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眼科急诊预检分诊标准的研究进展

Research progress in ophthalmic emergency pre-examination and triage

来源期刊: 眼科学报 | 2023年6月 第38卷 第6期 461-465 发布时间: 收稿时间:2023/9/5 15:52:41 阅读量:3226
作者:
关键词:
眼科急诊分诊分诊标准急症护理
ophthalmology department emergency triage triage criteria emergency nursing
DOI:
10.12419/2212280001
随着人口老龄化、生活方式的改变,眼科疾病患病人数的增加、国家眼病诊疗相关政策的持续推动、居民健康意识的逐渐提升,眼科门急诊患者数量持续增长,亟需构建科学的眼科急诊预检分诊标准,合理配置医疗资源,确保患者得到及时、恰当的治疗。国外已有医院依据患者症状或体征的严重程度对患者进行等级划分,建立起相对成熟的眼科急诊预检分诊模式,我国目前尚没有统一的、权威的眼科急诊预检分诊标准,国内外现行的眼科急诊预检分诊模式的分诊精准度及临床适用性有待进一步探索。该文通过综述国内外眼科急诊分诊标准及应用评价、眼科远程急诊预检分诊方式研究进展,以期为构建符合我国国情的、科学有效的眼科急诊预检分诊标准、提高眼科急诊分诊质量提供参考。
With the aging of population, the changing of lifestyle and the increasing number of ophthalmic emergency patients,Chinese national policies related to ophthalmic diagnosis and treatment are continually promoted, and residents' health awareness are gradually improved, the volume of ophthalmic outpatients and emergency patients continues to increase. It is urgent needed to establish scientific ophthalmic emergency pre-examination and triage criteria, to reasonably allocate medical resources, and to ensure that patients receive timely and appropriate treatment. The relatively mature ophthalmic emergency pre-examination and triage models with the severity of patients' symptoms or physical signs,have been established in foreign hospitals. Currently, there is no unified and authoritative ophthalmic emergency triage criteria in China. The accuracy and clinical applicability of the existing ophthalmic emergency triage models at home and abroad need to be further explored. This article reviewed the ophthalmic emergency triage criteria and application evaluation at home and abroad, and remote emergency triage in ophthalmology, in order to provide a reference for establishing a scientific and effective ophthalmic emergency triage criteria comformed Chinese national conditions, and improving the quality of ophthalmic emergency triage.
急诊预检分诊是指根据患者疾病的严重程度、治疗的优先原则和合理利用急诊医疗资源的原则对急诊患者进行快速分类,以确定治疗或进一步处理优先次序的过程[1]。据统计,由于眼部症状就诊的患者占急诊量的6%[2]。美国一项研究表明,每年约200万眼科急诊患者就诊,就诊人数呈逐年上升趋势[3]。眼科急症发病急,进展迅速,如果不及时诊断和处理,可能会导致永久性视力丧失或严重危害视功能[4]。有研究表明[5-6],非急症患者占用眼科急诊资源,加重了眼科急诊的工作负荷,使眼科急诊拥挤度和滞留度增加。因此,如何在众多就诊患者中迅速识别真正的急危重症患者,使其得到及时的诊治,已成为保障患者安全迫切需要解决的问题。研究显示[7],科学有效的急诊预检分诊能真实反映患者病情的危急程度,合理分配医疗资源,充分保证急危患者在最短时间内得到有效的治疗。目前,国内外关于眼科急诊预检分诊的研究相对较少。本文就国内外眼科急诊预检分诊标准进行综述,旨在为构建符合我国国情的、科学有效的眼科急诊预检分诊标准、提高眼科急诊预检分诊工作质量提供参考。

