Lean techniques for the improvement of patients' flow in emergency department

BACKGROUND: Emergency departments(EDs) face problems with overcrowding, access block, cost containment, and increasing demand from patients. In order to resolve these problems, there is rising interest to an approach called "lean" management. This study aims to(1) evaluate the current patient flow in ED,(2) to identify and eliminate the non-valued added process, and(3) to modify the existing process.METHODS: It was a quantitative, pre- and post-lean design study with a series of lean management work implemented to improve the admission and blood result waiting time. These included structured re-design process, priority admission triage(PAT) program, enhanced communication with medical department, and use of new high sensitivity troponin-T(hsTnT) blood test. Triage waiting time, consultation waiting time, blood result time, admission waiting time, total processing time and ED length of stay were compared.RESULTS: Among all the processes carried out in ED, the most time consuming processes were to wait for an admission bed(38.24 minutes; SD 66.35) and blood testing result(mean 52.73 minutes, SD 24.03). The triage waiting time and end waiting time for consultation were significantly decreased. The admission waiting time of emergency medical ward(EMW) was significantly decreased from 54.76 minutes to 24.45 minutes after implementation of PAT program(P<0.05).CONCLUSION: The application of lean management can improve the patient flow in ED. Acquiescence to the principle of lean is crucial to enhance high quality emergency care and patient satisfaction.

High-flow nasal cannula oxygen therapy during anesthesia recovery for older orthopedic surgery patients: A prospective randomized controlled trial

BACKGROUND Hypoxemia is a common complication in older patients during postoperative recovery and can cause pulmonary complications.Therefore,reducing the incidence of postoperative hypoxemia is a clinical concern.AIM To investigate the clinical efficacy of high-flow nasal cannula oxygen(HFNCO)in the resuscitation period of older orthopedic patients.METHODS In this prospective randomized controlled trial,60 older patients who underwent orthopedic surgery under general anesthesia were randomly divided into two groups:those who used conventional face mask and those who used HFNCO.All patients were treated with 60%oxygen for 1 h after extubation.Patients in the conventional face mask group were treated with a combination of air(2 L)and oxygen(2 L)using a traditional mask,whereas those in the HFNCO group were treated with HFNCO at a constant temperature of 34℃ and flow rate of 40 L/min.We assessed the effectiveness of oxygen therapy by monitoring the patients’arterial blood gas,peripheral oxygen saturation,and postoperative complications.RESULTS The characteristics of the patients were comparable between the groups.One hour after extubation,patients in HFNCO group had a significantly higher arterial partial pressure of oxygen(paO_(2))than that of patients in conventional face mask group(P<0.001).At extubation and 1 h after extubation,patients in both groups showed a significantly higher arterial partial pressure of carbon dioxide(paCO_(2))than the baseline levels(P<0.001).There were no differences in the saturation of peripheral oxygen,paO_(2),and paCO_(2) between the groups before anesthesia and before extubation(P>0.05).There were statistically significant differences in paO_(2) between the two groups before anesthesia and 1 h after extubation and immediately after extubation and 1 h after extubation(P<0.001).However,there were no significant differences in the oxygen tolerance score before leaving the room,airway humidification,and pulmonary complications 3 d after surgery between the two groups(P>0.05).CONCLUSION HFNCO can improve oxygen partial pressure and respiratory function in elderly patients undergoing orthopedic surgery under general endotracheal anesthesia.Thus,HFNCO can be used to prevent postoperative hypoxemia.

CEREBRAL BLOOD FLOW AND METABOLISM EVALUATION IN COMATOSE PATIENTS BY DYNAMIC SPECT

Thirty patients in coma state underwent dynamic SPECT with 133Xe, a validated technique for the quantitation of CBF by SPECT, using a new brain dedicated tomograph: CERTO-96. CMRO2 was computed by multiplying the mean CBF by AVDO2 according to the Fick’s principle. The mean values of CBF, AVDO2 and CMRO2 in patients with good outcome were significantly different from those with worse outcome. On the basis of the best "discriminant threshold", CBF and AVDO2 demonstrated an intermediate accuracy in separating the two groups, while CMRO2 showed a satisfactory accuracy.

