严重临床异常病例/事件监测不同实现途径的结果探讨  

Exploration on different pathways of reporting in severe and abnormal clinical cases/events surveillance

作　　者：宣舟斌 何翠芬[1] 商颖[1] 周海茵[2] 谢梦[1] 张珍[1] 吴寰宇[3] 徐鸣[2] 陶芳芳[3] 

机构地区：[1]上海市杨浦区疾病预防控制中心,上海200090 [2]上海市杨浦区中心医院 [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1412-1416,共5页Practical Preventive Medicine

基　　金：卫生行业科研专项基金(201202006)

摘　　要：目的探索严重临床异常病例/事件监测的不同实现途径。方法基于HIS系统自动触发报告、人工触发替代自动触发和回顾性搜索途径,在杨浦区中心医院发热、呼吸道、肠道等门诊科室开展监测工作。结果 2014年1-8月基于HIS系统自动触发报告病例为0,人工触发替代报告84例,其中重症肺炎59例,出血性肠炎1例,异常病例24例;回顾性搜索发现98例,其中重症肺炎59例,3例发热伴皮疹监测病例,4例出血性肠炎病例,异常病例32例。经核实,所有病例最终均排除,未被判定为严重临床异常病例/事件。结论在诊疗信息电子化转变过程中可通过不同的途径开展监测工作,人工触发替代报告途径能够及时有效的发现相关病例,是后期在诊疗信息电子化转变中开展项目监测的主要方法。Objective To explore different pathways to carry out severe and abnormal clinical cases/events surveillance. Methods Automatically triggered reporting based on hospital information system（HIS）, artificial trigger reporting in place of automatic one, and retrospective search approach were carried out in outpatient departments of fever, respiratory diseases, intesti- nal diseases and other diseases in the Central Hospital of Yangpu District. Results From January to August 2014, no cases were reported by the automatically triggered reporting system, while 84 cases were reported by the artificial trigger alternative ap- preach, including 59 cases with suspected severe pneumonia syndrome, 1 case with hemorrhagic colitis syndrome and 24 abnormal cases. 98 cases were found by retrospective searching approach, including 59 cases with suspected severe pneumonia syndrome, 3 cases with suspected fever with rash syndrome, 4 cases with hemorrhagic colitis syndrome and 32 abnormal cases. But ultimately none of them was confirmed as severe and abnormal clinical cases/events. Conclusions During the electronic transition of di- agnosis and treatment information, monitoring work can be carried out through different pathways. Artificial trigger alternative reporting can find relevant cases timely and effectively, and it will be an important approach to carry out cases/events surveil- lance.

关 键 词：严重临床异常病例/事件 监测 电子信息化 

分 类 号：R183.9[医药卫生—流行病学]