1 普适性急诊预检分诊标准

20世纪90年代起,国外发达国家纷纷改进急诊预检分诊标准,目前国际上公认急诊预检分诊标准有4种,即澳大利亚预检标尺(Australasian triage scale,ATS)、美国急诊危重指数(Emergency severity index,ESI)、加拿大检伤及急迫度量表(Canadian emergency department triage and acuity scale,CTAS)、 英国曼彻斯特预检系统(Manchester triage system,MTS)。ATS根据患者病情危急程度的可等待救治时间进行分诊[8-9]。ESI根据患者的生命体征、病情所需的医疗资源等指标进行分诊[10]。CTAS以患者主诉、病症为依据,护理人员分析患者病史、临床症状、生命体征等进行分诊[11],MTS 分诊过程中涉及的关键性鉴别指标主要有疼痛、意识、体温、急性发病与活动性出血等[12]。上述预检分诊工具均为根据患者病情危急情况将其分为5个等级,按照等级优先级别依次进行就诊。我国急诊预检分诊起步较晚,急诊预检分诊标准尚无统一标准。国内学者在借鉴国外成熟的急诊预检分诊模式的基础上,构建了符合我国国情的急诊预检分诊系统,如北京协和医院急诊分诊量表[13]、香港急诊分诊指南(Hong Kong authority emergency triage guidelines,HKAETG)[14]及台湾急诊检伤与急迫度分级量表(Taiwan triage acuity scale,TTAS)[15]等。但普适性急诊预检分诊标准缺乏特异性,同一标准应用于不同类别的危急重症,对于眼科急诊预检分诊的针对性较差,因此有必要构建并评价眼科专科急诊预检分诊标准。

2 眼科急诊分诊标准及应用效果评价

2.1 眼科急诊分诊系统(The rome eye system for scoring urgency and emergency)

意大利罗马眼科医院在回顾分析160 936份眼科急诊患者电子病历的基础上,于2007年构建了世界上首个眼科急诊分诊系统,命名为the rome eye system for scoring urgency and emergency (RESCUE)。RESCUE是一种使用眼红、眼痛、视力下降、开放性眼外伤这4项指标进行分诊的3级分诊系统。每项指标均根据无、中度和重度进行评分,眼红和眼痛均评0~2分,视力下降及开放性眼外伤评0~4分,RESCUE总分0~12分,根据患者的总分将其病情分为3个级别,使用不同颜色表示,黄色为最紧急(8~12分),绿色为亚紧急(4~7分),白色为不紧急(0~3分)[16]。随后研究者对1 000例眼科急诊患者使用RESCUE进行预检分诊,结果表明,前瞻性分配的病情等级与经诊断后患者病情等级高度相关,RESCUE用于眼科急诊分诊的准确率达到95%,灵敏度为90.7%,特异度为97.2%[17]。该系统对于紧急患者的识别能力强,实用性较强,简单易行,可以较准确快速判断患者病情,但也存在预检分诊指标不够全面的局限性。由于其简便性及即时性,在眼科领域经验有限的人员也可以较好地运用,得到广泛应用的可能性较高。