Feedback of inter-hospital transfer of patients under high-flow nasal cannula oxygen therapy

Severe forms of coronavirus disease 2019 (COVID-19)can lead to hypoxemic pneumonia and the need for treatment with high-flow nasal cannula (HFNC) oxygen therapy.This treatment decreases the need for subsequent invasive ventilation in patients with hypoxemic pneumonia.The oxygen flow in the nasal cannula is driven pneumatically or using a turbine.Oxygen and air are mixed (giving the fraction of inspired oxygen[FiO;]) and propelled at up to 80L·min;.The propelled gases must be heated and humidified.HFNC system is not intended for use outside a hospital environment.

End-of-life home care of an interstitial pneumonia patient supported by high-flow nasal cannula therapy:A case report

BACKGROUND High-flow nasal cannula(HFNC)therapy and morphine continuous subcutaneous infusion(CSI)have been used to ameliorate dyspnea in non-cancer patients with end-stage respiratory diseases,including chronic obstructive pulmonary disease and interstitial pneumonia,primarily in hospital settings.However,it is rare to perform home-based medical treatment using these.We observe a case to assess the feasibility of this treatment strategy.CASE SUMMARY Here,we report a case of a 75-year-old man who was diagnosed with interstitial pneumonia 11 years ago and was successfully nursed at home during his terminal phase for over 10 mo without hospitalization,by introducing domiciliary uses of HFNC and morphine CSI with a patient-controlled analgesia device.CONCLUSION Active utilization of HFNC and morphine CSI with patient-controlled analgesia device would substantiate successful end-of-life palliative home care of idiopathic interstitial pneumonia patients.

Lessons learned from the TIMI trials in rescue interventions for elderly patients after failed fibrinolytic therapy:look beyond the TIMI flow

In ST-segment elevation myocardial infarction (STEMI), acute reperfusion of the infarct-related artery (IRA)is the main goal in the early minutes after the patient seeks medical attention. Fibrinolytic therapy (FT) and/or primary coronary intervention (PCI) were proven to be effective in opening the IRA.

Forecasting patient demand at urgent care clinics using explainable machine learning

Urgent care clinics and emergency departments around the world periodically suffer from extended wait times beyond patient expectations due to surges in patient flows.The delays arising from inadequate staffing levels during these periods have been linked with adverse clinical outcomes.Previous research into forecasting patient flows has mostly used statistical techniques.These studies have also predominately focussed on short‐term forecasts,which have limited practicality for the resourcing of medical personnel.This study joins an emerging body of work which seeks to explore the potential of machine learning algorithms to generate accurate forecasts of patient presentations.Our research uses datasets covering 10 years from two large urgent care clinics to develop long‐term patient flow forecasts up to one quarter ahead using a range of state‐of‐the‐art algo-rithms.A distinctive feature of this study is the use of eXplainable Artificial Intelligence(XAI)tools like Shapely and LIME that enable an in‐depth analysis of the behaviour of the models,which would otherwise be uninterpretable.These analysis tools enabled us to explore the ability of the models to adapt to the volatility in patient demand during the COVID‐19 pandemic lockdowns and to identify the most impactful variables,resulting in valuable insights into their performance.The results showed that a novel combination of advanced univariate models like Prophet as well as gradient boosting,into an ensemble,delivered the most accurate and consistent solutions on average.This approach generated improvements in the range of 16%-30%over the existing in‐house methods for esti-mating the daily patient flows 90 days ahead.

The effects of decompressive craniectomy on cerebral blood flow volume and brain metabolism in different aged patients with severe traumatic brain injury

Objective To explore effects of decompressive craniectomy on cerebral blood flow volume and brain metabolism in different aged patients with severe traumatic brain injury. Methods 71 cases were divided into three groups according age: group A( 【 30 years) ,group B ( 30 ～ 50 years) 。

