急诊观察医学 Observation Medicine 中国医大一院急诊科 刘晓伟 2010.11

急诊留观的必要性 急诊留观病人的类型 如何观察急诊病人

急诊留观的必要性 急诊病人特点 医患关系 “拥挤”的急诊科

急诊病人的特点 处于疾病的早期阶段，不确定因素多,变化快 危重病人在明确诊断前就要给予医疗干预 来诊病人常以症状或体征为主导，而不是以某种病为主导 病情轻重相差大，从感冒到心跳呼吸骤停 病人和家属对缓解症状和稳定病情期望值高

“拥挤”的急诊科 急诊科是医院内最不具有确定性和最繁忙的一个部门 急诊科就诊病人数逐年增长 病人流量的增加是造成急诊科拥挤最基本因素 “拥挤”是指急诊病人的需求( 即等待急诊临床决策, 如分诊、候诊、留观、治疗、安置等) 超过了急诊科的处理能力

我院急诊科简介 成立于1984年 急诊医学硕士和博士学位授权点 国家急诊医师规范化培训基地 辽宁省急诊医疗质量控制中心 “急诊急救—留观—重症监护(EICU)”一体化 急诊初诊区实行“红、黄、绿”分区就诊 现有急诊抢救床位6张，监护床位16张，观察床位19张，每年接诊患者9万余人次，危重患者抢救成功率接近90%

急诊科拥挤的原因 综合性大医院的住院病人日益增多, 造成床位紧张, 急诊病人无法及时收住入院, 大量病人留在急诊观察室 医院病床越来越专科化( 甚至专病化) , 病房医师不愿意收本专业“不相关”的病人,而急诊病人往往比较复杂, 有多系统的问题或诊断未明, 是各专科病房拒收的主要对象 病人维权意识日益增强, 医疗风险有增无减, 尤其急诊病人医疗风险非常高, 病情危急, 病房往往不愿意收急诊病人 多数医院急诊科医师没有权力开住院证

急诊观察医学的地位和作用 a site to “park” patients awaiting a “real” bed evaluate and stabilize acutely ill patients discriminate patient really needed hospitalization formulate a prognosis devise a plan for treatment 提高诊断的准确性和病人的满意度 为急诊医生提供教学和研究的机会 not only useful but essential

repeated diagnostic assessment (laboratory, radiology and other clinical investigative services) treatments not routinely provided in an ED

patients with complex or undifferentiated conditions who may require lengthy evaluation, serial review rapid and comprehensive multidisciplinary assessment prolonged observation for conditions expected to resolve within 12 to 24 hours

those likely to respond to a brief course of therapy, which then can be modified so that treatment can be continued at home or another community setting an early specialist review by a consultant and/or senior medical registrar, including that performed by subspecialty services

Types of Observation Service Diagnostic Evaluation of Critical Diagnostic Syndromes Short-Term Treatment of Serious Emergency Conditions

Diagnostic Evaluation of Critical Diagnostic Syndromes a balance between probability and dangerousness of the disease under consideration the physician cannot readily diagnose the condition with testing 医生诊断暂时不确定，且诊断结果直接决定进一步处理

a balance between probability and dangerousness of the disease under consideration chest pain　→MI abdominal pain → kidney stone

the physician cannot readily diagnose the condition with testing 尚无确定的确诊试验，appendicitis靠转移性右下腹痛 确诊试验具有时限性：疑AMI，TNI、CK-MB在病情严重后一段时间始升高 确诊试验暂时无法获得：疑诊腹主动脉瘤、肺动脉栓塞， 夜间不做3D-CT

医生诊断暂时不确定，且诊断结果直接决定进一步处理 Appendicitis 手术? 保守? 异位妊娠？

Diagnostic Evaluation receive medical inpatients for intensive assessment, care and treatment for a designated period prior to departure home or transfer to medical wards if appropriate focuses on multidisciplinary early assessment and decision making, proactive planning and intervention

Diagnostic Evaluation Abdominal Pain Atrial Fibrillation Chest Pain Confusion Dizziness Fever Gastrointestinal Hemorrhage Headache Seizures Syncope Toxicology Trauma Vaginal Bleeding

Abdominal Pain 无确定的诊断试验，涉及疾病多，且包括致命疾病，接诊医生在综合分析疼痛部位、时间、性质和伴随情况等所有的助于诊断的线索后，准确诊断率约为72%。 可以借助临床评分系统协助诊断

MANTRELS评分（appendicitis） symptoms: Migration of pain 1point Anorexia 1point Nausea 1point sign: Tender right lower quadrant 2point Rebound 1point Elevated temperature 1point laboratory results: Leukocytosis 2point Shift 1point 动态监测提示意义更大

Clues to diagnosis in the patients with abdominal pain Type of pain Sex Disease pattern Location of pain

