛的病理特点制订相应的分诊工作流程,对547例急性腹痛患者经接诊护士快速评估判断病情的严重性、快速获得病史、进行必要的护理体检和针对性的辅助检查后,按危、重、一般患者进行分诊。结果 547例急性腹痛患者内科分诊准确率92.23%,外科分诊准确率95.04%,妇产科分诊准确率90.91%。结论对急性腹痛患者制订急诊分诊流程,迅速接诊和正确分流是护理工作中不可缺少的部分。可确保患者获得及时正确的诊治,减少漏诊误诊,保护患者的生命安全。     

急诊昏迷患者的迅速分诊与急救方法探讨

目的:探讨急诊昏迷患者的迅速分诊与急救方法。方法:参照5级急诊预检分诊系统和急诊危重病降阶梯治疗方法,对我院2012年1月至2014年12月120例急诊治疗昏迷患者进行规范化分诊、急救护理,回顾性分析其诊疗效果。结果:120例昏迷患者有90例(75.00%)治愈出院,17例(14.17%)因病情平稳转至相关科室进行治疗,13例(10.83%)病死,急诊治疗总有效率和病死率分别为89.17%和10.83%。结论:分诊和急救处置的规范化对患者治愈和预后有重要影响。     

基于移动技术的急诊预检分诊系统初步探讨

分析当前国内外医院急诊科室主要的分诊模式及分诊流程,讨论我国大型医院急诊科室信息技术应用现状与问题,提出构建基于移动技术的动态急诊预检分诊系统设想。     

基于体域网的家庭健康监护及远程急诊分诊模式

随着社会急诊医疗需求的快速增长,大量患者涌入医院,造成急诊室过度拥挤、医疗服务质量下降、医疗费用升高和住院时间延长等问题。基于体域网技术的家庭健康监护及远程急诊分诊模式通过加强对特殊人群的健康监护,起到疾病早期积极干预的作用,将急诊患者的分诊平台延伸到院前阶段,有效分流急诊患者到各级医疗机构,缓解急诊室过度拥挤,提高优质急诊医疗资源的利用效率。     

初步探讨非定点三级甲等医院无缝连接一体化新冠肺炎分诊体系的构建

目的探讨基于新冠肺炎"重点、疑似"患者诊断标准构建无缝连接一体化新冠肺炎分诊体系,在辨识新冠肺炎病例中的效果与机理。方法从院前急救、预检分诊、急诊分诊、急诊医师识别、发热门诊医师识别、专家网络会诊六个层面科学整合医疗资源,构建无缝连接一体化新冠肺炎分诊体系,准确高效分流门急诊患者。结果构建体系前,重点患者占门急诊患者比率13.3%,疑似患者占6.27%,两类患者筛查后转运平均耗时36.2 min;构建体系后,重点患者占5.27%、疑似患者占1.84%,筛查后转运平均耗时21.6 min。结论无缝连接一体化新冠肺炎分诊体系辨识新冠肺炎重点、疑似病例具有明显优越性。通过层层筛查,该体系能提高新冠肺炎患者甄别质量与效率,缓解定点医院就诊压力,缩短重点、疑似患者筛查后转运时间。     

急诊危重患者院内转运指导单的应用效果

目的探讨急诊科危重患者院内转运护理指导单在急诊危重患者院内转运工作中的应用效果,总结高效的急诊危重患者安全转运流程。方法选取2018年1～5月广西医科大学第一附属医院急诊科就诊并符合纳入标准的652例患者为研究对象,应用自制的院内转运指导单对其实施转运,比较应用转运指导单前后的转运准备符合率和不良事件发生率。结果应用急诊危重患者院内转运指导单对危重患者实施院内转运后,转运准备符合率由使用前的85%提高到98%,转运不良事件的发生率由原来的4.3%下降到0.9%。结论急诊危重患者院内转运护理指导单的应用有助于规范急诊危重患者院内转运流程,保障急危重症患者的安全转运过程。     

分诊护士在内科门诊应急事件处理中的作用

医院门诊具有就诊患者多、病种多、人流量大的特点.大多数内科门诊患者可择期就诊,但有部分患者家属不了解危重病人应该到急诊救治,而选择门诊就诊,从而也增加了门诊医疗和护理的风险.在门诊临床工作中,时有突发事件的发生,如果患者病情得不到及时有效处理,极可能引发医患纠纷.本文对医院门诊分诊护士抢救急危重病人应急处理进行总结,其临床经验供临床医务人员参考.     

