诊疗信息化医疗机构中严重临床异常病例/事件监测工作方法的探讨  

Discussion on the application of severe and abnormal clinical cases/events surveillance in a hospital using hospital information system

作　　者：胡越[1] 蔡恩茂[1] 杨欢[2] 张耀新[2] 吴寰宇[3] 陶芳芳[3] 庄建林[1] 

机构地区：[1]上海市长宁区疾病预防控制中心,上海200051 [2]上海市同仁医院 [3]上海市疾病预防控制中心

出　　处：《实用预防医学》2015年第12期1409-1411,1456,共4页Practical Preventive Medicine

基　　金：卫生行业科研专项基金(201202006)

摘　　要：目的探索如何在诊疗信息化医疗机构中推动严重临床异常病例/事件监测工作。方法试点期间,通过临床医生主动报告结合医院/疾控中心传染病管理人员主动搜索的联合报告方式,实施严重临床异常病例/事件监测工作。结果上海市长宁区监测点采用半结构式HIS系统,通过联合报告方式,正式运行7个月内,共上报49例监测病例,其中临床医生主动报告4例,管理人员主动搜索报告45例,症候群包括38例重症肺炎监测病例,10例发热伴皮疹监测病例,1例脑炎监测病例。所有病例最终均未被判定为严重临床异常病例/事件。结论严重临床异常病例/事件监测系统是现有监测体系的有益补充,但在采用半结构式HIS系统的医疗机构中的应用仍需改进。Objective To explore how to promote the surveillance of severe and abnormal clinical cases/events in a hospital us- ing hospital information system（HIS）. Methods The surveillance of severe and abnormal clinical cases/events was carried out through direct reporting by clinicians in a hospital using HIS and active search by infectious disease administrators from the hospi- tal and a center for disease control and prevention（CDC） during trial period. Results During the trial period, semi struc- tured HIS was used in the sentinel hospital of Changning District. 49 surveillance cases were reported from January to July, 2014.4 cases were collected by active reporting from the clinicians and the other 45 cases by active search of the administrators. 38 surveillance cases had severe pneumonia syndrome, 10 had fever with rash syndrome and 1 had encephalitis syndrome. But ul- timately none of them was confirmed as severe and abnormal clinical cases / events. Conclusions The severe and abnormal clinical cases/events surveillance system is a beneficial supplement for the present surveillance system. However, it needs adjust- ment and improvement when it is applied in a hospital using semi - structured hospital information system.

关 键 词：严重临床异常病例/事件 监测 主动报告 主动搜索 

分 类 号：R183.9[医药卫生—流行病学]