急诊观察医学.ppt

,急诊观察医学ObservationMedicine,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,asiteto“park”patientsawaitinga“real”bedevaluateandstabilizeacutelyillpatientsdiscriminatepatientreallyneededhospitalizationformulateaprognosisdeviseaplanfortreatment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notonlyusefulbutessential,repeateddiagnosticassessment(laboratory,radiologyandotherclinicalinvestigativeservices)treatmentsnotroutinelyprovidedinanED,patientswithcomplexorundifferentiatedconditionswhomayrequirelengthyevaluation,serialreviewrapidandcomprehensivemultidisciplinaryassessmentprolongedobservationforconditionsexpectedtoresolvewithin12to24hours,thoselikelytorespondtoabriefcourseoftherapy,whichthencanbemodifiedsothattreatmentcanbecontinuedathomeoranothercommunitysettinganearlyspecialistreviewbyaconsultantand/orseniormedicalregistrar,includingthatperformedbysubspecialtyservices,TypesofObservationService,DiagnosticEvaluationofCriticalDiagnosticSyndromesShort-TermTreatmentofSeriousEmergencyConditions,DiagnosticEvaluationofCriticalDiagnosticSyndromes,abalancebetweenprobabilityanddangerousnessofthediseaseunderconsiderationthephysiciancannotreadilydiagnosetheconditionwithtesting医生诊断暂时不确定，且诊断结果直接决定进一步处理,abalancebetweenprobabilityanddangerousnessofthediseaseunderconsiderationchestpainMIabdominalpainkidneystone,thephysiciancannotreadilydiagnosetheconditionwithtesting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？,DiagnosticEvaluation,receivemedicalinpatientsforintensiveassessment,careandtreatmentforadesignatedperiodpriortodeparturehomeortransfertomedicalwardsifappropriatefocusesonmultidisciplinaryearlyassessmentanddecisionmaking,proactiveplanningandintervention,DiagnosticEvaluation,AbdominalPainAtrialFibrillationChestPainConfusionDizzinessFeverGastrointestinalHemorrhageHeadacheSeizuresSyncopeToxicologyTraumaVaginalBleeding,AbdominalPain,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:Migrationofpain1pointAnorexia1pointNausea1pointsign:Tenderrightlowerquadrant2pointRebound1pointElevatedtemperature1pointlaboratoryresults:Leukocytosis2pointShift1point动态监测提示意义更大,Cluestodiagnosisinthepatientswithabdominalpain,TypeofpainSexDiseasepatternLocationofpain,Typeofpain,Vomiting,disention,obstipationandincreasedbowelsoundsobstructionReboundtendernessorrigidityperitonitis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,Diseasepattern,持续性or阵发性放散部位加重或缓解因素,Locationofpain,右下腹右上腹不固定侧腹部,AtrialFibrillation,SeriousacutemedicalconditionsassociatedwithatrialfirillationAcutemyocardialinfarctionUnstableanginapectorisAcutepulmonaryedemaPericardialtamponadePneumoniaAcutepulmonaryembolusThyrotoxicosisHypertensiveemergencyMarkedhypokalemia,AtrialFibrillation,基本措施-控制心率（地高辛、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,ChestPain,Potentiallylife-threateningMyocardialinfarctionUnstableanginaDissectingthoracicaneurysmPericarditiswithtamponadeTensionpneumothoraxoreffusionPulmonaryembolismEsophagealrupture,ChestPain,Generallynon-life-threateningStableanginaCongestiveheartfailurePericarditiswithouttamponadeMitralvalveprolapsePleurisyPneumoniaStablepneumothoraxoreffusionEsophagealspasmEsophagitisPepticulcerCholelithiasiswithbiliaryspasmPancreatitisCostochondritisIntercostalmusclestrainHerpeszoster,Confusion,FindingssuggestiveofaconfusionalstatePoorjudgmentPoororientationWorseningmemory(recent)WorseningintellectPoorcalculatingabilityLearningdifficultiesLabileaffectPersonalitychange,Confusion,FindingssuggestiveoforganicdiseaseAbnormalvitalsignsVisualhallucinationsElderlyOnmedicationsKnownorganicdiseaseAlcoholorsubstanceabuseHistoryofheadacheLossofcoordinationFocalneurologicfindings,Short-TermTreatment,Thesemeetthecareneedsofagroupofemergencypatientswhorequireextendedemergencycareandanexpectedhospitalstayoflessthan24hours.,Short-TermTreatment,AsthmaCongestiveHeartFailureDehydrationHyperglycemia/HypoglycemiaHypertensionInfectionsSickleCellAnemiaPainManagement,Observationmedicinecanimprovehealthoutcomesbyproviding:earlyaccesstoshort-termspecialistservices(suchasmultidisciplinary,specialistadviceandcare)andexperiencedstaffabletoobservepatientswithdiverseproblemsandaddressthecomplexneedsofpatients,intensiveorshort-termcare/frequentevaluation(assessment,observationand/ortherapy)ofaspecificgroupofEDpatientstorapidlydiagnoseconditionsandexpeditecareevidence-basedcarepathwaystofacilitateassessmentandtreatmentandreduceunnecessaryvariationsincaredelivery,Observationmedicinecanimprovehealthoutcomesbyproviding:acoordinatedinterdisciplinaryteamapproachwithearlyspecialistinterventionandintegrationwithbroaderhospitalandcommunityservicesdecreasedlengthofstayanddecreasedmultidayhospitaladmissionrateswithoutincreasingtherateofhospitalisationorreadmission,anenvironmentmorecomfortableforpatientsthantheEDavoidanceofinappropriatedeparturefromanEDgreatercontinuityofcarebyreducingthenumberoftransitionsthatcanleadtoerrors,delay,duplicationandlostinformation,Observationmedicinecanimprovepatientflowby:providingacomprehensivecaremodelspecificforpatientsrequiringshort-termtreatmentorobservationstreamliningthedeliveryofappropriatehealthservicestoensuremoretimelycaredeliveryandthusearlierdischargereducingavoidableadmissions(forexampleolderpatients,chestpain),increasingcapacitytomanagehighEDpatientvolumeactivelyseekingappropriatepatients(pull)fromtheEDearlyintheirepisodeofcareavoidingprolongedEDstaysand/ortheuseofmultidayinpatientbedsforpatientsrequiringlessthan24-48hoursofcare,KeyprinciplesforobservationmedicinePatientcentredQualityandsafetyEarlyaccessEvidence-basedcareSubstitutionCollaborationEfficiency,Patientcentredcarecareisrespectfulof,andresponsiveto,individualpatientpreferences,needsandvalues,andprovidedinacomfortableenvironmentQualityandsafetysystemsandprocessesdeliverqualityoutcomesandminimiserisks.,Earlyaccessthereisearlyaccesstodia