护理专案改善在提高急诊PCI患者签署知情同意书及时率中的应用

目的研究护理专案在提高急诊PCI患者签署知情同意书及时率的应用效果。方法实施提高急诊PCI患者签署知情同意书及时率护理专案改善,利用鱼骨图、问卷调查、柏拉图,比较护理专案实施前后急诊PCI患者签署知情同意书及时率的效果。结果实施护理专案改善后,急诊PCI患者签署知情同意书及时率显著提高,急诊PCI患者签署知情同意书不及时率由原来的80%下降到20%。结论提高急诊PCI患者签署知情同意书及时率护理专案改善有利于医生快速实施治疗,为患者赢得黄金生命时间。     

危机管理在急诊护理管理中的应用

目的:探讨急诊护理中实施危机管理对提高护理效率的作用及意义。方法:将我院实施危机管理前后2年的患者进行分组,其中实施危机管理前1年的患者132例作为对照组,实施风险管理后1年的患者143例作为观察组,分析我院实施危机管理前后急诊患者住院期间危机事件的发生率、抢救成功率、病例书写情况及患者满意度。结果:观察组病例书写合格率100.0%,对照组病例书写合格率89.4%,观察组抢救成功率98.6%,对照组抢救成功率92.4%,观察组患者满意度98.6%,对照组患者满意度87.1%,两组患者差异具有统计学意义(P0.05)。结论:实施危机管理能够有效提高急诊抢救成功率和患者满意度。     

Evaluation of nurse triage in a British accident and emergency department.

OBJECTIVE--To compare formal nurse triage with an informal prioritisation process for waiting times and patient satisfaction. SETTING--Accident and emergency department of a district general hospital in the midlands in 1990. DESIGN--Patients attending between 8:00 am and 9:00 pm over six weeks were grouped for analysis according to whether triage was operating at time of presentation and by their degree of urgency as assessed retrospectively by an accident and emergency consultant. PATIENTS--5954 patients presenting over six weeks. MAIN OUTCOME MEASURES--Time waited between first attendance in the department and obtaining medical attention, and patient satisfaction measured by questionnaire. RESULTS--Complete data on waiting time were collected on 5037 patients (85%). Only 1213 of the 2515 (48%) patients presenting during the triage period were seen by a triage nurse. Patients in the triage group waited longer than those in the no triage group in all four retrospective priority categories, though differences were significant for only the two most urgent categories (difference in median waiting time 10.5 (95% confidence interval 3.5 to 14) min for category 1 and 8.5 (3 to 12) min for category 2). Responses to the patient satisfaction questionnaire were similar in the two groups except for the question relating to anxiety relating to pain. CONCLUSIONS--This study fails to show the benefits claimed for formal nurse triage. Nurse triage may impose additional delay for patient treatment, particularly among patients needing the most urgent attention.     

First Nations status and emergency department triage scores in Alberta: a retrospective cohort study

Background:Previous studies have found that race is associated with emergency department triage scores, raising concerns about potential health care inequity. As part of a project on quality of care for First Nations people in Alberta, we sought to understand the relation between First Nations status and triage scores.Methods:We conducted a population-based retrospective cohort study of health administrative data from April 2012 to March 2017 to evaluate acuity of triage scores, categorized as a binary outcome of higher or lower acuity score. We developed multivariable multilevel logistic mixed-effects regression models using the levels of emergency department visit, patient (for patients with multiple visits) and facility. We further evaluated the triage of visits related to 5 disease categories and 5 specific diagnoses to better compare triage outcomes of First Nations and non–First Nations patients.Results:First Nations status was associated with lower odds of receiving higher acuity triage scores (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.92–0.94) compared with non–First Nations patients in adjusted models. First Nations patients had lower odds of acute triage for all 5 disease categories and for 3 of 5 diagnoses, including long bone fractures (OR 0.82, 95% CI 0.76–0.88), acute upper respiratory infection (OR 0.90, 95% CI 0.84–0.98) and anxiety disorder (OR 0.67, 95% CI 0.60–0.74).Interpretation:First Nations status was associated with lower odds of higher acuity triage scores across a number of conditions and diagnoses. This may reflect systemic racism, stereotyping and potentially other factors that affected triage assessments.