基于归因理论的护理干预在经鼻高流量氧疗患者中的应用效果

目的探讨基于归因理论的护理干预在经鼻高流量氧疗(HFNC)患者中的应用价值,以期为临床治疗提供参考。方法选取2021年2月-2023年5月于四川大学华西医院接受治疗的144例HFNC患者为研究对象。采用随机数字表法将患者分为观察组和对照组,每组72例。对照组患者给予常规护理干预,观察组患者在对照组基础上联合基于归因理论的护理干预。比较2组患者遵医情况及护理满意度;比较2组患者干预前后疾病感知问卷(BIPQ)、Borg疲劳量表、视觉类比呼吸困难法量表(VAS)、抑郁自评量表(SDS)及焦虑自评量表(SAS)评分。结果观察组患者总遵从率高于对照组,差异有统计学意义(P<0.05)。干预前,2组患者BIPQ中治疗控制、后果、情绪、持续时间、症状、关注、个人控制、疾病了解评分比较,差异无统计学意义(P>0.05)。干预后,2组患者BIPQ中治疗控制、后果、情绪、持续时间、症状、关注、个人控制、疾病了解评分均高于干预前,且观察组高于对照组,差异均有统计学意义(P<0.05)。干预前,2组患者Borg疲劳量表及VAS评分比较,差异无统计学意义(P>0.05)。干预后,2组患者Borg疲劳量表评分均低于干预前,且观察组低于对照组;VAS评分高于干预前,且观察组高于对照组,差异均有统计学意义(P<0.05)。干预前,2组患者SAS、SDS评分比较,差异无统计学意义(P>0.05)。干预后,2组患者SAS、SDS评分均低于干预前,且观察组低于对照组,差异均具有统计学意义(P<0.05)。观察组患者护理总满意度高于对照组,差异有统计学意义(P<0.05)。结论基于归因理论的护理干预能有效强化患者的遵医行为,减轻患者的疾病感知压力,缓解患者的负面情绪,提高患者的护理满意度,值得临床推广应用。

Response to Commentary by Dr. Matthew J. Clarkson on

Dear editor:We sincerely thank Matthew J.Clarkson for his insightful commentary1 on our recent publication in the Journal of Sport and Health Science.2 Clarkson's pioneering work in the development and application of blood flow restriction (BFR) exercise protocols has undeniably laid the groundwork for subsequent investigations in this field,including our own.(3-6)His commentary not only highlights the relevance and timeliness of our study but also offers valuable perspectives on refining safety considerations for intradialytic BFR exercise among hemodialysis patients.

四川省住院患者空间流向及其影响因素分析

目的分析住院患者跨区县就医现状,并从流入地和流出地2个维度分析其影响因素。方法以四川省作为研究区域,利用2019年第四季度病案首页数据,分别以患者所在区县、住院机构所在区县、流动患者数量作为空间流向的起点、终点和强度分析患者空间流向,并结合患者个人层面、医疗机构层面及区县层面的信息,从流入和流出的维度建立两水平随机截距logistic回归分析探究其影响因素。结果四川省跨区县就医占比22.90%,千人以上流向集中在东部地区,但西部地区跨区县就医患者比例更高。成都、绵阳同时是最大的患者流出地和流入地。患者层面汉族(49%,P<0.001)、男性(2%,P<0.001)、稳定的收入(6%,P<0.001)、更好的医疗保障(16%,P<0.001),机构层面更好的资源,区县层面更高的经济(20%,P<0.001)和医疗水平(5%,P<0.001)会促进患者跨区县就医。结论四川省跨区县住院患者从周边流向区县中心,也从各地流向成都。全面推进分级诊疗,促进患者合理就医,应从加强患者健康教育、提高机构服务水平和促进经济与医疗协调发展等多个方面进行协同。

传染病医院设计研究——以旬邑县医院传染科设计为例

烈性传染性疾病的蔓延,对人民身体和社会造成了严重伤害,我国医疗系统加强了传染病医院的建设和研究,尤其增加了对中小城市医疗资源升级和传染病楼的建设。文章结合工程案例,通过新建传染科楼的选址、建筑内部功能分区、医患流线等多方面内容展开分析,对小城市医院内新建传染科建筑进行了全面探讨。

Experimental Investigation on Cavitating Flow Shedding over an Axisymmetric Blunt Body

