急診觀察醫(yī)學(xué)ObservationMedicine

1、急診觀察醫(yī)學(xué)ObservationMedicine急診留觀的必要性急診留觀病人的類型如何觀察急診病人急診留觀的必要性急診病人特點醫(yī)患關(guān)系“擁擠”的急診科急診病人的特點處于疾病的早期階段，不確定因素多,變化快危重病人在明確診斷前就要給予醫(yī)療干預(yù)來診病人常以癥狀或體征為主導(dǎo)，而不是以某種病為主導(dǎo)病情輕重相差大，從感冒到心跳呼吸驟停病人和家屬對緩解癥狀和穩(wěn)定病情期望值高“擁擠”的急診科急診科是醫(yī)院內(nèi)最不具有確定性和最繁忙的一個部門急診科就診病人數(shù)逐年增長病人流量的增加是造成急診科擁擠最基本因素“擁擠”是指急診病人的需求( 即等待急診臨床決策, 如分診、候診、留觀、治療、安置等) 超過了急診科的處理能

2、力我院急診科簡介成立于1984年急診醫(yī)學(xué)碩士和博士學(xué)位授權(quán)點國家急診醫(yī)師規(guī)范化培訓(xùn)基地遼寧省急診醫(yī)療質(zhì)量控制中心“急診急救留觀重癥監(jiān)護(hù)(EICU)”一體化急診初診區(qū)實行“紅、黃、綠”分區(qū)就診現(xiàn)有急診搶救床位6張，監(jiān)護(hù)床位16張，觀察床位19張，每年接診患者9萬余人次，危重患者搶救成功率接近90%急診科擁擠的原因綜合性大醫(yī)院的住院病人日益增多, 造成床位緊張, 急診病人無法及時收住入院, 大量病人留在急診觀察室醫(yī)院病床越來越?？苹? 甚至專病化) , 病房醫(yī)師不愿意收本專業(yè)“不相關(guān)”的病人,而急診病人往往比較復(fù)雜, 有多系統(tǒng)的問題或診斷未明, 是各?？撇》烤苁盏闹饕獙ο蟛∪司S權(quán)意識日益增強(qiáng), 醫(yī)

3、療風(fēng)險有增無減, 尤其急診病人醫(yī)療風(fēng)險非常高, 病情危急, 病房往往不愿意收急診病人多數(shù)醫(yī)院急診科醫(yī)師沒有權(quán)力開住院證急診觀察醫(yī)學(xué)的地位和作用a site to “park” patients awaiting a “real” bedevaluate and stabilize acutely ill patientsdiscriminate patient really needed hospitalization formulate a prognosis devise a plan for treatment提高診斷的準(zhǔn)確性和病人的滿意度為急診醫(yī)生提供教學(xué)和研究的機(jī)會not only

4、useful but essential repeated diagnostic assessment (laboratory, radiology and other clinical investigative services)treatments not routinely provided in an EDpatients with complex or undifferentiated conditions who may require lengthy evaluation, serial review rapid and comprehensive multidisciplin

5、ary assessment prolonged observation for conditions expected to resolve within 12 to 24 hoursthose likely to respond to a brief course of therapy, which then can be modified so that treatment can be continued at home or another community settingan early specialist review by a consultant and/or senio

6、r medical registrar, including that performed by subspecialty servicesTypes of Observation ServiceDiagnostic Evaluation of Critical Diagnostic SyndromesShort-Term Treatment of Serious Emergency Conditions Diagnostic Evaluation of Critical Diagnostic Syndromesa balance between probability and dangero

7、usness of the disease under consideration the physician cannot readily diagnose the condition with testing 醫(yī)生診斷暫時不確定，且診斷結(jié)果直接決定進(jìn)一步處理a balance between probability and dangerousness of the disease under consideration chest painMI abdominal pain kidney stone the physician cannot readily diagnose the con

8、dition with testing 尚無確定的確診試驗，appendicitis靠轉(zhuǎn)移性右下腹痛 確診試驗具有時限性：疑AMI，TNI、CK-MB在病情嚴(yán)重后一段時間始升高 確診試驗暫時無法獲得：疑診腹主動脈瘤、肺動脈栓塞， 夜間不做3D-CT 醫(yī)生診斷暫時不確定，且診斷結(jié)果直接決定進(jìn)一步處理 Appendicitis 手術(shù)? 保守? 異位妊娠？Diagnostic Evaluationreceive medical inpatients for intensive assessment, care and treatment for a designated period prior t

9、o departure home or transfer to medical wards if appropriatefocuses on multidisciplinary early assessment and decision making, proactive planning and interventionDiagnostic EvaluationAbdominal PainAtrial FibrillationChest Pain ConfusionDizzinessFeverGastrointestinal Hemorrhage HeadacheSeizuresSyncop