Type of pain Vomiting, disention, obstipation and increased bowel sounds→obstruction Rebound tenderness or rigidity→peritonitis 上腹部烧灼样疼痛伴有恶心、呕吐，抑酸剂有效→胃部疾病 腹痛症状（重）和体征（相对轻）分离，恶心呕吐，血便，休克→血管疾病

Sex 女性腹痛更复杂，涉及异位妊娠和盆腔器官疾病 很多女患者并未意识到她已经怀孕 除了月经推迟，早孕并无确切的可靠表现 异位妊娠在破裂前很难诊断 检测HCG很有必要

Disease pattern 持续性or阵发性 放散部位 加重或缓解因素

Location of pain 右下腹 右上腹 不固定 侧腹部

Atrial Fibrillation Serious acute medical conditions associated with atrial firillation Acute myocardial infarction Unstable angina pectoris Acute pulmonary edema Pericardial tamponade Pneumonia Acute pulmonary embolus Thyrotoxicosis Hypertensive emergency Marked hypokalemia

Atrial Fibrillation 基本措施---控制心率（地高辛、β受体阻滞剂、非二氢吡啶类钙通道阻滞剂如地尔硫卓等） 选择性措施---纠正心律紊乱（药物转复或电击转复） 必要措施---预防血栓栓塞

Chest Pain Potentially life-threatening Myocardial infarction Unstable angina Dissecting thoracic aneurysm Pericarditis with tamponade Tension pneumothorax or effusion Pulmonary embolism Esophageal rupture

Chest Pain Generally non-life-threatening Congestive heart failure Stable angina Congestive heart failure Pericarditis without tamponade Mitral valve prolapse Pleurisy Pneumonia Stable pneumothorax or effusion Esophageal spasm Esophagitis Peptic ulcer Cholelithiasis with biliary spasm Pancreatitis Costochondritis Intercostal muscle strain Herpes zoster

Confusion Findings suggestive of a confusional state Poor judgment Poor orientation Worsening memory(recent) Worsening intellect Poor calculating ability Learning difficulties Labile affect Personality change

Confusion Findings suggestive of organic disease Abnormal vital signs Visual hallucinations Elderly On medications Known organic disease Alcohol or substance abuse History of headache Loss of coordination Focal neurologic findings

Short-Term Treatment These meet the care needs of a group of emergency patients who require extended emergency care and an expected hospital stay of less than 24 hours.

Short-Term Treatment Asthma Congestive Heart Failure Dehydration Hyperglycemia/Hypoglycemia Hypertension Infections Sickle Cell Anemia Pain Management

Observation medicine can improve health outcomes by providing: early access to short-term specialist services (such as multidisciplinary, specialist advice and care) and experienced staff able to observe patients with diverse problems and address the complex needs of patients

intensive or short-term care/frequent evaluation (assessment, observation and/or therapy) of a specific group of ED patients to rapidly diagnose conditions and expedite care evidence-based care pathways to facilitate assessment and treatment and reduce unnecessary variations in care delivery

Observation medicine can improve health outcomes by providing: a coordinated interdisciplinary team approach with early specialist intervention and integration with broader hospital and community services decreased length of stay and decreased multiday hospital admission rates without increasing the rate of hospitalisation or readmission

an environment more comfortable for patients than the ED avoidance of inappropriate departure from an ED greater continuity of care by reducing the number of transitions that can lead to errors, delay, duplication and lost information

Observation medicine can improve patient flow by: providing a comprehensive care model specific for patients requiring short-term treatment or observation streamlining the delivery of appropriate health services to ensure more timely care delivery and thus earlier discharge reducing avoidable admissions (for example older patients, chest pain)

increasing capacity to manage high ED patient volume actively seeking appropriate patients (‘pull’) from the ED early in their episode of care avoiding prolonged ED stays and/or the use of multiday inpatient beds for patients requiring less than 24-48 hours of care

Key principles for observation medicine Patient centred Quality and safety Early access Evidence-based care Substitution Collaboration Efficiency

Patient centred care—care is respectful of, and responsive to, individual patient preferences, needs and values, and provided in a comfortable environment Quality and safety—systems and processes deliver quality outcomes and minimise risks.

• Early access—there is early access to diagnostics, specialist advice, observation and reassessment to inform rapid decision-making and treatment Evidence-based care—pathways and protocols are in place to guide the delivery of care and reduce variation Substitution—observation medicine units are used as an alternative to traditional ED and inpatient models of care for patients requiring an extension of ED services

Collaboration—observation medicine units are managed in a way that improves links within the organisation (for example, between multidisciplinary clinicians and specialists) and with external stakeholders (for example, general practitioner and community service providers) Efficiency—observation medicine units contribute to efficient use of resources by streamlining the care of selected patients and reducing service duplication and avoidable use of inpatient resources.