張少麗,韓　萍,魏薇萍,段艷梅,王飛燕,張文慧

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綜合性三級(jí)甲等醫(yī)院急診搶救室病人滯留相關(guān)因素分析

張少麗,韓萍,魏薇萍,段艷梅,王飛燕,張文慧

摘要:[目的]分析急診搶救室病人滯留影響因素,進(jìn)一步加快急診搶救病人分流,提出有效應(yīng)對(duì)策略,為提高急診服務(wù)質(zhì)量提供依據(jù)。[方法]采用回歸分析方法分析某綜合性三級(jí)甲等醫(yī)院2013年度急診搶救室病人滯留時(shí)間及發(fā)生滯留的相關(guān)因素。[結(jié)果]該院急診搶救室全年搶救病人8 631例次,3 045例次搶救病人滯留時(shí)間>6 h,其中403例次病人滯留時(shí)間≥24 h;滯留時(shí)間≥24 h病人排名前3位科室為神經(jīng)內(nèi)外科、心內(nèi)科、呼吸內(nèi)科;Logstic單因素分析影響因素為年齡、專(zhuān)科病房床位情況、病情涉及多科室、不配合治療、臨終病人。Cox多因素分析與是否涉及多科室、專(zhuān)科病房床位情況、年齡(>75歲)具有相關(guān)性。[結(jié)論]通過(guò)對(duì)急診搶救室病人滯留狀況調(diào)查分析,可及早發(fā)現(xiàn)急診搶救室病人滯留特點(diǎn)及主要影響因素,提出相關(guān)措施,減少危重病人在急診搶救室的滯留時(shí)間。

關(guān)鍵詞:急診搶救室;滯留時(shí)間;相關(guān)因素;三級(jí)甲等醫(yī)院

急診搶救室是搶救危急重病人、處理突發(fā)意外事件的第一場(chǎng)所,然而,一些三級(jí)甲等醫(yī)院的急診室人滿為患,過(guò)度擁擠已成為普遍問(wèn)題[1-2]。與國(guó)外相比,我國(guó)醫(yī)院急診搶救室擁擠現(xiàn)象更為突出,嚴(yán)重影響急診病人救治,而造成這種狀況的原因之一是急診搶救室病人大量滯留。病人滯留時(shí)間過(guò)長(zhǎng)不僅阻礙了現(xiàn)有病人,還阻礙了新病人的治療[3]。調(diào)查研究表明，急診滯留時(shí)間是影響病人對(duì)急診室滿意度的一個(gè)非常重要的因素[4]。針對(duì)上述現(xiàn)象,如何減少病人急診搶救室不合理滯留和緩解急診搶救室過(guò)度擁擠是當(dāng)前醫(yī)院管理工作中的一個(gè)重大任務(wù)。國(guó)外對(duì)急診室滯留問(wèn)題雖有一定研究,但尚未提出有效解決方案[5]。國(guó)內(nèi)至今僅有少數(shù)相關(guān)報(bào)道。本研究回顧性調(diào)查某綜合性三級(jí)甲等醫(yī)院2013年急診室搶救病人滯留狀況,分析其相關(guān)因素,進(jìn)一步提高急診護(hù)理服務(wù)質(zhì)量,及時(shí)合理地分流病人,保障急診搶救室病人的醫(yī)療護(hù)理安全。

1對(duì)象與方法

1.1對(duì)象選擇2013年1月—2013年12月某三級(jí)甲等綜合性醫(yī)院急診搶救室危重病人8 631例次。納入標(biāo)準(zhǔn):由急診高年資護(hù)士承擔(dān)預(yù)檢分診,預(yù)檢護(hù)士應(yīng)用5級(jí)國(guó)際預(yù)檢系統(tǒng)(5 level national triage system，5L NTS)[6]進(jìn)行分診,將Ⅰ級(jí)、Ⅱ級(jí)、部分Ⅲ級(jí)病人視為病情較重,進(jìn)入搶救室救治。

1.2方法采用SPSS 15.0統(tǒng)計(jì)軟件進(jìn)行數(shù)據(jù)分析和整理,初步分析病人在搶救室滯留時(shí)間,描述并比較不同科室、病人在搶救室滯留情況。調(diào)查分析進(jìn)入急診搶救室的急危重病人信息,通過(guò)國(guó)內(nèi)外文獻(xiàn)檢索列出13個(gè)影響因素,包括病人的性別、年齡、入院意愿、醫(yī)療費(fèi)用、是否急診手術(shù)、是否涉及多科室、專(zhuān)科病房床位情況、醉酒、不配合檢查、自殺服毒、臨終病人、院外糾紛及有無(wú)特殊因素,以滯留時(shí)間為應(yīng)變量,病人離開(kāi)急診室及住院時(shí)間點(diǎn)為自變量,分別進(jìn)行單因素和多因素的回歸分析。RR為相對(duì)危險(xiǎn)度,遠(yuǎn)離1表明該因素影響作用大,>1時(shí)表明該因素加快病人分流;RR<1時(shí)表明該因素導(dǎo)致病人滯留,等于1則不影響或作為參照水平。

