Sutton David, Stanley Paul, Babl Franz E, Phillips Fiona
Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.
Arch Dis Child. 2008 Jan;93(1):17-22. doi: 10.1136/adc.2007.117960.
A subgroup of children with special health care needs (CSHCN) have chronic and complex medical conditions and frequently attend the emergency department (ED). Some of these ED visits could be prevented through appropriate clinician advice or, if an ED visit is unavoidable, the management time could be decreased. We set out to determine whether an ED-based advice and coordination programme was feasible and could prevent or accelerate ED care for these patients. METHODS, SETTING AND PATIENTS: We identified CSHCN who frequently attended the ED at a large tertiary children's hospital. These patients were enrolled in an ED-based coordination programme, the Accelerated Care through Emergency (ACE) programme providing 24-hour mobile-phone access to experienced ED nurses. We prospectively tracked usage patterns and determined the rate of ED visits after receiving phone advice and the waiting time for patients to be seen in ED. Parental satisfaction and cost of the programme were also assessed.
After a pilot phase in 2002, enrollment in the programme increased from 125 in 2003 to 220 patients in 2006. Patients had a broad range of medical conditions. All had two or more and up to 22 medical services involved in their care. 80% of patients used a technical device or implant. Phone calls increased from an initial average of 31 per month in 2003 (0.24 calls per participant) to 66 per month in 2006 (0.3 calls per participant), 60% of which were after hours. The percentage of ED reviews per phone call dropped from an initial 74.2% (95% CI 55.2%-88.1%) in 2003 to 50.0% (95% CI 37.4%-62.5%) in 2006 (p = 0.02). However, decreases in ED visits and admissions as a percentage of enrolled patients and as a percentage of phone calls to ACE staff were not statistically significant. Mean waiting time for enrolled patients remained below 30 minutes. Parent satisfaction with the programme was rated 8.3 on a 0-10 scale (0 meaning poor, 10 meaning excellent). The approximate cost of the programme per child was AU$750 (292 pounds sterling) per year.
We have developed a coordinated approach towards the provision of healthcare for a group of families with diverse severe chronic medical conditions who frequently present to the ED. Through a comprehensive programme including the development of patient-care plans, care coordination and 24-hour mobile-phone access we were able to enhance families' capacities to manage their children's conditions in the community.
有特殊医疗需求的儿童（CSHCN）中的一个亚组患有慢性和复杂的疾病，并且经常前往急诊科（ED）就诊。其中一些急诊就诊是可以通过适当的临床医生建议避免的，或者，如果急诊就诊不可避免，也可以缩短诊疗时间。我们旨在确定一项基于急诊科的建议和协调计划是否可行，以及是否可以预防或加快对这些患者的急诊护理。
方法、地点和患者：我们确定了一所大型三级儿童医院中经常前往急诊科就诊的有特殊医疗需求的儿童。这些患者参加了一项基于急诊科的协调计划，即“通过急诊加速护理（ACE）计划”，该计划提供24小时手机接入服务，让经验丰富的急诊科护士提供帮助。我们前瞻性地跟踪了使用模式，并确定了在接受电话建议后急诊就诊的比率以及患者在急诊科就诊的等待时间。还评估了家长的满意度和该计划的成本。
在2002年的试点阶段之后，该计划的注册人数从2003年的125人增加到2006年的220人。患者患有广泛的疾病。所有患者的护理都涉及两种或更多、多达22种医疗服务。80%的患者使用技术设备或植入物。电话呼叫次数从2003年最初平均每月31次（每位参与者0.24次）增加到2006年的每月66次（每位参与者0.3次），其中60%是在工作时间之外。每次电话呼叫后进行急诊复查的百分比从2003年最初的74.2%（95%可信区间55.2%-88.1%）降至2006年的50.0%（95%可信区间37.4%-62.5%）（p = 0.02）。然而，作为注册患者百分比和拨打ACE工作人员电话百分比的急诊就诊和住院次数的减少没有统计学意义。注册患者的平均等待时间仍低于30分钟。家长对该计划的满意度在0至10分的评分中为8.3分（0表示差，10表示优）。该计划每个孩子每年的大致成本为750澳元（292英镑）。
我们针对一组经常前往急诊科的患有各种严重慢性疾病的家庭，制定了一种协调的医疗保健提供方法。通过一个包括制定患者护理计划、护理协调和24小时手机接入的综合计划，我们能够提高家庭在社区中管理孩子病情的能力。
