2997例皮肤软组织损伤住院患者的回顾性分析

Retrospective analysis of 2997 inpatients with skin and soft tissue injuries

目的分析皮肤软组织损伤住院患者的流行病学特征以及相关诊疗信息。方法回顾性分析解放军总医院第四医学中心(下称笔者单位)2014年1月1日—2018年12月31日收治的符合入选标准的皮肤软组织损伤住院患者的病历资料。统计如下指标:性别、年龄、创面病程、基础性疾病,创面类型、部位和创面微生物培养结果,治疗方式和结局,医疗费用支付类型、住院天数及住院费用。对数据行Mann-Whitney U检验、Kruskal-Wallis H检验、χ2检验。结果(1)笔者单位5年间共收治2997例符合入选标准的患者,男1803例(60.16%)、女1194例(39.84%),本组患者5年间性别分布差异明显(χ2=13.203,P<0.05),女性患者年龄明显高于男性患者(Z=-6.387,P<0.01)。急性创面患者882例(29.43%),慢性创面患者2115例(70.57%),本组患者5年间急慢性创面分布差异明显(χ2=66.806,P<0.01)。慢性创面患者的年龄明显高于急性创面患者(Z=-12.582,P<0.01)。共计1910例患者合并基础性疾病,共3847例次,常见基础性疾病依次为糖尿病1151例次(29.92%)、高血压884例次(22.98%)、冠状动脉粥样硬化性心脏病414例次(10.76%)、陈旧性脑梗死258例次(6.71%)、截瘫258例次(6.71%)。慢性创面患者合并基础性疾病例数明显多于急性创面患者(χ2=130.649,P<0.01)。(2)本组患者常见创面类型依次为术后难愈性创面、烧伤创面、糖尿病足溃疡、压疮、皮肤软组织感染。本组患者5年间创面类型分布差异明显(χ2=342.265,P<0.01)。本组患者共3957处创面。常见创面部位依次为足部、腿部、胸部等。976例患者行创面微生物培养,719例(73.67%)患者结果为阳性,257例(26.33%)患者结果为阴性。慢性创面患者的创面微生物培养阳性率明显高于急性创面患者(χ2=33.981,P<0.01)。急性创面患者中单纯感染111例(72.08%)、混合感染43例(27.92%),慢性创面患者中单纯感染364例(64.42%)、混合感染201例(35.58%)。719例患者共检出病原菌1010株,其中革兰阳性菌447株(44.26%)、革兰阴性菌548株(54.26%)、真菌15株(1.48%)。急性和慢性创面患者的病原微生物分布差异明显(χ2=12.215,P<0.01)。本组患者创面常见菌株为金黄色葡萄球菌、大肠杆菌、铜绿假单胞菌等。急性创面患者常见菌株为金黄色葡萄球菌、大肠杆菌、表皮葡萄球菌等,慢性创面患者常见菌株为金黄色葡萄球菌、铜绿假单胞菌、大肠杆菌等。(3)本组患者主要行手术治疗。最终痊愈1330例、好转1393例、未愈257例、死亡17例。慢性和急性创面患者治疗结局分布差异明显(Z=-7.622,P<0.01)。(4)本组患者医疗费用支付类型主要为地方医疗保险、异地医疗保险、自费。本组患者总体住院费用为169268523.65元,以材料费用与药物费用为主。本组患者住院天数为21.00(11.00,36.00)d,住院费用为30016.34(14439.41,63685.60)元。不同医疗费用支付类型患者的住院天数与住院费用均差异明显(χ2=285.986、327.436,P<0.01)。不同创面类型患者的住院天数与住院费用均差异明显(χ2=125.912、131.485,P<0.01)。结论皮肤软组织损伤住院患者以中老年为主,男性患者多于女性,慢性创面患者多于急性创面;皮肤软组织损伤好发生于骨性突出、皮下脂肪菲薄、血供差的部位;创面微生物培养结果以革兰阴性菌为主,且慢性创面患者的阳性率高于急性创面患者;急性创面患者中革兰阳性菌占比最高,慢性创面患者中革兰阴性菌占比最高;慢性创面患者多伴有各类基础性疾病且病程长,其痊愈患者比例低于急性创面;皮肤软组织损伤患者住院天数长、材料费用占比高,与慢性创面愈合能力差、治疗周期长的临床特点直接相关,建议医疗保险管理部门针对老年慢性创面类住院病例的临床实际需求调节耗占比等管理指标。