2結(jié)果

2.1急診搶救室搶救病人滯留時(shí)間情況搶救病人中3 045例次(35.3%)滯留時(shí)間>6 h,其中403例次(4.7%)病人滯留時(shí)間≥24 h。403例病人中占前3位的滯留科室為神經(jīng)內(nèi)外科、心內(nèi)科、呼吸內(nèi)科,分別為129例、101例、81例，其余為消化內(nèi)科58例、其他34例。

2.2影響急診搶救室滯留時(shí)間的Logstic單因素分析(見(jiàn)表1)

表1　急診搶救室危重病人滯留時(shí)間Logstic單因素分析

2.3影響急診搶救室滯留時(shí)間的Cox多因素分析(見(jiàn)表2)

表2　急診搶救室危重病人滯留時(shí)間的Cox多因素分析

3討論

本研究結(jié)果顯示，2013年該院經(jīng)急診搶救室搶救危重病人8 631例次,其中3 045例次滯留時(shí)間>6 h,占35.3%,403例次滯留時(shí)間≥24 h。有報(bào)道，美國(guó)急診室24%的病人存在滯留現(xiàn)象[7],從數(shù)據(jù)看高于美國(guó)急診室,說(shuō)明該家醫(yī)院急診搶救室病人滯留時(shí)間狀況嚴(yán)重。國(guó)際給予急診搶救室滯留時(shí)間的定義是指病人從預(yù)檢分診開(kāi)始到離開(kāi)急診搶救室的時(shí)間段,包括急診預(yù)檢分診時(shí)間(T1)、搶救治療時(shí)間(T2)、初步搶救后決定住院到實(shí)際離開(kāi)急診室的時(shí)間(T3)[8]。急診預(yù)檢分診時(shí)間通常很短,可忽略不計(jì);初步搶救后決定住院到實(shí)救治療時(shí)間國(guó)外稱等待住院時(shí)間(boarding time),對(duì)于搶救后好轉(zhuǎn)出院及死亡的病人均不涉及T3。如何鑒定急診搶救室滯留時(shí)間,已成為全球關(guān)注的焦點(diǎn)。有研究提出收治病人入院大概需要1 h,一個(gè)醫(yī)院理想的病人收治入院時(shí)間是80 min,如果收治入院的時(shí)間晚了4 h,則就會(huì)導(dǎo)致急診室擁擠現(xiàn)象發(fā)生,將4 h選為分界點(diǎn)[9]。一項(xiàng)對(duì)巴基斯坦卡拉奇大學(xué)一所附屬醫(yī)院的調(diào)查顯示該院9 630例病人中1 999例病人滯留時(shí)間大于6 h[10]。國(guó)際藍(lán)十字會(huì)規(guī)定滯留時(shí)間小于6 h是急診質(zhì)量的標(biāo)準(zhǔn)[11]。美國(guó)門(mén)診醫(yī)療服務(wù)調(diào)查中同樣認(rèn)定急診滯留時(shí)間應(yīng)小于6 h[12]。國(guó)內(nèi)外學(xué)者目前基本認(rèn)為急診室搶救病人要在一個(gè)合理的時(shí)間內(nèi)(通常6 h～8 h)收住相應(yīng)專(zhuān)科的病房,如果超出此范圍就可以認(rèn)為是不合理的滯留[13-14]。本研究結(jié)果顯示，全年急診搶救室的床位主要被3個(gè)科室的病人所占用,依次為神經(jīng)內(nèi)外科、心內(nèi)科、呼吸內(nèi)科。據(jù)文獻(xiàn)資料顯示,在滯留病人中,內(nèi)科系統(tǒng)老年病人在急診搶救室滯留比例高,并呈持續(xù)增長(zhǎng)趨勢(shì)[15-16]。隨著我國(guó)經(jīng)濟(jì)社會(huì)快速發(fā)展,醫(yī)療衛(wèi)生保健事業(yè)的巨大改善,老齡化進(jìn)程逐步加快。老年人機(jī)體隨年齡的增長(zhǎng),生理狀況逐漸衰退,心、腦血管疾病高發(fā),意外傷害也逐漸增加,而這兩大類(lèi)疾病的共同特點(diǎn)是發(fā)病急、進(jìn)展快、病情危重、變化快,仍是當(dāng)前的主要疾病,與國(guó)內(nèi)外報(bào)道基本一致[17]。因?yàn)楹粑到y(tǒng)疾病一般病情發(fā)展慢,住院時(shí)間長(zhǎng),住院周期周轉(zhuǎn)慢,床位周轉(zhuǎn)率不高,形成普通病房的爆滿,造成病人滯留于搶救室。

