广西重症感染诊断临床思维问卷调查分析

Investigation and analysis of questionnaire on clinical thinking in the diagnosis of severe infection in Guangxi

目的了解临床医务人员对重症感染诊断的临床思维,评估其对重症感染早期识别的能力。方法对2019年9月26日至28日参加广西医师协会重症医学医师分会学术年会的临床医务人员就重症感染诊断临床思维情况进行问卷调查。调查对象包括医师、护士、临床药师、医学研究生,除外非临床人员。诊断感染的临床思维依据包括临床症状、特异生化检查、微生物培养、高通量测序技术(NGS)。对各指标的可信度级别归纳为高(可信度51%~100%)、低(可信度0%~50%)进行数据统计。结果参会人员共600余人,有540人参与问卷调查,参与率约为90.0%;回收合格问卷466份,有效率86.3%;其中医师280份,临床护士155份,临床药师10份,临床研究生21份。医师、护士、临床药师、医学研究生的工作年限分别为(8.2±6.0)、(6.4±6.3)、(4.5±4.0)、(3.8±2.6)年。医师组以中级职称为主(占43.2%),护士组、临床药师组、医学研究生组均以初级职称为主(分别占各自组的53.5%、80.0%、81.0%)。且医师、护士主要来自综合重症监护病房(ICU;分别占73.2%、51.0%)。重症感染诊断临床思维调查结果显示,医生、护士、临床药师、医学研究生4类人群对感染相关症状的认同高度可信度均较一致,其中发热高度可信的比例为80.0%~91.1%,低血压为76.2%~90.0%,意识障碍为80.0%~85.0%,呼吸急促为81.0%~100.0%,尿量减少为81.9%~90.0%。对于病原学培养与NGS结果的解读存在认识水平不足,29.3%~42.6%的医务人员表示对NGS不了解;对病原学标本培养结果的解读也存在差异,医生、护士、临床药师、医学研究生认为标本培养阳性能诊断感染的比例分别为93.6%、85.2%、90.0%、85.7%(P=0.021)。不同人群对于某些传统的感染相关的实验室指标如白细胞计数(WBC)增高(χ^(2)=8.542、P=0.026)、C-反应蛋白(CRP)增高(χ^(2)=8.826、P=0.024)、白细胞介素-6(IL-6)增高(χ^(2)=13.944、P=0.002)、1,3-β-D葡聚糖检测(G试验)阳性(χ^(2)=10.988、P=0.009)以及半乳甘露聚糖抗原检测(GM试验)阳性(χ^(2)=12.306、P=0.004)的可信度认同差异存在统计学意义。结论不同岗位的临床医务人员对重症感染诊断临床思维存在差异,综合诊断能力有待培养提高。

Objective To understand the clinical thinking of clinical staff in the diagnosis of severe infection and evaluate their ability to recognize severe infection in the early stage.Methods A questionnaire survey was conducted to investigate the clinical thinking of clinical staff attending the academic annual meeting of critical care physicians of Guangxi Medical Doctors Association from September 26 to September 28,2019.The objects of investigation included doctors,nurses,clinical pharmacists and medical graduate students,except for non-clinical personnel.The basis factors of clinical diagnosis of infection included clinical symptoms,specific biochemical examination,microorganism examination and Next-generation sequencing technology(NGS).The credibility level of each indicator was summarized as high(credibility of 51%-100%)and low(credibility of 0%-50%).Results Among the more than 600 participants,540 people participated in the questionnaire survey(participation rate of about 90.0%),and 466 qualified questionnaires(effective rate of 86.3%)were collected,including 280 from doctors,155 from clinical nurses,10 from clinical pharmacists and 21 from clinical graduate students.The working years of doctors,nurses,clinical pharmacists and medical graduate students were(8.2±6.0),(6.4±6.3),(4.5±4.0)and(3.8±2.6)years,respectively.The intermediate title(43.2%)dominated in the doctors group,while junior title dominated in the nurses group,clinical pharmacists group and medical postgraduate group(53.5%,80.0%and 81.0%respectively).Doctors and nurses were mainly from the general intensive care unit(ICU;73.2%and 51.0%respectively).According to the results of investigation of clinical thinking on the diagnosis of severe infection,there was similar degree of recognition and credibility for infection-related symptoms in the four groups of doctors,nurses,clinical pharmacists and medical graduate students(the credibility of fever was 80.0%-91.1%,low blood pressure 76.2%-90.0%,disturbance of consciousness 80.0%-85.0%,breathing 81.0%-100.0%,reduced of urine 81.9%-90.0%).The interpretation for pathogen culture and NGS results was insufficient because 29.3%-42.6%of the medical staff did not understand NGS.There were differences in the interpretation of the results of pathogen culture(positive specimen culture could diagnose infection;medical vs.nursing vs.pharmacists vs.student:93.6%vs.85.2%vs.90.0%vs.85.7%,P=0.021).There were significant differences among the four groups in some traditional infection-related laboratory indexes which included increased white blood cell count(WBC;χ^(2)=8.542,P=0.026),increased C-reactive protein(CRP;χ^(2)=8.826,P=0.024),increased interleukin-6(IL-6;χ^(2)=13.944,P=0.002),positive 1,3-β-D glucan detection test(G test;χ^(2)=10.988,P=0.009)and positive galactomannan antigen detection test(GM test;χ^(2)=12.306,P=0.004).Conclusion There is difference in clinical thinking of diagnosis of severe infection among clinical medical staff in different positions,and the comprehensive diagnostic ability needs to be improved.