摘要
目的 调查创伤患者院前急救信息采集现状并进行分析总结.方法 本研究为中国人民解放军东部战区总医院发起的一项前瞻性研究,2022年2-4月制定、发放并回收创伤患者院前急救信息采集调查问卷,问卷内容主要包括急救单位信息、创伤急救信息采集与存储方式、创伤患者病历资料登记情况、创伤患者信息院前和院内交接的情况以及当前院前急救信息采集存在的问题与建议等几个部分.调查问卷采用微信方式发放至江苏省、浙江省、重庆市等地的院前急救相关的120医师、急诊科医师以及军队医院野战医疗所医师,对回收的有效调查问卷进行统计分析.结果 本次研究共计发放调查问卷150份,收回有效调查问卷148份.使用制式信息表格进行信息采集的有143份(96.6％),其余5份为非制式表格.一般资料情况全部可以获取的占16.9％(25/148).既往健康资料方面全部可获取占16.2％(24/148),伤员关键信息全部可获取占23.0％(34/148),超过50％伤员关键信息缺失的占17.6％(26/148),伤情信息如能动态多次记录更利于后期救治,但问卷调查显示仅记录1次的占56.1％(83/148).伤情信息记录方式以文字记录为主,占98.7％(146/148),采用语音、照片、视屏方式记录的均不到50％.被调查者当前所采用的创伤急救信息采集方式的缺点集中于:身份识别存在困难(89/148,60.1％)、患者个人信息不全(99/148,66.9％)、创伤急救过程病情信息记录不全和更新不及时(71/148,48.0％)等几个方面.创伤急救信息采集困难主要原因:信息化程度低(90/148,60.8％)、人手紧张(86/148,58.1％)以及缺乏规范化信息采集方式(84/148,56.8％)等.结论 当前,我国创伤患者院前急救信息的采集方式有电子信息系统录入、制式表格、手写伤票等多种方式,存在信息化程度低、伤员身份识别存在困难、个人一般信息和既往健康信息存在较大程度缺失以及院前急救与医院急诊科交接不流畅等问题,亟待优化和改进.
Abstract
To investigate and analyze the current status of pre-hospital emergency information collection for trauma patients.Methods This prospective study,initiated by the our hospital,was conducted between Feb.and Apr.2022 by questionnaire survey.The questions investigated mainly included(1)information of the emergency care affiliations,(2)collection and storage methods of trauma emergency information,(3)registration of medical re-cords of trauma patients,(4)pre-and in-hospital information exchange,and(5)current issues and suggestions on pre-hospital emergency information collection.The questionnaires were sent via WeChat to 120 doctors and emergen-cy physicians related to pre-hospital care in Jiangsu,Zhejiang,Chongqing and other regions,as well as military medi-cal officers working in field medical facilities.The retrieved questionnaires were verified and statistically analyzed.Results A total of 150 questionnaires were sent and 148 valid samples were collected.Among them,143(96.6％)questionnaires reported information collection using standardized forms and the rest 5 in freestyles.For data collec-tion quality,16.9％(25/148)respondents reported complete collection of general information(such as names,ID,contact details,etc.),16.2％(24/148)reported complete collection of past health records,and 23.0％(34/148)reported complete collection of patient crucial information(including names,ages,medical histories,allergies,family contact details,etc.).However,as high as 17.6％(26/148)of respondents reported missing of＞50％crucial infor-mation.As we know,dynamic recording of injury information can benefit following treatment procedures,but the re-sults showed that 56.1％(83/148)respondents conducted data recording only once;moreover,98.7％(146/148)records were by text documentation and those by voice,photos,and video were less than 50％.The identified short-comings of current trauma emergency information collection presented as difficulties in patient identification(89/148,60.1％),incomplete recording of patient information(99/148,66.9％),and inadequate recording or untimely updating of injury-related information during the emergency process(71/148,48.0％).The significant challenges in trauma emergency information collection were attributed to low levels of informatization(90/148,60.8％),limited human resources(86/148,58.1％),and lack of standardized information collection procedures(84/148,56.8％).Conclusion Currently,there are several ways to collect pre-hospital emergency information for trauma patients in China,including electronic information system input,standardized forms,handwritten injury tickets,etc.During the in-formation collection,many problems exist,like low levels of informatization,hard identification of the wounded,signifi-cant missing of personal general information and past health information,and unsmooth handover between the pre-hos-pital and emergency departments.All these problems need to be solved and optimized urgently.
维普
万方数据