急诊观察医学Observation-Medicine.ppt

急诊观察医学急诊观察医学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的必要性急诊留观病人的类型急诊留观病人的类型如何观察急诊病人如何观察急诊病人急诊留观的必要性急诊留观的必要性急诊病人特点急诊病人特点医患关系医患关系“拥挤拥挤”的急诊科的急诊科急诊病人的特点急诊病人的特点处于疾病的早期阶段，不确定因素多处于疾病的早期阶段，不确定因素多,变化快变化快危重病人在明确诊断前就要给予医疗干预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，而不是以来诊病人常以症状或体征为主导，而不是以某种病为主导某种病为主导病情轻重相差大从感冒到心跳呼吸骤停病情轻重相差大，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病人和家属对缓解症状和稳定病情期望值高“拥挤拥挤”的急诊科的急诊科急诊科是医院内最不具有确定性和最繁忙急诊科是医院内最不具有确定性和最繁忙的一个部门的一个部门急诊科就诊病人数逐年增长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病人流量的增加是造成急诊科拥挤最基本因素因素“拥挤拥挤”是指急诊病人的需求是指急诊病人的需求(即等待急即等待急诊临床决策诊临床决策,如分诊、候诊、留观、治疗、如分诊、候诊、留观、治疗、安置等安置等)超过了急诊科的处理能力超过了急诊科的处理能力我院急诊科简介我院急诊科简介成立于成立于1984年年急诊医学硕士和博士学位授权点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辽宁省急诊医疗质量控制中心“急诊急救急诊急救留观留观重症监护重症监护(EICU)”一体一体化化急诊初诊区实行急诊初诊区实行“红、黄、绿红、黄、绿”分区就诊分区就诊现有急诊抢救床位现有急诊抢救床位6张，监护床位张，监护床位16张，观张，观察床位察床位19张，每年接诊患者张，每年接诊患者9万余人次，危万余人次，危重患者抢救成功率接近重患者抢救成功率接近90%急诊科拥挤的原因急诊科拥挤的原因综合性大医院的住院病人日益增多综合性大医院的住院病人日益增多,造成床位紧张造成床位紧张,急诊病人急诊病人无法及时收住入院无法及时收住入院,大量病人留在急诊观察室大量病人留在急诊观察室医院病床越来越专科化医院病床越来越专科化(甚至专病化甚至专病化),病房医师不愿意收本病房医师不愿意收本专业专业“不相关不相关”的病人的病人,而急诊病人往往比较复杂而急诊病人往往比较复杂,有多系统有多系统的问题或诊断未明的问题或诊断未明,是各专科病房拒收的主要对象是各专科病房拒收的主要对象病人维权意识日益增强病人维权意识日益增强,医疗风险有增无减医疗风险有增无减,尤其急诊病人医尤其急诊病人医疗风险非常高疗风险非常高,病情危急病情危急,病房往往不愿意收急诊病人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急诊观察医学的地位和作用a site to“park”patients awaiting a“real”bedevaluate and stabilize acutely ill patientsdiscriminate 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 EDpatients 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 hoursthose 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 settingan early specialist review by a consultant and/or senior medical registrar,including that performed by subspecialty servicesTypes of Observation ServiceDiagnostic Evaluation of Critical Diagnostic SyndromesShort-Term Treatment of Serious Emergency Conditions Diagnostic Evaluation of Critical Diagnostic Syndromesa 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 painMI 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 Evaluationreceive medical inpatients for intensive assessment,care and treatment for a designated period prior to departure home or transfer to medical wards if appropriatefocuses on multidisciplinary early assessment and decision making,proactive planning and interventionDiagnostic EvaluationAbdominal PainAtrial FibrillationChest Pain ConfusionDizzinessFeverGastrointestinal Hemorrhage HeadacheSeizuresSyncopeToxicologyTraumaVaginal BleedingAbdominal 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 1pointsign: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 painType of pain SexDisease pattern Location of painType of painVomiting,disention,obstipation and increased bowel soundsobstructionRebound tenderness or rigidityperitonitis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 FibrillationSerious 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 hypokalemiaAtrial Fibrillation基本措施基本措施-控制心率（地高辛、控制心率（地高辛、受体阻滞剂、非二氢吡啶类钙通道受体阻滞剂、非二氢吡啶类钙通道阻滞剂如地尔硫卓等）阻滞剂如地尔硫卓等）选择性措施选择性措施-纠正心律紊乱（药物纠正心律紊乱（药物转复或电击转复）转复或电击转复）必要措施必要措施-预防血栓栓塞预防血栓栓塞Chest PainPotentially life-threatening Myocardial infarction Unstable angina Dissecting thoracic aneurysm Pericarditis with tamponade Tension pneumothorax or effusion Pulmonary embolism Esophageal ruptureChest PainGenerally non-life-threatening 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 ConfusionFindings suggestive of a confusional state Poor judgment Poor orientation Worsening memory(recent)Worsening intellect Poor calculating ability Learning difficulties Labile affect Personality change ConfusionFindings 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 TreatmentThese 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 TreatmentAsthmaCongestive Heart Failure DehydrationHyperglycemia/HypoglycemiaHypertensionInfectionsSickle Cell Anemia Pain ManagementObservation 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 patientsintensive or short-term care/frequent evaluation(assessment,observation and/or therapy)of a specific group of ED patients to rapidly diagnose conditions and expedite careevidence-based care pathways to facilitate assessment and treatment and reduce unnecessary variations in care deliveryObservation medicine can improve health outcomes by providing:a coordinated interdisciplinary team approach with early specialist intervention and integration with broader hospital and community servicesdecreased length of stay and decreased multiday hospital admission rates without increasing the rate of hospitalisation or readmissionan environment more comfortable for patients than the EDavoidance of inappropriate departure from an EDgreater continuity of care by reducing the number of transitions that can lead to errors,delay,duplication and lost informationObservation medicine can improve patient flow by:providing a comprehensive care model specific for patients requiring short-term treatment or observationstreamlining the delivery of appropriate health services to ensure more timely care delivery and thus earlier dischargereducing avoidable admissions(for example older patients,chest pain)increasing capacity to manage high ED patient volumeactively seeking appropriate patients(pull)from the ED early in their episode of careavoiding prolonged ED stays and/or the use of multiday inpatient beds for patients requiring less than 24-48 hours of careKey principles for observation medicine Patient centred Quality and safety Early access Evidence-based care Substitution Collaboration Efficiency Patient centred carecare is respectful of,and responsive to,individual patient preferences,needs and values,and provided in a comfortable environmentQuality and safetysystems and processes deliver quality outcomes and minimise risks.Early accessthere is early access to diagnostics,specialist advice,observation and reassessment to inform rapid decision-making and treatmentEvidence-based carepathways and protocols are in place to guide the delivery of care and reduce variationSubstitutionobservation medicine units are used as an alternative to traditional ED and inpatient models of care for patients requiring an extension of ED servicesCollaborationobservation 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)Efficiencyobservation 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.