视觉模拟评分法评估急诊科拥挤度研究

Bland-Altman analysis for determining the coincidence between two methods for measuring emergency department crowding： visual analogue scale versus national emergency department overcrowding scale

目的 急诊科拥挤度测量方法是当前急诊科拥挤研究的瓶颈.本研究通过急诊科拥挤度主观评分（视觉模拟评分法,VAS）与国家急诊科拥挤度评分（NEDOCS）进行相关分析和一致性验证,旨在初步构建中国急诊科拥挤度评估系统.方法 对一家年急诊患者流量11万、2 000张住院病床的临床教学医院急诊科进行为期6个月的研究,研究期间每隔8 h （1：00,9：00,17：00）采集急诊科拥挤度评估数据,对拥挤度测量方法进行相关分析和Bland-Altman法进行一致性检验.结果 视觉模拟评分法（VAS）中,医师VAS （VAS-p）值显著低于护士VAS （VAS-n）值[（6.49±1.82） vs.（7.12±1.78）,P＜0.01];信度检验（Kappa检验）显示,Kappa值为0.112 （P＜0.01）,提示两者一致性强度微弱.医师和护士VAS均数（VAS-m）与NEDOCS具有显著相关性（r =0.714,P＜0.01）,但Bland-Altman法一致性检验结果显示,95％的一致性界限为-32.47至71.42,其范围明显超过40分（一个拥挤度评分等级）,提示两种方法的一致性差.结论 视觉模拟评分法存在明显不足,医师与护士VAS评分一致性差;VAS与NEDOCS两种测量方法间一致性也不理想,提示NEDOCS评分值与急诊工作人员对急诊科拥挤问题的主观感受并不一致,有必要对NEDOCS评估模型进行修订.

Objective To establish a practicable and easily mastered emergency department overcrowding （EDO） assessment system suitable for domestic ED setting by determining the validity and usefulness of the national emergency department over-crowding study （NEDOCS） tool in a 2000-bed tertiary care academic institution in China in comparison with visual analogue scale （VAS） in order to address the worldwide grave concern of EDO.Methods In a period of 6 months,data of subjective and objective EDO assessed simultaneously three times a day （1：00,9：00,17：00） were collected.The data were analyzed by using Bland-altmann method and Kappa test to determine the coincidence between VAS and NEDOCS assessments.Results The VAS-p value evaluated by physicians was significantly lower than VAS-n value evaluated by nurses [（6.49 ± 1.82） vs.（7.12 ± 1.78）,P ＜ 0.01].The reliability analysis showed that Kappa value was as low as 0.112 （P ＜0.01） suggesting there was a great discrepancy between VAS-p value and VAS-n value.VAS-m （average value of VAS-p and VAS-n） was taken for comparing different evaluation systems.The significant correlation was found between the VAS-m and NEDOCS （r =0.7l4,P ＜0.01）.However,the Bland-Altman plot showed the 95％ limit of coincidence was in an extensive range （-32.47 to 71.42） suggesting discrepancy existed between two methods.Conclusions The present study suggested there was a significant discrepancy between the two subjective assessments of ED crowding （VAS-p vs.VAS-n）.There might be a fatal flaw existed in the assumptions of the original VAS method for EDO measurement.Using the Bland-Altman plot analysis,the results showed that NEDOCS did not authentically reflect the staff＇ s sense of overcrowding in the ED.It is very important and urgent to establish an objective and effective EDO evaluation system for ED management.