Nowadays,most researchers focus on the cavity shedding mechanisms of unsteady cavitating flows over different objects,such as 2D/3D hydrofoils,venturi-type section,axisymmetric bodies with different headforms,and so on.But few of them pay attention to the differences of cavity shedding modality under different cavitation numbers in unsteady cavitating flows over the same object.In the present study,two kinds of shedding patterns are investigated experimentally.A high speed camera system is used to observe the cavitating flows over an axisymmetric blunt body and the velocity fields are measured by a particle image velocimetry（PIV）technique in a water tunnel for different cavitation conditions.The U-type cavitating vortex shedding is observed in unsteady cavitating flows.When the cavitation number is 0.7,there is a large scale cavity rolling up and shedding,which cause the instability and dramatic fluctuation of the flows,while at cavitation number of 0.6,the detached cavities can be conjunct with the attached part to induce the break-off behavior again at the tail of the attached cavity,as a result,the final shedding is in the form of small scale cavity and keeps a relatively steady flow field.It is also found that the interaction between the re-entrant flow and the attached cavity plays an important role in the unsteady cavity shedding modality.When the attached cavity scale is insufficient to overcome the re-entrant flow,it deserves the large cavity rolling up and shedding just as that at cavitation number of 0.7.Otherwise,the re-entrant flow is defeated by large enough cavity to induce the cavity-combined process and small scale cavity vortexes shedding just as that of the cavitation number of0.6.This research shows the details of two different cavity shedding modalities which is worthful and meaningful for the further study of unsteady cavitation.

Passive control of cavitating flow around an axisymmetric projectile by using a trip bar

Quasi-periodical evolutions such as shedding and collapsing of unsteady cloud cavitating flow, induce strong pressure fluctuations, what may deteriorate maneuvering stability and corrode surfaces of underwater vehicles. This paper analyzed effects on cavitation stability of a trip bar arranged on high-speed underwater projectile. Small scale water tank experiment and large eddy simulation using the open source software Open FOAM were used, and the results agree well with each other. Results also indicate that trip bar can obstruct downstream re-entrant jet and pressure wave propagation caused by collapse, resulting in a relatively stable sheet cavity between trip bar and shoulder of projectiles.

Effects of Micro Vibration Therapy Nursing Care on Muscle Hardness and Skin Blood Flow: A Pre/Post Group Comparison Study

Purpose: The purpose of this study was to investigate the effects of Micro Vibrational therapy (MVT) on muscle stiffness and blood flow in the skin before and after Micro Vibrational therapy in healthy subjects in order to scientifically verify the effects of MVT. Methods: Micro Vibrational therapy is nurse care use in Japan. It was performed on the backs of 30 subjects (8 males and 22 females) in their 20 s to 50 s according to the eligibility criteria. The resting state before implementation was set as the baseline for the control group, and after 30 seconds of MVT was set as the intervention group. The effects of the MVT were statistically analyzed by these factors and subjective sensation by Visual Analog Scale. Results: The muscle hardness of the area where the MVT was applied for 30 seconds decreased to 29.54 (SD 5.04) after the application, compared to 30.45 (SD 5.05) before. A corresponding t-test showed a significant difference (p = 0.019). Skin blood flow increased from a median of 0.76 (variance 0.062) before to a median of 0.86 (variance 0.16) after the procedure. The Wilcoxon rank test showed a significant difference (p = 0.000). Circulatory response was confirmed by SBP, DBP, and HR. SBP of 108.6 mmHg (SD 14.8) before the study decreased to 105.7 mmHg (SD 15.0) after the study, and DBP of 65.6 mmHg (SD 11.1) before the study decreased to 62.7 mmHg (SD 11.8) after the study. HR decreased from 71.6 beats per minute (SD 10.3) before to 69.2 beats per minute (SD 11.7) after. There was a significant difference in all cardiovascular indices (p < 0.05). VAS (pain, stiffness, and fatigue) was significantly decreased after MVT (p < 0.05). Conclusion: Micro Vibrational therapy tended to decrease muscle hardness and increase skin blood flow even in the short time of 30 seconds. The results suggest that local vibration stimulation is not likely to cause a sudden increase in blood pressure or pulse rate fluctuation. These results suggest that hand vibration nursing care may be applicable to acute patients with unstable circulatory conditions.

