五级成人急诊分诊标准对急危重症患者分诊的准确性：一项真实世界的回顾性研究

Accuracy of five-level adult emergency triage system on critically ill patients： a retrospective observation study in real world

目的分析五级成人急诊分诊标准（FLAETS）对急危重症患者分诊的准确性及影响分诊准确性的因素。方法回顾性分析复旦大学附属华山医院北院2014年7月开始实施FLAETS前后各1年内就诊患者的分诊资料，以实施后的患者（2014年9月至2015年8月）作为观察组，采用FLAETS对就诊患者进行分诊；实施前的患者（2013年7月至2014年6月）作为对照组，采用改良早期预警评分（MEWS）对就诊患者进行手工分诊。纳入分诊Ⅰ、Ⅱ、Ⅲ级（危急、危重、紧急）患者，以急诊总值班分诊结果设为“金标准”。比较两组患者性别、年龄、分诊级别、过度分诊比例、分诊不足比例和病死率，分析过度分诊或分诊不足的原因，计算FLAETS对急危重症患者分诊的准确率。结果观察组共纳入18449例患者，其中Ⅰ、Ⅱ、Ⅲ级患者分别为720、1641、16088例；“金标准”分诊Ⅰ、Ⅱ、Ⅲ级患者分别为637、l476、15265例，修正后总例数17378例。对照组共纳入6352例患者，其中Ⅰ、Ⅱ、Ⅲ级患者分别为204、771、5377例；“金标准”分诊Ⅰ、Ⅱ、Ⅲ级患者分别为308、836、4858例，修正后总例数6002例。两组患者性别和年龄比较差异无统计学意义（均P〉O．05）。观察组对Ⅲ级患者过度分诊的比例低于对照组[8．3％（1329／16088）比12．5％（674／5377），P〈0．01]，对Ⅱ级和Ⅲ级患者分诊不足的比例也显著降低[Ⅱ级分诊：0．6％（9／1641）比7．0％（54／771），m级分诊：0．4％（63／16088）比4．7％（254／5377），均P〈0．01]。观察组的抢救成功率高于对照组[80．70％（619／767）比75．23％（41~545），P=0．020]，而且能够降低病死率[1．11％（193／17378）比2．35％（141／6002），P=0．037]。过度分诊主要见于慢性阻塞性肺疾病（COPD）、高血压和以“胸闷、气促”为主诉就诊的患者；分诊不足主要见于老年多器官功能障碍、不典型性心脏病及气胸患者。观察组Ⅰ、Ⅱ、Ⅲ级分诊准确率（分别为99．37％、97．42％、89．58％）均显著高于对照组（分别为97．51％、92．54％、80．16％，均P〈0．01）。结论采用FLAETS分诊急危重症患者客观可靠，能使预检护士更好地处理病情急与缓、重与轻、先与后的关系，使得急危重症患者得到及时有效的救治。

Objective To observe the accuracy of the five-level adult emergency triage system （FLAETS） in determining the severity of critically ill patients, and to analyze the factors that influenced the accuracy of the triage. Methods The triage information of patients admitted to Huashan North Hospital Affiliated to Fudan University between 1 year before and 1 year （started in July 2014） after the implementation of the FLAETS were retrospective analyzed. The patients who triaged by FLAETS （from September 2014 to August 2015） were served as observational group, and those manual triaged by modified early warning score （MEWS, from July 2013 to June 2014） were set as control group. The patients with triage of I , Ⅱ, and Ⅲ levels were enrolled （fatal, critical, urgent）, and the triage results of emergency physicians-in-chief on duty were set as ＂gold standard＂. The gender, age, triage level, the proportion of over-triage, the proportion of under-triage, and mortality were compared between two groups. The reasons for the over- triage and under-triage were analyzed. The accuracy of FLAETS in determining severity of critically ill patients was calculated. Results 18449 patients were enrolled in observational group, and 720, 1 641 and 16088 patients were triaged as level Ⅰ, level Ⅱ, level Ⅲ respectively; 17 378 patients were triaged as critically ill patients according to ＂gold standard＂, and level I , level Ⅱ, level m were 637, 1 476 and 15 265 patients respectively. 6 352 patients were enrolled in control group, and level Ⅰ, level Ⅱ, level Ⅲ were 204, 771 and 5 377 patients respectively; 6 002 patients were triaged as critically ill patients according to ＂gold standard＂, and level Ⅰ, level Ⅱ, level m were 308, 836 and 4 858 patients respectively. There were no statistically significant differences in gender and age between two groups （both P 〉 0.05）. Compared with the control group, the proportion of over-triage of level m was significantly lowered [8.3% （1329/16088） vs. 12.5% （674/5377）, P 〈 0.01], the proportion of under-triage of level Ⅱ and level m was significantly lowered [level Ⅱ ： 0.6% （9/1641） vs. 7.0% （54/771）, level Ⅲ： 0.4% （63/16088） vs. 4.7% （254/5377）, both P 〈 0.01]. The success rate of resuscitation in observation group was significantly higher than that of control group [80.70% （619/767） vs. 75.23% （410/545）, P = 0.020], and the mortality was significantly lowered [1.11% （193/17 378） vs. 2.35% （141/6002）, P = 0.037]. Over-triages were mainly found in patients with chronic obstructive pulmonary disease （COPD）, hypertension and the main complaint of ＂chest tightness, shortness of breath＂, and under-triages were mainly found in patients with the multiple organ dysfunction in the elder, atypical heart disease and pneumothorax. The accuracy rates of level Ⅰ , level Ⅱ and level Ⅲin observation group （99.37%, 97.42% and 89.58%） were significantly higher than those of the control group （97.51%, 92.54%, and 80.16%, all P 〈 0.01）. Conclusion The FLAETS in determining severity of critically ill patients were objective and reliable, which enable the nurse to better handle the relationship of the emergency and the ordinary, the severe and the mild, the priority and the non-priority, which made the patients received timely and effective treatment.