Validation of different pediatric triage systems in the emergency department

BACKGROUND: Triage system in children seems to be more challenging compared to adults because of their different response to physiological and psychosocial stressors. This study aimed to determine the best triage system in the pediatric emergency department.METHODS: This was a prospective observational study. This study was divided into two phases. The fi rst phase determined the inter-rater reliability of fi ve triage systems: Manchester Triage System(MTS), Emergency Severity Index(ESI) version 4, Pediatric Canadian Triage and Acuity Scale(CTAS), Australasian Triage Scale(ATS), and Ramathibodi Triage System(RTS) by triage nurses and pediatric residents. In the second phase, to analyze the validity of each triage system, patients were categorized as two groups, i.e., high acuity patients(triage level 1, 2) and low acuity patients(triage level 3, 4, and 5). Then we compared the triage acuity with actual admission.RESULTS: In phase I, RTS illustrated almost perfect inter-rater reliability with kappa of 1.0(P<0.01). ESI and CTAS illustrated good inter-rater reliability with kappa of 0.8–0.9(P<0.01). Meanwhile, ATS and MTS illustrated moderate to good inter-rater reliability with kappa of 0.5–0.7(P<0.01). In phase II, we included 1 041 participants with average age of 4.7±4.2 years, of which 55% were male and 45% were female. In addition 32% of the participants had underlying diseases, and 123(11.8%) patients were admitted. We found that ESI illustrated the most appropriate predicting ability for admission with sensitivity of 52%, specifi city of 81%, and AUC 0.78(95%CI 0.74–0.81).CONCLUSION: RTS illustrated almost perfect inter-rater reliability. Meanwhile, ESI and CTAS illustrated good inter-rater reliability. Finally, ESI illustrated the appropriate validity for triage system.

Application of emergency severity index in pediatric emergency department

BACKGROUND： The purpose of triage is to identify patients needing immediate resuscitation, toassign patients to a pre-designed patient care area, and to initiate diagnostic/therapeutic measures asappropriate. This study aimed to use emergency severity index （ESI） in a pediatric emergency room.METHODS： From July 2006 to August 2010, a total of 21 904 patients visited the InternationalDepartment of Beijing Children＇s Hospital. The ESI was measured by nurses and physicians, andcompared using SPSS.RESULTS： Nurses of the hospital took approximately 2 minutes for triage. The results of triagemade by nurses were similar to those made by doctors for ESI in levels 1-3 patients. This findingindicated that the nurses are able to identify severe pediatric cases.CONCLUSION： In pediatric emergency rooms, ESI is a suitable tool for identifying severecases and then immediate interventions can be performed accordingly.

The mortality of patients in a pediatric emergency department at a tertiary medical center in China: An observational study

BACKGROUND: The quality of treatment for critically ill children varies widely at different hospitals. This study aimed to analyze the characteristics of mortality in a pediatric emergency department(PED) at a tertiary children's hospital in Guangzhou, China and to investigate the risk factors associated with the mortality.METHODS: The mortality of pediatric patients at the hospital from 2011 to 2013 was retrospectively analyzed using descriptive statistics.RESULTS: Altogether 466 919 patients visited the PED during the period and 43 925 of them were admitted for further observation. In 230 deaths, the ratio of boys to girls was 1.4:1, and their age ranged from 2 hours to 16 years(median, 5 months). The time from admission to death ranged from 0 to 216 hours(median, 1.5 hours). There were 92(40%) patients who died within 24 hours after admission and 104(45.2%) patients who died on arrival. The prominent causes of the deaths were respiratory diseases, neuromuscular disorders, cardiovascular diseases, and sepsis, most of which were ascribed to severe infection. Sixty-five deaths were associated with more than one concomitant problem. The top concomitant problems were congenital malformation, low gestational age, and severe birth asphyxia.CONCLUSIONS: In our center, 40% of the patients in the PED died of fatal acute diseases, and pneumonia was the first leading cause of the deaths. Almost half of the deaths occurred on arrival and the rest were due to end-stage malignant diseases. This study emphasized the importance of prevention of birth deficits by reducing deaths in infants and children.

