某三级甲等医院重症医学科总住院医师会诊病例构成分析  

Analysis of composition of chief resident consultation cases in critical care department of a tertiary hospital

作　　者：谢璐璐 王迪芬 Xie Lulu;Wang Difen(Department of Intensive Care Unit,Affiliated Hospital of Guizhou Medical University,Guiyang 550004,Guuizhou,China)

机构地区：[1]贵州医科大学附属医院重症医学科,贵州贵阳550004

出　　处：《中国中西医结合急救杂志》2020年第6期725-728,共4页Chinese Journal of Integrated Traditional and Western Medicine in Intensive and Critical Care

基　　金：国家重点研发计划(2018YFC2001900);国家临床重点专科建设项目(2011-170);贵州省临床重点学科建设项目(2011-52);贵州省高层次人才特助经费(TZJE-2011-25)。

摘　　要：目的通过分析重症医学科总住院医师会诊患者的构成特点,以反映重症医学科患者来源及总住院医师的工作情况.方法回顾性分析笔者2018年11月16日至2019年12月25日担任贵州医科大学附属医院综合重症监护病房(ICU)总住院医师期间所会诊1457例次患者的相关资料,统计会诊患者所在科室构成、病种构成、临床结局及会诊类型,并计算医疗纠纷发生率,分享总住院医师会诊经验.结果共会诊患者1457例次,其中58.7%为急会诊(855例次),38.7%为普通会诊(564例次),2.6%为全院会诊(38例次).会诊涉及39个临床科室,占全院临床科室的76.47%(39/51),其中急诊科会诊最多(占15.2%),其次为肝胆外科和神经外科(分别占11.4%和8.9%).会诊患者的病种构成前3位分别为休克(55.04%)、肺部感染(51.41%)和心力衰竭(26.84%),而在休克患者中又以分布性休克为主(占73.57%).对363例尚未达到ICU收治标准的患者提供治疗方案并进行随诊,同时笔者参与就地抢救76次(5.2%);会诊期间医疗纠纷发生率为0%.结论ICU总住院医师会诊涉及大部分临床科室,会诊类型多为急会诊,会诊患者以休克和肺部感染患者为主.Objective To analyze the characteristics of the composition of patients in chief resident consultation to relct the sources of patients and the work situations of chief residents in intensive care unit(ICU).Methods Retrospectively,the clinical data of 1457 cases times consulted by the Chief Residents(the authors of this article)of the ICU from November 16,2018 to December 25,2019 in the Affiliated Hospital of Guizhou Medical University were reviewed,including the contents as compositions of departments and disease entities requiring consultation,clinical outcomes and consultation types as well as counting the occurrence rate of medical disputes in order to share the chief residents'experiences in medical consultation.Results Of the 1457 cases times,58.6%(855)were emergency,38.7%(564)general and 2.6%(38)multi-disciplinary consultations,involving 76.47%(39/51)clinical departments in the whole hospital,of which the most frequent number of calls for consultations was from emergency department accounting for 18.35%followed by 11.3%and 8.8%respectively from hepatobiliary and neurological surgical departments.The top 3 disease entities of consultation were shock(55.04%),lung infection(51.41%)and heart failure(26.84%),and among the patients with shock,the largest proportion was of distribution shock accounting for(73.57%).The 363 patients who did not meet the ICU admission criteria were provided with treatment plans and follow up,and the authors also participated in the on-site rescue for 76 times(5.2%);the rate of medical disputes during this period was 0%.Conclusions The chief resident consultations in ICU have to face the critically ill patients in a large part of various clinical departments in the whole hospital every day.The most common type of consultation is emergent one with complex conditions and the disease entities are primarily shock and pulmonary infection.

关 键 词：重症医学科 总住院医师 会诊 

分 类 号：R47[医药卫生—护理学]