Health outcomes are markedly worse for First Nations than non–First Nations people. Although this is largely because of inequities in the social determinants of health,^1–4 inequities in the provision of health care also exist.^5,6 Emergency departments serve as a point of accessible health care. Status First Nations patients make up 4.8% of unique patients and 9.4% of emergency visits in Alberta,⁷ and Canadian studies describe First Nations patients’ experiences with racism when seeking emergency care.^8,9Evaluating triage contributes empirically to understanding the health care of First Nations patients insofar as triage is a quantifiable, intermediate process by which systemic racism¹⁰ may influence patient outcomes. The Canadian Triage Acuity Scale¹¹ is a 5-level scale used to classify the severity of patient symptoms. Triage nurses use a brief assessment, medical history, and presenting signs and symptoms to assign each patient a triage score that determines the priority in which the patient should be seen by a provider. Therefore, accurate triage is important for patient health outcomes.¹² In practice, triage is a social interaction where local practice, biases, stereotypes and communication barriers come into play. Studies have found that women receive less acute triage scores than men,^13,14 and that racial minority^13,15–17 and Indigenous^18–20 patients receive less acute triage scores than white or non-Indigenous patients. Indeed, Indigenous patients in Canada have described a perception “of social triaging in the [emergency department], whereby decisions about who is seen first seemed to them [to be] based less on triaged clinical priorities but on the social positioning of the patient.”²¹ Differential triage scores for minority populations raise health equity concerns.As part of a larger mixed-methods project evaluating the quality of emergency care for First Nations people in Alberta, we sought to evaluate quantitative differences in emergency visit characteristics and outcomes of First Nations and non–First Nations people in Alberta. Specifically, we aimed to estimate the relation between First Nations status and acuity of triage, and to evaluate whether predictors of acuity differ by First Nations status.     

Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department

Objectives

The Canadian C-Spine Rule for imaging of the cervical spine was developed for use by physicians. We believe that nurses in the emergency department could use this rule to clinically clear the cervical spine. We prospectively evaluated the accuracy, reliability and acceptability of the Canadian C-Spine Rule when used by nurses.

Methods

We conducted this three-year prospective cohort study in six Canadian emergency departments. The study involved adult trauma patients who were alert and whose condition was stable. We provided two hours of training to 191 triage nurses. The nurses then assessed patients using the Canadian C-Spine Rule, including determination of neck tenderness and range of motion, reapplied immobilization and completed a data form.

Results

Of the 3633 study patients, 42 (1.2%) had clinically important injuries of the cervical spine. The kappa value for interobserver assessments of 498 patients with the Canadian C-Spine Rule was 0.78. We calculated sensitivity of 100.0% (95% confidence interval [CI] 91.0%–100.0%) and specificity of 43.4% (95% CI 42.0%–45.0%) for the Canadian C-Spine Rule as interpreted by the investigators. The nurses classified patients with a sensitivity of 90.2% (95% CI 76.0%–95.0%) and a specificity of 43.9% (95% CI 42.0%–46.0%). Early in the study, nurses failed to identify four cases of injury, despite the presence of clear high-risk factors. None of these patients suffered sequelae, and after retraining there were no further missed cases. We estimated that for 40.7% of patients, the cervical spine could be cleared clinically by nurses. Nurses reported discomfort in applying the Canadian C-Spine Rule in only 4.8% of cases.