Screening for asymptomatic chlamydia and gonorrhea in adolescent males in an urban pediatric emergency department

AIM To determine the prevalence of Chlamydia trachomatis(CT) and Neisseria gonorrhea(GC) in young men seeking care in the emergency department(ED) for non-sexually transmitted infection(STI) related symptoms.METHODS This was a prospective, cross-sectional study in an urban ED. The main outcome was the rate of positive CT and GC on urine nucleic acid amplification testing in males aged 16-21 presenting with non-STI related complaints. RESULTS Two hundred and eighty-four patients were enrolled, 271 were included in the final data analysis [age range 16-21, median: 18(quartiles 16-18, 19-21)]. Overall, 17(6.3%, 95%CI: 4%-10%) tested positive for CT and 0%(95%CI: 0%-2%) were found to have GC. The proportion of sexually active subjects was 71%(95%CI: 65%-76%) and 2%(95%CI: 0.6%-4%) reported sex with men. Previous STI testing was reported in 46%(95%CI: 43%-54%) and 13%(95%CI: 8%-20%) of those patients previously tested had a history of STI. Of the patients who tested positive for CT in the ED, 88%(95%CI: 64%-98%) were successfully followed up. CONCLUSION The prevalence of CT infection found by screening was 6.3%. Screening and follow-up from the ED was successful. The findings justify routine STI screening in male adolescents presenting to the ED with non-STI related complaints.

Exploration of the Barriers and Education Needs of Non-Pediatric Hospital Emergency Department Providers in Pediatric Trauma Care

Study Objective: Nine million children are seen in emergency departments each year for traumatic injuries. Eighty percent of these children will be cared for in non-children’s hospital settings. We sought to understand the barriers and opportunities for optimal pediatric trauma care in non-pediatric emergency departments and to define practice-specific educational needs. Methods: This qualitative study consisted of focus groups from rural, regional and urban non-pediatric emergency department sites discussing pediatric trauma care. Groups were homogenous for the provider role and included 8 physician groups and 9 non-physician groups. Focus groups were led by a trained moderator using a discussion guide composed of open-ended questions which covered various topics of pediatric trauma care. Focus groups were audio-taped and later transcribed and the data were analyzed for major themes and key concepts. Results: A total of 107 providers participated in the focus groups (32 physicians and 75 non-physicians). Barriers to provide optimal pediatric trauma care expressed by providers included the lack of pediatric trauma experience, inadequate pediatric trauma training and the lack of confidence with assessment of the pediatric trauma patient. All providers across all types of hospitals indicated a need and interest in training focused on pediatric trauma, but topics covered, and skills needed varied by type of facility. Conclusions: Community emergency room providers indicated a need for pediatric trauma education. Specifically, hands-on training with high-fidelity simulation was identified as the most useful type of training to gain the skills and confidence needed to manage pediatric trauma patients in their emergency departments.

Evaluation of Predictors of Suicidal Re-Attempt in Pediatric Patients in the Emergency Department

Background: Suicidal attempt in children is a serious public health problem. A proper identification of features of suicide-related behavior may help physicians to develop an accurate approach. The aim of this study was to clarify the characteristics of children with poisoning due to suicidal attempt and to determine the risk factors of suicidal re-attempt in the Emergency Department (ED) via a simple questionnaire. Methods: We collected medical data of patients under 18 years who were admitted to our ED with intoxication due to suicidal attempt, retrospectively. General characteristics of patients were evaluated. Patients were divided into 2 groups as 1) High risk: patients with repetitive suicide attempt;2) Low risk: patients with first time suicidal attempt. Results: A total of 57 patients were included in this study. The mean age was 15.91 ± 0.97. Majority of the patients were female (73.7%). Analgesics were the most frequent abused drugs with a ratio of 51.1%. It is determined that the most important variables affecting the risk of suicidal re-attempt are “idea about the suicide” and “purpose”. It was determined that patients with an idea of repetitive suicide (I will try again) and whose purpose was to die (I wish I have died) were in the most risky group with a history of previous suicidal attempt. Conclusion: This study suggests that answers of the pediatric patients to some question have a potential to predict the high risk patients. The risk of suicidal re-attempt may be predicted by the answers given to these questions: 1) What is your idea about suicide? 2) What was your purpose?

Improving antibiotic prescribing in the emergency department for uncomplicated community-acquired pneumonia