10、eToxicologyTraumaVaginal BleedingAbdominal Pain無確定的診斷試驗，涉及疾病多，且包括致命疾病，接診醫(yī)生在綜合分析疼痛部位、時間、性質(zhì)和伴隨情況等所有的助于診斷的線索后，準(zhǔn)確診斷率約為72%?？梢越柚R床評分系統(tǒng)協(xié)助診斷MANTRELS評分（appendicitis）symptoms: Migration of pain 1point Anorexia 1point Nausea 1pointsign: Tender right lower quadrant 2point Rebound 1point Elevated temperature 1po

11、int laboratory results: Leukocytosis 2point Shift 1point動態(tài)監(jiān)測提示意義更大Clues to diagnosis in the patients with abdominal painType of pain SexDisease pattern Location of painType of painVomiting, disention, obstipation and increased bowel soundsobstructionRebound tenderness or rigidityperitonitis上腹部燒灼樣疼痛伴

12、有惡心、嘔吐，抑酸劑有效胃部疾病腹痛癥狀（重）和體征（相對輕）分離，惡心嘔吐，血便，休克血管疾病Sex女性腹痛更復(fù)雜，涉及異位妊娠和盆腔器官疾病很多女患者并未意識到她已經(jīng)懷孕除了月經(jīng)推遲，早孕并無確切的可靠表現(xiàn)異位妊娠在破裂前很難診斷檢測HCG很有必要Disease pattern持續(xù)性or陣發(fā)性 放散部位 加重或緩解因素Location of pain右下腹 右上腹 不固定 側(cè)腹部Atrial FibrillationSerious acute medical conditions associated with atrial firillation Acute myocardial inf

13、arction Unstable angina pectoris Acute pulmonary edema Pericardial tonade Pneumonia Acute pulmonary embolus Thyrotoxicosis Hypertensive emergency Marked hypokalemiaAtrial Fibrillation基本措施-控制心率（地高辛、受體阻滯劑、非二氫吡啶類鈣通道阻滯劑如地爾硫卓等）選擇性措施-糾正心律紊亂（藥物轉(zhuǎn)復(fù)或電擊轉(zhuǎn)復(fù)）必要措施-預(yù)防血栓栓塞Chest PainPotentially life-threatening Myoca

14、rdial infarction Unstable angina Dissecting thoracic aneurysm Pericarditis with tonade Tension pneumothorax or effusion Pulmonary embolism Esophageal ruptureChest PainGenerally non-life-threatening Stable angina Congestive heart failure Pericarditis without tonade Mitral valve prolapse Pleurisy Pneu

15、monia Stable pneumothorax or effusion Esophageal spasm Esophagitis Peptic ulcer Cholelithiasis with biliary spasm Pancreatitis Costochondritis Intercostal muscle strain Herpes zoster ConfusionFindings suggestive of a confusional state Poor judgment Poor orientation Worsening memory(recent) Worsening

16、 intellect Poor calculating ability Learning difficulties Labile affect Personality change ConfusionFindings suggestive of organic disease Abnormal vital signs Visual hallucinations Elderly On medications Known organic disease Alcohol or substance abuse History of headache Loss of coordination Focal

17、 neurologic findings Short-Term TreatmentThese meet the care needs of a group of emergency patients who require extended emergency care and an expected hospital stay of less than 24 hours.Short-Term TreatmentAsthmaCongestive Heart Failure DehydrationHyperglycemia/HypoglycemiaHypertensionInfectionsSi

18、ckle Cell Anemia Pain ManagementObservation medicine can improve health outcomes by providing:early access to short-term specialist services (such as multidisciplinary, specialist advice and care) and experienced staff able to observe patients with diverse problems and address the complex needs of p

19、atientsintensive or short-term care/frequent evaluation (assessment, observation and/or therapy) of a specific group of ED patients to rapidly diagnose conditions and expedite careevidence-based care pathways to facilitate assessment and treatment and reduce unnecessary variations in care deliveryOb

20、servation medicine can improve health outcomes by providing:a coordinated interdisciplinary team approach with early specialist intervention and integration with broader hospital and community servicesdecreased length of stay and decreased multiday hospital admission rates without increasing the rat

21、e of hospitalisation or readmissionan environment more comfortable for patients than the EDavoidance of inappropriate departure from an EDgreater continuity of care by reducing the number of transitions that can lead to errors, delay, duplication and lost informationObservation medicine can improve

22、patient flow by:providing a comprehensive care model specific for patients requiring short-term treatment or observationstreamlining the delivery of appropriate health services to ensure more timely care delivery and thus earlier dischargereducing avoidable admissions (for exle older patients, chest

23、 pain)increasing capacity to manage high ED patient volumeactively seeking appropriate patients (pull) from the ED early in their episode of careavoiding prolonged ED stays and/or the use of multiday inpatient beds for patients requiring less than 24-48 hours of careKey principles for observation me

24、dicine Patient centred Quality and safety Early access Evidence-based care Substitution Collaboration Efficiency Patient centred carecare is respectful of, and responsive to, individual patient preferences, needs and values, and provided in a comfortable environmentQuality and safetysystems and processes deliver quality outcomes and minimise risks. Early accessthere is early access to diagnostics, specialist a