Conclusion

Use of the Canadian C-Spine Rule by nurses was accurate, reliable and clinically acceptable. Widespread implementation by nurses throughout Canada and elsewhere would diminish patient discomfort and improve patient flow in overcrowded emergency departments.Each year, Canadian emergency departments treat 1.3 million patients who have suffered blunt trauma from falls or motor vehicle collisions and who are at risk for injury of the cervical spine.¹ Most of these cases involve adults who are alert and in stable condition, and less than 1% involve fracture of the cervical spine.² Most trauma patients who have been transported in ambulances are protected by a backboard, collar and neck supports. Nurses are responsible for initial triage in the emergency department and usually send such patients to high-acuity resuscitation rooms, where they may remain fully immobilized for hours until assessment by a physician and radiography are complete. This prolonged immobilization is often unnecessary and adds considerably to patient discomfort. The delay also adds to the burden of overcrowded Canadian emergency departments in an era when they are under unprecedented pressures.^3–5 These patients occupy valuable space in resuscitation rooms, and repeated efforts to obtain satisfactory radiographs or computed tomography scans of the cervical spine use valuable time on the part of physicians, nurses and technicians.A clinical decision rule is defined as a decision-making tool incorporating three or more variables from the patient’s history, a physical examination or simple tests. Such rules are derived from original research and help clinicians with diagnostic or therapeutic decisions at the bedside. We previously developed a clinical decision rule for evaluation of the cervical spine.^6,7 The Canadian C-Spine Rule comprises simple clinical variables (Figure 1) and was designed to allow clinicians to “clear” immobilization of the cervical spine (i.e., remove neck collar and other devices) without radiography and to decrease immobilization times.⁸ We also validated the accuracy of the rule when used by physicians.⁹ We recently completed an implementation trial at 12 Canadian hospitals to evaluate the impact on patient care and outcomes of the Canadian C-Spine Rule when used by physicians.¹⁰Open in a separate windowFigure 1The Canadian C-Spine Rule to rule out cervical spine injury, adapted for use by nurses. The rule is intended for patients who have experienced trauma, who are alert (score on Glasgow Coma Scale = 15) and whose condition is stable. *The following mechanisms of injury were defined as dangerous: fall from elevation of more than 3 ft (91 cm) or five stairs, axial load to the head (e.g., diving injury), motor vehicle collision at high speed (> 100 km/h), motor vehicle collision involving a rollover or ejection, injury involving a motorized recreational vehicle, bicycle-related injury (rider struck or collision). †Simple rear-end motor vehicle collisions exclude incidents in which the patient was pushed into oncoming traffic or was hit by a bus, large truck or vehicle travelling at high speed, as well as rollovers; all such incidents would be considered high risk. ‡Neck pain with delayed onset is any pain that did not occur immediately following the precipitating incident. Adapted, with permission, from Stiell IG, Wells GA, Vandemheen K, et al. The Canadian Cervical Spine Radiography Rule for alert and stable trauma patients. JAMA 2001;286:1841–8.⁸ Copyright © 2001 American Medical Association. All rights reserved.Nurses in the emergency department usually do not evaluate the cervical spine of trauma patients, and they routinely send all immobilized patients to the emergency department’s resuscitation room. We believe that nurses could safely evaluate alert patients who have arrived by ambulance and whose condition is stable and could “clear” immobilization of the cervical spine of low-risk patients upon arrival at the triage station.¹¹ Patients could then be much more rapidly, comfortably and efficiently managed in other areas of the emergency department. An expanded decision-making role for nurses has the potential to improve the efficiency of trauma care in all Canadian hospitals. Very little research has been done to determine the ability of nurses to clear immobilization of the cervical spine.^12–15 Our objective in this study was to prospectively evaluate the accuracy, reliability and acceptability of the Canadian C-Spine Rule when used by nurses to assess patients’ need for immobilization.     

Reduction of radial-head subluxation in children by triage nurses in the emergency department: a cluster-randomized controlled trial

Background:

Radial-head subluxation is an easily identified and treated injury. We investigated whether triage nurses in the emergency department can safely reduce radial-head subluxation at rates that are not substantially lower than those of emergency department physicians.

Methods:

We performed an open, noninferiority, cluster-randomized control trial. Children aged 6 years and younger who presented to the emergency department with a presentation consistent with radial-head subluxation and who had sustained a known injury in the previous 12 hours were assigned to either nurse-initiated or physician-initiated treatment, depending on the day. The primary outcome was the proportion of children who had a successful reduction (return to normal arm usage). We used a noninferiority margin of 10%.

Results:

In total, 268 children were eligible for inclusion and 245 were included in the final analysis. Of the children assigned to receive physician-initiated care, 96.7% (117/121) had a successful reduction performed by a physician. Of the children assigned to receive nurse-treatment care, 84.7% (105/124) had a successful reduction performed by a nurse. The difference in the proportion of successful radial head subluxations between the groups was 12.0% (95% confidence interval [CI] 4.8% to 19.7%). Noninferiority of nurse-initiated radial head subluxation was not shown.

Interpretation:

In this trial, the rate of successful radial-head subluxation performed by nurses was inferior to the physician success rate. Although the success rate in the nurse-initiated care group did not meet the non-inferiority margin, nurses were able to reduce radial head subluxation for almost 85% of children who presented with probable radial-head subluxation. Trial registration: Clinical Trials.gov, no. {"type":"clinical-trial","attrs":{"text":"NCT00993954","term_id":"NCT00993954"}}NCT00993954.Radial-head subluxation is a common arm injury among young children and often results in a visit to the emergency department.¹ This type of injury occurs when forceful longitudinal traction is applied to an extended and pronated forearm.² Radial-head subluxation is easily recognized by its clinical presentation and can be treated by a simple reduction technique involving hyperpronation or supination and flexion of the injured arm.^3–7Despite the ease of diagnosis and treatment, children with radial-head subluxation often wait hours in the emergency department for a reduction that takes minutes to perform.⁸ These visits have direct health care costs and involve time and stress for the child and their family. Early treatment and shorter wait times correlate with patient satisfaction.^9,10 Patient satisfaction is comparable when minor injuries are cared for by a nurse instead of by a physician.^11–13 Nurse-initiated treatments are increasingly a focus of health care.^14–17Treatment of radial-head subluxation is an appropriate area to consider nurse-initiated care. Our objective was to determine whether triage nurses, trained in the recognition and treatment of radial-head subluxation, could successfully reduce radial-head subluxation at a rate similar to that of physicians.     