本研究結(jié)果顯示,引起急診病人滯留時(shí)間長(zhǎng)的主要原因?yàn)槟挲g、涉及多科室、專(zhuān)科病房床位不足、不配合治療病人、臨終病人,RR<1表明該因素影響作用大,能導(dǎo)致病人滯留。研究認(rèn)為,醫(yī)院專(zhuān)科床位不足是絕大多數(shù)醫(yī)院急診科擁擠的主要原因[18]。二次Cox多因素分析也進(jìn)一步證明急診搶救病人滯留與病人疾病涉及多科室、專(zhuān)科病房床位情況、年齡(>75歲)具有相關(guān)性,而與性別、入院意愿性、醫(yī)療費(fèi)用無(wú)關(guān)。急診病人滯留相關(guān)因素大致可分為3種情況:其一,就診于急診的病人老年病人較多,基礎(chǔ)疾病多，疾病涉及多系統(tǒng)、多器官,專(zhuān)科屬性不明顯,專(zhuān)科收治這類(lèi)病人的積極性不高,因?yàn)楝F(xiàn)在的專(zhuān)科越分越細(xì),屬于專(zhuān)科疾病的救治能力確實(shí)得到大幅的提升,但面對(duì)復(fù)雜的多系統(tǒng)病人,需要請(qǐng)多個(gè)專(zhuān)科醫(yī)生前來(lái)共同會(huì)診,專(zhuān)科的綜合診治能力就相對(duì)不足,這些都難免使病人在急診搶救室就診時(shí)間延長(zhǎng)；其二,雖然有些病人的病癥專(zhuān)科屬性很強(qiáng),但由于醫(yī)院沒(méi)有足夠床位收治眾多的專(zhuān)科病人,這類(lèi)病人也因此而滯留在急診科；其三,目前衛(wèi)生部門(mén)對(duì)住院的床位周轉(zhuǎn)率、死亡率都有考核,大多數(shù)臨終病人有很高的死亡率,這意味著醫(yī)院治愈率下降,死亡率上升,對(duì)病床周轉(zhuǎn)率和治愈率都會(huì)造成影響,給科室?guī)?lái)一些負(fù)面影響。

4小結(jié)

通過(guò)系統(tǒng)化的分析,該家醫(yī)院急診搶救室病人滯留狀況比較嚴(yán)重,其中前3位的滯留科室為神經(jīng)內(nèi)外科、心內(nèi)科、呼吸內(nèi)科,主要與相應(yīng)專(zhuān)科病房床位供應(yīng)不足、病人年齡、病種涉及多科室、臨終病人、病人不配合治療有關(guān)。醫(yī)院可以根據(jù)研究結(jié)果采取相應(yīng)對(duì)策,優(yōu)化急診就診流程,打破病房專(zhuān)科劃分的現(xiàn)狀,實(shí)行跨科收治病人等多方法來(lái)緩解急診搶救室病人滯留現(xiàn)象。本研究不足之處局限于地方1所醫(yī)院進(jìn)行的回顧性研究,限于數(shù)據(jù)庫(kù)局限性,不能將所有可能影響因素納入研究,如病人的會(huì)診次數(shù)、影像學(xué)檢查等，有待于今后進(jìn)一步深入探討。

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(本文編輯蘇琳)

作者簡(jiǎn)介張少麗,主管護(hù)師,本科,單位：200233，上海交通大學(xué)附屬第六人民醫(yī)院；韓萍(通訊作者)、魏薇萍、段艷梅、王飛燕、張文慧單位：200233，上海交通大學(xué)附屬第六人民醫(yī)院。

中圖分類(lèi)號(hào)：R472

文獻(xiàn)標(biāo)識(shí)碼：A

doi:10.3969/j.issn.1009-6493.2016.21.013

文章編號(hào)：1009-6493(2016)07C-2602-04

(收稿日期:2015-09-15;修回日期:2016-05-05)

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Zhang Shaoli,Han Ping,Wei Weiping,et al

(Affiliated Sixth People’s Hospital of Shanghai Jiao Tong University,Shanghai 200233 China)

AbstractObjective:To analyze the remaining influencing factors of patients remaining in emergency resuscitation room,further speed up the shunt of emergency rescue patients,put forward the effective coping strategies,so as to provide the basis for improving the quality of emergency services.Methods:The regression method was used to analyze the remaining time and remaining related factors of patients remaining in emergency resuscitation room in a comprehensive third grade A hospital in 2013.Results:In hospital emergency resuscitation room,8 631 cases of patients were rescued throughout the year,the remaining time of 3 045 cases was longer than 6 h,of which the remaining time of 403 patients was longer than 24 h;the top three departments with time of patients which were longer than 24 h were the department of neurology,department of cardiology and department of respiratory medicine;the logistic single factor analysis showed that the influencing factors were age,specialist ward beds status,disease involving multiple departments,the incompatibility of the treatment and terminal patients.Cox multivariate analysis showed that the patienits remaining in emergency resuscitation room had relationship with disease involving multiple departments or not,specialist ward beds status and age(>75 years old).Conclusion:Through the investigation and analysis of remaining status of patients in emergency resuscitation room,it can early detect the remaining characteristics of patients remaining in emergency resuscitation room and its main influencing factors,put forward relevant measures,and reduce the remaining time of critically ill patients in the emergency resuscitation room.

Key wordsemergency resuscitation room;residence time;related factors;third grade A hospitals