BACKGROUND:The Pediatric Infectious Disease Society(PIDS)and Infectious Disease Society of America(IDSA)published an evidence-based guideline for the treatment of uncomplicated communityacquired pneumonia(CAP)in children,recommending aminopenicillins as the first-line therapy.Poor guideline compliance with 10%–50%of patients admitted to the hospital receiving narrow-spectrum antibiotics has been reported.A new clinical practice guideline(CPG)was implemented in our emergency department(ED)for uncomplicated CAP.The aim of this study was to examine baseline knowledge and ED provider prescribing patterns pre-and post-CPG implementation.METHODS:Prior to CPG-implementation,an anonymous case-based survey was distributed to evaluate knowledge of the current PIDS/IDSA guideline.A retrospective chart review of patients treated in the ED for CAP from January 2015 to February 2017 was performed to assess prescribing patterns for intravenous(IV)antibiotics in the ED at Children’s National Health System pre-and post-CPG implementation.RESULTS:ED providers were aware of the PIDS/IDSA guideline recommendations,with 86.4%of survey responders selecting ampicillin as the initial antibiotic of choice.However,only 41.2%of patients admitted to the hospital with uncomplicated CAP pre-CPG received ampicillin(P<0.01).There was no statistically signifi cant increase in ampicillin prescribing post-CPG(P=0.40).CONCLUSIONS:Providers in the ED are aware of the PIDS/IDSA guideline regarding the first-line therapy for uncomplicated CAP;however,this knowledge does not translate into clinical practice.Implementation of a CPG in isolation did not significantly change prescribing patterns for uncomplicated CAP.

基于Kaiser模型的灾害脆弱性分析在儿科应急管理中的应用

目的通过Kaiser模型对基层儿科的灾害脆弱性现状进行分析,评估儿科灾害事件风险,以提高应急管理能力。方法基于Kaiser模型,从自然灾害、技术灾害、人员伤害和危险品伤害4类、48种灾害来源调查儿科面临的各类潜在危害,通过对危害风险的分析和风险值排序,明确儿科应急管理的重点,有针对性地强化应急管理的措施,从而健全儿科应急管理体系。结果自然灾害事件中,相对风险值排前5位的依次为地震(34.44%)、暴雨(25.69%)、火灾(23.94%)、极端高温(22.13%)及干旱(15.95%)。技术灾害事件中,相对风险值排前5位的依次为针刺伤(27.62%)、穿刺失败(25.52%)、停水/停电(24.99%)、信息系统故障(24.13%)及电梯意外事件(23.22%)。人员伤害事件中,相对风险值排前5位的依次为“新冠”肺炎院内传播(16.26%)、药物不良反应(15.57%)、跌倒/坠床(12.10%)、暴力伤医事件(11.07%)及误服药物(10.59%)。危险品类事件中,相对风险值排前5位的依次为玻璃体温计断裂(11.77%)、危险气体泄漏(7.89%)、放射性物体泄漏(7.52%)、化学品泄漏(5.40%)及氧气泄漏(5.34%)。全部事件按照风险值由高至低排序,前5位依次为地震(34.44%)、针刺伤(27.62%)、暴雨(25.69%)、穿刺失败(25.52%)及停水/停电(24.99%)。结论Kaiser模型是一种科学有效的应急风险分析工具,为全面保障医疗安全提供了一定参考,对科室应急事件管理有较高的适用性,值得在医院内推广应用。根据灾害脆弱性分析(HVA)结果和报告,应针对暴露的防控薄弱点,修订和完善科室突发事件的应急预案,加强科室应急培训和演练,提高应急反应和医疗保障能力。

数字化技术助力儿科急诊能力提升的实践与思考

针对儿科急救医疗服务体系面临的业务特点、管理模式以及标准化等问题,依托数字化技术,探索建立了一套涵盖院前、院中、院后的儿科急诊全周期管理体系。实践证明,数字化技术对促进儿科急诊能力提升具有重要作用,但应重视医疗数据的有效利用和医疗风险评估,探索建立临床辅助决策体系,关注儿童全周期健康管理。

SBAR沟通模式在儿科急诊患者院内交接中的应用

目的 :探讨标准化沟通模式(SBAR)在儿科急诊患者交接过程中的应用效果。方法 :选取2015年1-3月在我院儿科急诊转运的患者48例作为对照组,使用传统口头交接方式进行交接;选取2015年4-6月在我院儿科急诊转运的患者51例作为观察组,使用参照SBAR标准制定的急诊患儿交接单进行交接。比较两组在不良事件发生率、转运交接耗时、医护人员满意度的差异。结果 :观察组不良事件发生率及交接时间与对照组比较,差异具有统计学意义(P<0.05);观察组医护人员对交接内容全面性、病情描述准确、实用性/可操作性的满意度高于对照组(P<0.05)。结论 :使用SBAR标准化沟通模式进行交接后,不良事件发生率降低,交接耗时缩短,医护人员满意度提高,从而更好地保障了急诊患儿交接安全,因此SBAR沟通模式值得推广。

