急诊预检分诊患者主诉标准化术语库的构建及应用研究

doi:10.3761/j.issn.2096-7446.2024.08.005

摘要/Abstract

摘要： 目的建立患者主诉标准化术语库并观察其在急诊预检分诊中的应用效果。方法以加拿大急诊信息化系统主诉列表为基础,增补各大疾病系统和近5年该院急诊分诊系统中主诉信息,根据标准医学术语集进行规范的表达,通过专家函询确定主诉列表（主主诉模块）,辅以疾病持续时间（子主诉模块）和国际疾病分类10（International Classification of Diseases 10,ICD10）诊断列表（主诉辅助模块）形成主诉标准化术语库,联合信息部门将主诉标准化术语库应用于急诊预检分诊系统。选取2023年9月应用主诉标准化术语库分诊的急诊患者为试验组,2022年9月同期应用常规自由文本形式录入主诉的急诊患者为对照组;比较两组患者的分诊时间、分诊符合率及72 h非计划重返率。结果应用主诉标准化术语库后,分诊时间从（327.33±44.32） s缩短至（174.23±49.02） s,预检分诊符合率从应用前的95.27%提高至98.34%,差异有统计学意义（P<0.001）。72 h非计划重返率均是零。结论将主诉标准化术语库用于急诊预检分诊,对主诉规范、分诊时效、急诊急救效率起到了促进作用,有助于医学数据统计和分诊质量控制,以及提高急诊工作效率。

关键词: 急诊, 预检分诊, 主诉, 标准化, 术语库, 护理

Abstract: Objective To establish the standardized terminology database of patient complaint and observe its application effect in emergency triage. Methods Based on the list of chief complaints in the Canadian emergency information system,the information of chief complaints in the major disease systems and the emergency triage system of our hospital in the past five years was added. According to the standard medical terminology set,the chief complaint list（chief complaint module） was determined by expert inquiry,supplemented by disease duration （sub-chief complaint module） and International Classification of Diseases（ICD） 10 diagnosis list（auxiliary chief complaint module）,the standardized chief complaint terminology database was formed. Then the standardized chief complaint terminology database was applied to the emergency triage system by jointing with information department. Emergency patients in September 2023 who were triaged using the standardized terminology database of chief complaint were selected as the experimental group,and emergency patients who were recorded in the form of routine free text in the same period of 2022 were selected as the control group. The triage time,triage coincidence rate and 72-h unplanned return rate were compared between the two groups. Results After applying the standardized terminology database of chief complaint,triage time was reduced from（327.33±44.32） seconds to （174.23±49.02） seconds,and the triage coincidence rate increased from 95.27% to 98.34%,which was statistically significant （P<0.001）. The 72-hour unplanned return rate was zero in both groups. Conclusion The application of the standardized terminology database of chief complaint to the emergency triage has played a role in promoting the standardization of chief complaint,the timeliness of triage and the efficiency of emergency care,contributing to the statistics of medical data and the quality control of triage,and improving the efficiency of emergency care.

Key words: Emergency, Triage, Chief Complaint, Standardized Terminology, Database, Nursing Care

陈晨, 闫丹萍, 王飒, 周帅帅, 黄畅, 王钰炜. 急诊预检分诊患者主诉标准化术语库的构建及应用研究[J]. 中华急危重症护理杂志, 2024, 5(8): 701-705.

CHEN Chen, YAN Danping, WANG Sa, ZHOU Shuaishuai, HUANG Chang, WANG Yuwei. Study on the construction and application of standardized terminology database for the chief complaint of patients in emergency triage[J]. Chinese Journal of Emergency and Critical Care Nursing, 2024, 5(8): 701-705.

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