Shapiro Susan E, Rosenfeld Anne G, Daya Mohamud, Larson Janet L, McCauley Linda A
Department of Nursing, University of California at San Francisco, 94143-0210, USA.
Prehosp Emerg Care. 2005 Jul-Sep;9(3):310-7. doi: 10.1080/10903120590962067.
This preliminary investigation represents the first step in developing a clinical decision rule (CDR) to assist out-of-hospital providers in caring for older patients in respiratory distress. The specific aims of the study were: 1) to identify up to ten candidate clinical indicators of severe respiratory distress in older out-of-hospital patients and 2) to determine the feasibility of obtaining data on these indicators from out-of-hospital treatment records, and of obtaining a measure of severe respiratory distress from the emergency department (ED) medical record.
This mixed-methods study included a qualitative component to list possible clinical indicators of severe respiratory distress, and a Delphi survey N = six experts) to reduce the comprehensive list that resulted (aim 1). The feasibility of gathering clinical indicators and a measure of severe distress was evaluated using a retrospective chart review (N = 640) of out-of-hospital and ED medical records (aim 2).
Nine clinical indicators were identified: level of consciousness/mentation, inability to speak in full sentences, position of the patient on arrival, decreased oxygen saturation, accessory muscle use, dyspnea, increased respiratory effort, altered respiratory rate, and retractions. There were sufficient data available on all indicators except dyspnea and retractions; a measure of severe distress was readily obtained from the ED medical record.
Medical record data were available on seven out-of-hospital clinical indicators and an ED measure of severe distress. Further work needs to be done to refine the operational definitions of the indicators and to standardize the way they are documented in the out-of-hospital medical record.
这项初步调查是制定临床决策规则（CDR）的第一步，该规则旨在协助院外急救人员护理呼吸窘迫的老年患者。本研究的具体目标是：1）识别出多达十个院外老年患者严重呼吸窘迫的候选临床指标；2）确定从院外治疗记录中获取这些指标数据以及从急诊科（ED）病历中获取严重呼吸窘迫衡量指标的可行性。
这项混合方法研究包括一个定性部分，用于列出严重呼吸窘迫可能的临床指标，以及一项德尔菲调查（N = 6名专家），以减少由此产生的综合列表（目标1）。通过对院外和ED病历进行回顾性图表审查（N = 640），评估收集临床指标和严重窘迫衡量指标的可行性（目标2）。
确定了九个临床指标：意识/精神状态水平、无法完整说出句子、患者到达时的体位、血氧饱和度降低、辅助肌使用情况、呼吸困难、呼吸用力增加、呼吸频率改变和凹陷。除呼吸困难和凹陷外，所有指标都有足够的数据；从ED病历中很容易获得严重窘迫的衡量指标。
院外病历数据提供了七个临床指标以及ED严重窘迫衡量指标。需要进一步开展工作，以完善指标的操作定义，并规范它们在院外病历中的记录方式。