2.2 Ophthalmic instrument of patient self-triage (ISET)

眼科急诊接收患者的来源包括患者自行就诊和由全科医生、视光师或下级医院转诊,其中自行就诊的患者比例高达89%[18]。2014年,沙特阿拉伯一家医院为了克服RESCUE的灵敏度仅为90.7%且分诊指标不够全面的局限性,对RESCUE进行了修订,构建了患者自行分诊的分诊系统,即ophthalmic instrument of patient self-triage (ISET)[19-20]。ISET分诊的重心在于患者的主诉和症状,包含了18种临床表现,不同的临床表现有其对应的评分,评1~4分。患者据此被分为3级,依次为:1级最紧急(≥4分),需45 min内处理;2级紧急(2~3分),需在无最紧急患者等待的情况下立即处理;3级不紧急(0~1分),指引患者至门诊就诊。分诊流程为患者到急诊科就诊登记后,自行填写分诊问卷,通过问卷筛查患者的视力及过去一周内的症状及病史,包括有无眼部创伤史、化学伤史、佩戴角膜接触镜史、角膜移植史。当患者存在眼科急症的临床表现时,再进一步评估,根据临床表现的对应评分得出最后的分数。AlSamnan等[19]对842例患者实施ISET分诊,结果表明,ISET识别紧急与非紧急患者灵敏度达98.7%,高于RESCUE,但特异度仅87%,低于RESCUE。ISET识别最紧急患者的灵敏度达99%,特异度达90%,ISET分诊较常规分诊使患者候诊时间从58 min缩短至46 min,可减少不必要的眼科急诊负荷。但ISET仍存在以下局限性:由于仅关注眼科急症的典型临床表现,可能会遗漏一些症状非典型患者,另外整个分诊过程需要护士密切跟进,确保患者自我评估的准确性。该工具在应用过程中,部分患者需要在医护人员指导下才能完成问卷填写,因此Eijk等[20]对ISET进行了修订,删除不适合患者自我评估的条目,最终形成11个条目,修订版ISET的灵敏度为94.3%、特异度为76.4%。由于该工具对患者及分诊工作人员的要求较高,暂未能在临床广泛推广应用。

2.3 The alphabetical triage score for ophthalmology (ATSO)

2018年,意大利巴里市的一家大学附属医院再次对RESCUE进行了修订,制定了the alphabetical triage score for ophthalmology (ATSO),在RESCUE的基础上增加了一些严重危害视力的眼病的临床表现。制定的ATSO包括:视力下降、眼部表现(突发性复视、突发性斜视、突发性眼球突出)、眼红、眼痛、眼外伤和漂浮物/闪光感6项分级指标,每项指标根据严重程度进行评分,根据评分将患者分成3个级别决定患者的优先就诊顺序,分别是:低危(0~3分),患有眼科急症的风险为2.9%,可以在处理完高危和中危患者后再处理;中危(4~5分),患有眼科急症的风险为75.3%,需要尽快处理;高危(≥ 6分),患有眼科急症的风险为100%,需要马上评估和尽早治疗。ATSO区分紧急与非紧急患者的灵敏度达91.4%、特异度为98.2%,可以准确识别出需住院治疗的高危患者,是眼科急诊中安全、有效的预检分诊工具,但研究结果仍需大样本、多中心的研究进一步验证[21]。ATSO较RESCUE纳入的指标更全面,每项指标的严重程度评分也更为具体,分诊时间较ISET短,临床可操作性强。

2.4 我国眼科急诊分诊标准

我国目前尚没有统一的、权威的眼科急诊分诊标准,眼科急诊分诊往往沿用“经验分诊模式”。中山大学中山眼科中心于2021年成立了我国首个眼科急症科,根据Ⅰ、Ⅱ、Ⅲ三级对患者进行分诊:Ⅰ级需立即诊治,主要包括24 h内突发双眼或单眼视力下降至无光感、眼部/眼周重度疼痛(数字等级评定量表7~10分)、未经处置过的化学物品入眼、眼外伤伴眼内容物脱出/异物嵌顿/流血不止,需在15 min内处理。Ⅱ级为7 d内进行性视力下降、眼部/ 眼周中度疼痛(4~6分)、简单处置后的化学物品入眼、未经处置过的、除Ⅰ级之外的眼外伤,需在30 min内处理。Ⅲ级指1个月内出现视力下降、眼部/眼周无或轻度疼痛(0~3分),除上述外,其他病情稳定、症状轻微的眼部疾病,需在45 min内进行处理。近年来,有部分国内学者对眼科急诊预检分诊进行了一些探索,香港公立眼科专科医院提出将机器学习技术应用到转诊患者的智能分诊中,初级保健机构提供患者的转诊记录和眼底彩照,通过临床医疗系统的智能算法输出患者的紧急程度评分,患者分为3个级别,分别为需马上处理、很可能为紧急情况及很可能为非紧急情况。需马上处理及很可能为紧急情况者再次进行人工分诊。3个级别的患者优先就诊次序均由智能算法得出的评分高低决定。但该预检分诊模式暂未实施,有待进一步研究验证其效果[22]。复旦大学附属眼耳鼻喉科医院为提高急诊预检分诊正确率以快速识别危重患者,进行了一项急诊患者住院手术或观察的回顾性队列研究,结果表明就诊时间、就诊季节、居住地、年龄、性别、主诉和受累部位是独立危险因素,该结果将为智能预检分诊软件的开发提供参考依据[23]