患者自控镇痛泵的质量控制检测与分析

探讨患者自控镇痛(PCA)泵的应用质量检测,根据PCA泵的原理结构、技术指标及相关的国家检测标准,梳理PCA泵的主要质量控制参数,结合IDA4Plus型输液设备分析仪分析检测方法和检测步骤。对PCA泵的负荷量、流速精度、流量精度、PCA剂量、锁定间隔、保持静脉开放(KVO)流速、阻塞压力以及报警功能进行检测获得数据,采用计量手段将示值和测量值分别进行对比分析,评估PCA泵的质量是否符合要求。

“医患沟通流程图”在肾内科住院医师规范化培训中的应用

目的通过调研并设计医患沟通流程图,提高肾内科住院医师规范化培训学员医患沟通能力。方法对2021年5月到2022年5月在肾内科进行住院医师规范化培训的医师,指导使用医患沟通流程图,并就入科及出科医患沟通能力进行评估。结果分别使用两个版本医患沟通流程图培养学员医患沟通能力,使用医患沟通流程图前,两组学员医患沟通能力无差异(P=0.56)。使用医患沟通流程图后两组学员医患沟通能力均有提高(P<0.01),并且,使用第二版医患沟通流程图的学员医患沟通能力优于使用第一版医患沟通流程图的学员(P=0.002)。结论医患沟通流程图有利于提升规范化培训学员医患沟通能力,可在肾内科规范化培训学员带教过程中推广使用。

紧密型县域医共体医保打包支付对患者就诊流向的影响

为分析紧密型县域医共体医保打包支付对患者就诊流向的影响,选取福建省某国家试点医共体为研究对象,采用描述性分析和间断时间序列分析等方法研究该医共体实行医保打包支付前后患者就诊流向指标变化。结果显示,改革后门诊患者县域内就诊人次、县域就诊率上升,住院患者县域内住院人次占比下降趋势放缓;门诊患者基层就诊率下降,住院患者的基层住院人次及占比下降趋势放缓。医共体实行医保打包支付有助于引导患者回到县域内就诊,但尚未推动患者向基层分流。未来需进一步完善医保打包支付机制,提升医共体整体及基层服务能力,落实配套制度建设,引导患者合理就医。

基于麻雀搜索算法考虑病患流的医院诊疗设备维护优化研究

针对医院诊疗设备出现故障后对病人的影响不可控、产生的维修费用高等问题,提出了一种基于病患流分布不均的预防性维护决策模型。首先,针对医院诊疗设备退化速度受病患流分布影响的特点,采用病患流因子反映其人流量变化规律,并基于设备衰退演化规则构建了设备退化过程模型。其次,通过将量化的诊疗设备故障风险成本以及延迟或提前维护带来的变动成本纳入成本计算体系,提出了病患流分布不均状况下以故障风险值为约束的设备维护策略。最后,采用麻雀搜索算法进行寻优获取关键初始变量,并对模型进行数值仿真分析,结果表明,新维护策略在保障诊疗设备可靠度的同时,也能保持较低的维护成本。

下肢静脉血流流速监测对神经外科术后患者深静脉血栓风险筛查的临床价值

目的 探讨超声监测下肢静脉血流流速对筛查下肢深静脉血栓(DVT)风险的临床价值。方法 选取陆军军医大学第二附属医院神经外科2020年4月—2021年4月收治的353例术后患者,使用彩色多普勒超声对其术后第1~3天进行每日4次下肢静脉血流流速监测。根据患者住院期间是否发生深静脉血栓,分为DVT组和非DVT组,并对数据进行分析,对监测下肢血流流速筛查下肢深静脉血栓风险的价值进行分析和评估。结果 DVT组与非DVT组之间的股总静脉、腘静脉和大隐静脉血流流速存在显著差异(P<0.01)。术后第1天ROC曲线分析显示腘静脉血流流速筛查神经外科患者术后血栓风险AUC最大,当截断值为13.504 cm/s时,灵敏度为99.7%,特异度为100%。结论 监测下肢静脉血流流速,特别是腘静脉血流流速,对筛查神经外科患者术后深静脉血栓形成的风险具有重要临床价值。