儿童急诊分诊信息系统的研发及应用

目的探讨以五级预检分诊标准为基础的儿科急诊分诊信息系统的应用效果。方法选取2015年10~12月的急诊患儿作为对照组(10 704例),采用"一看,二问,三查体"传统分诊方法进行急诊分诊;选取2017年5~7月的急诊患儿作为观察组(10 366例),使用以五级预检分诊标准为基础的急诊分诊信息系统分诊。比较两组患儿分诊一致性,分诊时间,患儿(或家属)及医护人员满意度等方面的应用效果。结果护士与医生分诊级别比较,观察组Kappa值为0.98,对照组Kappa值为0.58;观察组分诊时间显著短于对照组,患者(或家属)满意度、医护人员满意度显著高于对照组(均P<0.01)。结论以五级预检分诊标准为基础的儿科急诊分诊信息系统能缩短急诊分诊时间,提高分诊准确性,提高医护人员及患儿满意度。

儿科急诊心肺复苏特点与预后分析

目的分析小儿院外呼吸或心跳停止(或呼吸、心跳停止)的病因、临床特征及影响心肺复苏预后的相关因素,为提高儿科急诊心肺复苏成功率及改善预后寻找可行方法。方法对急诊创伤中心(EDTC)2001年3月至2007年3月急诊心肺复苏(CPR)患儿的临床资料、心肺复苏原因及预后进行总结分析。结果共有199例患儿在EDTC进行CPR。就诊时呼吸停止84例(42.21%),出院时存活54例(64.29%);心跳停止115例(57.79%),急诊CPR后恢复自主循环(ROSC)38例(33.04%),出院时存活9例(7.83%);呼吸停止与心跳停止者病死率比较差异有统计学意义(χ2=71.52,P=0.000)。呼吸停止或心跳停止时157例(78.89%)有现场目击者,其中137例目击者为家长(87.26%),42例(21.11%)无目击者;有目击者予院前CPR20例(12.74%);有目击者与无目击者最终病死率比较差异无统计学意义(χ2=0.09,P=0.45)。意外伤害性疾病(58例,29.15%)是导致小儿急诊CPR的首要原因,其次为先天性心脏病(49例,24.62%)和严重感染性疾病(32例,16.08%)。院前救护车转运52例(26.13%)。结论小儿院外呼吸或心跳停止者病死率高,尤其是院外心跳停止者;意外伤害是儿童期急诊CPR的最常见原因,家长是儿童呼吸或心跳停止最常见的目击者;要提高儿科急诊CPR成功率,需要加强监护人对儿童的监护意识,预防意外伤害的发生;同时需要对监护人普及儿科急救的基本知识,提高他们第一时间救护患儿的能力,从而改善院外呼吸或心跳停止患儿的预后。

六西格玛原理在提高儿科门急诊静脉注射患儿家长满意度中的应用

目的运用六西格玛原理,将儿科门急诊静脉输液作为一个工作流程,寻找静脉注射的各个环节以及有可能影响患儿家长满意度的关键因素并加以改进,从而提高患儿家长满意度,提高儿科护理质量。方法通过设计数据收集表,收集影响静脉注射满意度的各个因数以及对结果的影响程度,用统计学的方法得出结论。结果215例样本中,满意选项177例,不满意选项38例,占总调查人数的17.67%;在不满意选项中护士的技术占首位,为52.6%;一次穿刺成功率、护士的表情和态度、注射持续时间对家长满意度有统计学差异(P<0.01)。结论制定改善护士行为的一系列具体方案和措施,规范操作流程,提高服务和沟通能力和水平;提高护士的静脉穿刺水平,一针见血;改善注射流程,提高技术操作的能力和速度,缩短注射持续时间,以提高儿科门急诊静脉注射患儿家长满意度。

处方前置审核系统在儿科门急诊临床用药中的应用及效果分析

目的探讨处方前置审核系统在儿科门急诊临床用药中的应用及效果。方法回顾性分析江苏省苏北人民医院2018年1月至12月未采用处方前置审核系统进行处方点评的儿科门急诊处方185857张和2020年1月至12月采用处方前置审核系统进行处方点评的儿科门急诊处方103432张。统计2018、2020年处方合格率,分析2018、2020年不合理处方类型。结果2020年处方合格率高于2018年(P<0.05);2020年1月至12月处方合格率均高于97.00%。2018、2020年不合理处方中,无适应证用药、相互作用占比均较高;2018年、2020年不合理处方类型比较,差异有统计学意义(P<0.05)。结论处方前置审核系统可有效提高儿科门急诊的临床合理用药水平,值得推广使用。