The effect of a charted history of depression on emergency department triage and outcomes in patients with acute myocardial infarction

Background

Patients with acute myocardial infarction may have worse outcomes if they also have a history of depression. The early management of acute myocardial infarction is known to influence outcomes, and patients with a coexisting history of depression may be treated differently in the emergency department than those without one. Our goal was to determine whether having a charted history of depression was associated with a lower-priority emergency department triage score and worse performance on quality-of-care indices.

Methods

We conducted a retrospective population-based cohort analysis involving patients with acute myocardial infarction admitted to 96 acute care hospitals in the province of Ontario from April 2004 to March 2005. We calculated the adjusted odds of low-priority triage (Canadian Emergency Department Triage and Acuity Scale score of 3, 4 or 5) for patients with acute myocardial infarction who had a charted history of depression. We compared these odds with those for patients having a charted history of asthma or chronic obstructive pulmonary disease (COPD). Secondary outcome measures were the odds of meeting benchmark door-to-electrocardiogram, door-to-needle and door-to-balloon times.

Results

Of 6784 patients with acute myocardial infarction, 680 (10.0%) had a past medical history of depression documented in their chart. Of these patients, 39.1% (95% confidence interval [CI] 35.3%–42.9%) were assigned a low-priority triage score, as compared with 32.7% (95% CI 31.5%–33.9%) of those without a charted history of depression. The adjusted odds of receiving a low-priority triage score with a charted history of depression were 1.26 (p = 0.01) versus 0.88 (p = 0.23) with asthma and 1.12 (p = 0.24) with COPD. For patients with a charted history of depression, the median door-to-electrocardiogram time was 20.0 minutes (v. 17.0 min for the rest of the cohort), median door-to-needle time was 53.0 (v. 37.0) minutes, and median door-to-balloon time was 251.0 (v. 110.0) minutes. The adjusted odds of missing the benchmark time with a charted history of depression were 1.39 (p < 0.001) for door-to-electrocardiogram time, 1.62 (p = 0.047) for door-to-needle time and 9.12 (p = 0.019) for door-to-balloon time.

Interpretation

Patients with acute myocardial infarction who had a charted history of depression were more likely to receive a low-priority emergency department triage score than those with other comorbidities and to have worse associated performance on quality indicators in acute myocardial infarction care.In the United States, more than six million patients with conditions related to mental health are seen each year in the nation’s emergency departments.¹ Some of these comprise the six million patients with chest pain who are also seen annually in the emergency department.² Several studies have suggested that patients with acute myocardial infarction fare worse if they also suffer from depression.^3–5 The cause for less favourable outcomes is thought to be multifactorial and to include poor adherence to treatment.⁵ To our knowledge, quality of care in emergency departments has not been examined as a possible contributor. It has been suggested that patients with mental illness receive a lower-priority triage score than other patients in emergency departments because of the stigma of the disease.^6,7Virtually all patients who present to an emergency department are initially assessed by a trained triage nurse. The nurse assigns them a triage score based on their illness acuity, prioritizing them for subsequent emergency care. In Ontario, all emergency departments are mandated to use the five-level Canadian Emergency Department Triage and Acuity Scale.⁸ This uniformity provides an opportunity to study the effect of triage at the population level. In the United States, various triage tools are used.⁹Previously, we established that the emergency department triage scores assigned to patients who are ultimately found to be having an acute myocardial infarction are independently associated with delays in diagnostic testing and reperfusion.¹⁰ In this study, we examined the emergency department care of patients with acute myocardial infarction who had a medical history of depression noted in their emergency department chart. We aimed to determine whether these patients were assigned lower-priority triage scores than other patients with acute myocardial infarction and whether there was an association between a charted history of depression and performance on established quality-of-care indices.¹¹     

Using triage for environmental remediation in Antarctica

Remediation of sites impacted by human activity in Antarctica is a difficult and resource intensive process. With increasing activity and climate change, the extent of damage from human activities is expected to increase and it will not be feasible to protect the environment entirely. We recommend a triage process be used to provide informed and transparent management decisions for comprehensive and adequate environmental remediation in Antarctica. We provide examples that demonstrate realistic outcomes where we have avoided tying up resources on disturbed sites that will recover naturally, are stable, or too damaged to recover, and that also incorporate feasible operational practices. Not all disturbed sites will be remediated and many of those that are, are unlikely to be returned to pristine condition. The decisions around remediation are not based solely on the desired environmental outcome. In the absence of effective legal obligation, we recognize that financial, social, policy, health and safety, technological confidence, and operational feasibility are part of the decision‐making process.