Objective To analyze the epidemiological characteristics and the related information on the diagnosis and treatment of inpatients with skin and soft tissue injuries.Methods The medical records of inpatients with skin and soft tissue injuries who were admitted to the Fourth Medical Center of PLA General Hospital(hereinafter referred to as the author′s unit)from January 1,2014 to December 31,2018,conforming to the study criteria,were retrospectively analyzed.The indexes included inpatients′gender,age,wound course,underlying disease,wound type,wound site,and wound microbiological culture result,methods and outcome of treatment,type of medical payment,hospital day,and hospitalization cost.Data were statistically analyzed with Mann-Whitney U test,Kruskal-Wallis H test,and chi-square test.Results(1)A total of 2997 inpatients,conforming to the study criteria,were admitted to the author′s unit during the 5 years.There were 1803(60.16%)males and 1194(39.84%)females.The distribution of gender of patients showed significant differences during the 5 years(χ2=13.203,P<0.05).The age of female patients was significantly older than that of male patients(Z=-6.387,P<0.01).There were 882(29.43%)patients with acute wounds and 2115(70.57%)patients with chronic wounds.The distribution of acute wounds and chronic wounds of patients showed significant differences during the 5 years(χ2=66.806,P<0.01).The age of patients with chronic wounds was significantly older than that of patients with acute wounds(Z=-12.582,P<0.01).A total of 1910 patients(3847 cases)were complicated with underlying diseases.The common underlying diseases orderly were diabetes 1151(29.92%)cases,hypertension 884(22.98%)cases,coro-nary atherosclerotic heart disease 414(10.76%)cases,old cerebral infarction 258(6.71%)cases,and paraplegia 258(6.71%)cases.More patients with chronic wounds were complicated with various underlying diseases compared with patients with acute wounds(χ2=130.649,P<0.01).(2)The common types of wounds were postoperative non-healing wounds,burn wounds,diabetic foot ulcers,pressure ulcers,and skin and soft tissue infection.The distribution of types of wounds showed significant differences during the 5 years(χ2=342.265,P<0.01).There were 3957 wounds.The common wound sites were feet,legs,chests,and so on.A total of 976 patients underwent microbiological examination.The results of 719(73.67%)patients were positive and 257(26.33%)patients were negative.The positive rate of wound microbiological culture of patients with chronic wounds was significantly higher than that of patients with acute wounds(χ2=33.981,P<0.01).Among the patients with acute wounds,111 patients(72.08%)were simply infected,43(27.92%)patients were mixed infected.Among the patients with chronic wounds,364(64.42%)patients were simply infected,and 201(35.58%)patients were mixed infected.A total of 1010 strains of pathogenic bacteria were detected in 719 patients,including 447(44.26%)Gram-positive bacteria,548(54.26%)Gram-negative bacteria,and 15(1.48%)fungi.There was a significant difference in the distribution of pathogenic microorganisms between patients with acute wounds and chronic wounds(χ2=12.215,P<0.01).In this group of patients,the common strains of wounds were Staphylococcus aureus,Escherichia coli,Pseudomonas aeruginosa,and so on.The common strains of patients with acute wounds were Staphylococcus aureus,Escherichia coli,Staphylococcus epidermidis,and so on.The common strains of patients with chronic wounds were Staphylococcus aureus,Pseudomonas aeruginosa,Escherichia colis,and so on.(3)The patients in this group were mainly treated by surgery.Finally,1330 patients were cured,1393 patients were improved,257 patients were not cured,and 17 patients died.There was a significant difference in the distribution of outcome in patients with acute wounds and chronic wounds(Z=-7.622,P<0.01).(4)The main types of payment of medical expenses for patients in this group were local medical insurance,remote medical insurance,and self-paying.The total hospitalization cost of patients in this group was 169268523.65 yuan,which was mainly consist of the costs of materials and drugs.The hospital day of patients in this group was 21.00(11.00,36.00)d,and the hospitalization cost was 30016.34(14439.41,63685.60)yuan.There were significant differences in the hospital day and hospitalization cost among patients with different medical payment types(χ2=285.986,327.436,P<0.01).There were significant differences in the hospital day and hospitalization cost among patients with different wound types(χ2=125.912,131.485,P<0.01).Conclusions The patients with skin and soft tissue injuries are mainly middle-aged and elderly patients,with more males than females,more chronic wounds than acute wounds.Skin and soft tissue injuries are prone to occur in sites with prominent bone,thin subcutaneous fat,and poor blood supply.The result of wound microbiological culture is mainly Gram-negative bacteria,and the positive rate of wound microbiological culture of patients with chronic wounds is higher than that of patients with acute wounds.The proportion of Gram-positive bacterial infection ranks the highest in patients with acute wounds.The proportion of Gram-negative bacterial infection ranks the highest in patients with chronic wounds.Patients with chronic wounds are often complicated with various underlying diseases,and the course of disease is long,so the constituent ratio of cured patients is lower than that of patients with acute wounds.Patients with skin and soft tissue injuries have long hospital days and high proportion of material cost,which are directly related to the clinical characteristics and long treatment cycle of chronic wounds.Therefore,it is suggested that the medical insurance administration department should adjust the consumption ratio and other management indicators according to the actual clinical needs of elderly patients with chronic wounds.