手足口病急诊留观患儿转归的相关因素分析

目的探讨儿科手足口病患儿的临床特点及急诊留观患儿转归的危险因素,为手足口病患儿的护理提供依据。方法对2012年8月至2013年3月儿科急诊留观室收治的471例手足口病患儿及同期住院的40例患儿一般资料、临床症状及实验室检查结果进行比较,分析急诊留观患儿转归的危险因素。结果 3岁以下、高热、肢体抖动、血糖大于7.0 mmol/L、白细胞增高的手足口病患儿作为独立的危险因素使患儿转入住院的机会增多(P<0.01或P<0.05)。结论关注高危急诊留观患儿,有助于及时发现手足口病患儿的病情变化,提高其治愈率。存在病情加重危险的患儿,必要时住院进一步治疗。

三级综合医院儿科急诊预检分诊的规范化管理

目的对三级综合医院儿科急诊预检实施规范化管理,提高预检分诊效率。方法对儿科门诊的3 396例患儿实施规范化的预检分诊管理,即成立预检分诊小组,制订预检分诊流程图,建立预检分诊工具;由预检分诊护士对患儿应用快速评估工具、4级预检分诊标准进行评估、分诊,准确、快速分诊患儿至相应就诊区,候诊期间分诊护士定时巡视候诊区域,发现问题及时处理。结果分诊为1级、2级、3级、4级的患儿分别为7例(0.21%)、232例(6.83%)、761例(22.41%)、2 396例(70.55%);急诊患儿均在就诊2min内分诊至相应的诊室。患儿入院率、入PICU/NICU率及医疗资源使用情况与分诊级别显著相关(均P<0.01)。结论对三级综合医院儿科急诊预检实施规范化管理,能够准确识别出患儿病情的轻重缓急,而且能够在有限的时间内规范分诊,提高预检分诊效率。

医护一体化床边交班在儿科急诊留观室中的应用效果分析

目的探讨医护一体化床边交班模式在儿科急诊留观室中的应用效果。方法 2015年4月-6月实施医护一体化床边交班模式,与2015年1月-3月的传统医护分开交班摸式相比较,对比交班模式变化前后护理工作质量、医护合作度、患儿及家属对护理工作满意度等的效果。结果实施医护一体化床边交班后,护理工作质量评分、医护合作度、患儿家属对护理工作的满意率显著提高(P<0.05)。结论医护一体化床边交班对提高护理质量有一定促进作用,可促进医护更好地沟通与合作,提高家属满意度,同时可提高护士职业认同感,丰富优质护理服务内涵,值得临床推广应用。

实景模拟演练在提高儿科低年资护士综合技能培训中的应用

目的:探讨实景模拟演练在提高儿科低年资护士综合能力中的应用效果。方法:根据本专科特点,安排护士进行专业理论知识、抢救仪器使用、技术操作示范、急救药品知识、病情观察和评估、沟通协调能力等方面的培训,并结合实际病例,采用医护配合的方法,开展应急预案学习及现场实景模拟演练,演练结束后进行分析、总结。结果:随着模拟演练次数的增加,护士各项考核指标达标率均明显提高。结论:新入科低年资护士通过理论培训考核结合现场实景模拟演练,能快速提高急救应急能力、整体综合素质、医护配合满意度,护理服务质量得到明显改善。

儿科门急诊输液室中优化输液流程的应用研究

目的观察儿科门急诊输液室应用优化输液流程的效果。方法湖南省儿童医院2011年6月至2014年6月收治输液治疗的患儿共700例,随机分为观察组和对照组各350例。观察组患儿给予优化输液流程,对照组患儿给予常规输液流程,对比分析两组患儿的输液效果,具体包括输液等待时间、患儿家属对输液治疗的满意程度以及输液过程中发生的不良护理事件概率。结果观察组输液平均等待时间为(10.98±3.49)分,显著低于对照组(31.04±4.12)分,差异有统计学意义(P<0.05);观察组患儿家属治疗满意度为97.7%(342/350),显著高于对照组86.9%(304/350),差异有统计学意义(P<0.05);观察组发生不良护理事件概率为5.7%(20/350),显著低于对照组17.7%(62/350),差异有统计学意义(P<0.05)。结论优化输液流程在儿科门急诊输液室中的应用效果比常规流程更为有效,值得临床推广。

儿科急诊预检分诊系统建立与应用

儿童疾病起病急、变化快,随着我国儿童就医需求的持续增长,有限的儿科急诊医疗服务资源面临较大压力。制订儿科急诊五级预检分诊标准,以急诊智能化信息系统为工具,以急救理论和技能培训考核为保障,以5G+区块链转运技术为手段,构建了智能化儿科急诊预检分诊系统,对优化急诊资源配置、持续改进急诊工作质量发挥了积极作用。认为统一儿科急诊预检分诊标准,强化急诊医护人员儿科急诊急救能力提升培训,建立医院间信息互联互通机制是儿科急诊急救发展方向。