3 远程预检急诊分诊在眼科中的应用

Wedekind等[24]研究表明,远程医疗有利于解决区域间眼科急诊护理覆盖的差距,在眼科急诊预检分诊中发挥着重要作用。将眼科急诊患者的分诊延伸到院前,有效分流急诊患者到各级医疗机构,可提高优质急诊医疗资源的利用效率。

3.1 电话分诊

爱尔兰皇家维多利亚眼耳医院于2020年3月开始正式实施由护士主导的电话预检分诊。负责电话预检分诊的护士需满足以下其中一项条件:1)高级执业护士(Advanced practice nurse,APN);2)临床护理专家;3)研究生学历,并有6个月以上的急诊工作经验;4)具有2年以上的急诊工作经验。电话分诊时间为每天8时至22时,由两名护士和一名医生负责。患者通过拨通专门的电话预检分诊号码或者全科医生转诊接受电话预检分诊。分诊护士与患者就体征和症状进行对话,患者可向分诊护士通过邮件发送图片,分诊护士将患者分为5种情况,分别为需马上至急诊就诊(包括化学伤、青光眼急性发作、眼球穿通伤、突然失明、伴有疼痛、上睑下垂或复视的可疑第三动眼神经麻痹)、需在当天处理、需在3 d内处理、需给出一般性建议及由医生提供咨询。研究结果表明,电话预检分诊可大幅度减少眼科急诊就诊人数,减少患者等待时间[25-26]

3.2 视频分诊

英国莫菲尔眼科医院于2020年4月对眼科急诊患者实施视频预检分诊,患者注册视频分诊后,由1名经验丰富的眼科医生进行初步评估,识别出需当天亲自至急诊进一步评估的患者,再由眼科医生进行检查和处理。对于不需要当天面对面评估的患者,给予一般性建议或指引更合适的医疗服务。包括指引患者到当地眼科医院就诊,指引患者购买非处方药、远程开具处方、转诊至初级保健医生或验光师。研究显示,较年轻患者与女性患者更倾向于选择视频预检分诊,选择视频预检分诊或面对面分诊的患者均无发生由于分诊不当而延误治疗或误诊导致伤害的情况。但视频预检分诊对老年人、不会或无法上网的患者群体仍具有较大的局限性。改进及创新移动应用程序和家庭监控设备(用于测量视力、色觉、变态视觉、视网膜成像)将极大地影响远程护理的深度和广度[27]

4 小结

综上所述,虽然国外已建立眼科急诊预检分诊标准,但仍有待进一步完善。因国内外医疗政策、医疗环境等方面存在差异,国外的眼科预检分诊标准不一定适用于我国眼科急诊的管理。我国眼科急诊预检分诊研究起步较晚,目前尚未形成统一的眼科急诊预检分诊标准和评价系统,临床多依赖经验分诊,执行分诊工作存在一定难度,应在借鉴国外眼科急诊预检分诊系统的同时,构建适合我国国情的眼科急诊预检分诊系统。眼科疾病有明显的专科特点,眼科急诊预检分诊应将视功能损害的严重程度、抢救后视力恢复可能性作为重要的考虑因素,建立灵敏、可靠和易于操作并能对眼科急诊患者进行精准病情分级,以便及时实施医疗救护的眼科急诊预检分诊标准及评价系统。随着信息化的发展和大数据的应用,应致力于构建基于计算机的临床决策支持系统,实现智能预检分诊,缩短预检分诊时间,提高分诊准确性,合理分配医疗资源。

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