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。
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.
[1] Chen L,Zheng H,Chen LJ,et al.National Early Warning Score in predicting severe adverse outcomes of emergency medicine patients:a retrospective cohort study[J]. J Multidiscip Healthc,2021,14:2067-2078.
[2] 金静芬,陈玉国,朱华栋,等. 急诊预检分诊标准(成人部分)[J]. 中华急危重症护理杂志,2020,1(1):45-48.
Jin JF,Chen YG,Zhu HD,et al.Emergency Triage Scale(Adult part)[J]. Chin J Emerg Crit Care Nurs,2020,1(1):45-48.
[3] 方珏,王钰炜,王飒,等. 浙江省综合性医院急诊预检分诊现况的调查研究[J]. 中华急危重症护理杂志,2023,4(9):842-847.
Fang J,Wang YW,Wang S,et al.Investigation of current status of emergency pre-examination triage in Zhejiang general hospitals[J]. Chin J Emerg Crit Care Nurs,2023,4(9):842-847.
[4] 许敬华. 基于“加拿大分诊标尺”的急诊电子分诊系统的优化研究[D]. 上海:上海交通大学,2020.
Xu JH.A study on optimization of emergency electronic triage system based on Canadian triage and acuity scale[D]. Shanghai:Shanghai Jiao Tong University,2020.
[5] 李国民,吕剑平,陈吉祥,等. 主诉书写的探讨[J]. 中国病案,2013,14(1):38-39,37.
Li GM,Lü JP,Chen JX,et al.Study on writing of chief complaint[J]. Chin Med Rec,2013,14(1):38-39,37.
[6] Chang D,Hong WS,Taylor RA.Generating contextual embeddings for emergency department chief complaints[J]. JAMIA Open,2020,3(2):160-166.
[7] Zachariasse JM,van der Hagen V,Seiger N,et al. Performance of triage systems in emergency care:a systematic review and meta-analysis[J]. BMJ Open,2019,9(5):e026471.
[8] Zhu AQ,Zhang JP,Zhang HL,et al.Comparison of reliability and validity of the Chinese four-level and three-district triage standard and the Australasian triage scale[J]. Emerg Med Int,2019,2019:8490152.
[9] 陈亚玲,李玉肖,黄陵生,等. 智能急诊分诊诊断治疗系统的研发与应用[J]. 护理学报,2021,28(22):75-78.
Chen YL,Li YX,Huang LS,et al.Development and application of smart emergency triage system[J]. J Nurs China,2021,28(22):75-78.
[10] 王钰炜,刘亚洁,陈晨,等. HIT技术与大数据分析在智慧化急诊预检分诊的应用[J]. 中华急诊医学杂志,2023,32(6):846-849.
Wang YW,Liu YJ,Chen C,et al.Application of HIT technology and big data analysis in intelligent emergency pre-examination and triage[J]. Chin J Emerg Med,2023,32(6):846-849.
[11] 国家卫生健康委员会. 国家卫生健康委关于印发三级医院评审标准(2020年版)的通知[J]. 国家卫生健康委员会公报,2020(12):149-192.
National Health Commission. Circular of the national health commission on issuing the accreditation standards for tertiary hospitals(2020 edition)[J]. Gaz Natl Health Comm People's Repub China,2020(12):149-192.
[12] 李春燕,黄萍,周田田,等. 急诊拥挤预测模型的研究进展[J]. 护理研究,2022,36(10):1798-1802.
Li CY,Huang P,Zhou TT,et al.Research progress of emergency department crowding prediction model[J]. Chin Nurs Res,2022,36(10):1798-1802.
[13] 詹玥,杨旻斐,姚晓月,等. 时效性管理在急诊预检分诊中的应用效果分析[J]. 护理与康复,2023,22(4):69-71,76.
Zhan Y,Yang MF,Yao XY,et al.Analysis of the application effect of timeliness management in emergency pre-examination and triage[J]. J Nurs Rehabil,2023,22(4):69-71,76.
[14] 王宏秋,刘颖青,赵丽新. 三甲医院急诊预检分诊岗位的改进与管理[J]. 护理学杂志,2020,35(16):20-22,62.
Wang HQ,Liu YQ,Zhao LX.Improvement and management of emergency triage post in a 3A hospital[J]. J Nurs Sci,2020,35(16):20-22,62.
[15] 田胜男,时保军,茹丽娜,等. 从证据角度论病历书写原则[J]. 中国卫生人才,2021(7):44-47.
Tian SN,Shi BJ,Ru LN,et al.On the principle of medical record writing from the perspective of evidence[J]. China Health Hum Resour,2021(7):44-47.
[16] Kuster T,Nickel CH,Jenny MA,et al.Combinations of symptoms in emergency presentations:prevalence and outcome[J]. J Clin Med,2019,8(3):345.
[17] Koleck TA,Dreisbach C,Bourne PE,et al.Natural language processing of symptoms documented in free-text narratives of electronic health records:a systematic review[J]. J Am Med Inform Assoc,2019,26(4):364-379.
[18] Tootooni MS,Pasupathy KS,Heaton HA,et al.CCMapper:an adaptive NLP-based free-text chief complaint mapping algorithm[J]. Comput Biol Med,2019,113:103398.
