Koning Salomon Willem, Haverkort Mark J J, Leenen Luke P H
Department of Emergency Medicine, Major Incident Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.
Department of Surgery, Major Incident Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.
Am J Disaster Med. 2019;14(1):9-15. doi: 10.5055/ajdm.2019.0311.
Improve documentation during a mass casualty incident (MCI).
This is a retrospective chart review.
This chart review was done in the Major Incident Hospital (MIH). The MIH is a highly prepared back-up hospital in the center of the Netherland that can be deployed in case of a major incident.
PATIENTS, PARTICIPANTS: Until recently, the MIH used an extensive paper medical record: the hospital in special circumstances medical record (HSCMR). A concise primary survey form was developed and attached to the HSCMR, forming the pilot disaster medical record (pDMR). In this retrospective chart review, primary survey data documented in the HSCMR (during a MCI) were compared to the pDMR (during a drill exercise). Three triage categories were used: T1, immediate; T2, urgent; and T3, delayed.
The MIH hypothesized that a dedicated, concise, and practical primary survey form could improve quantitative patient documentation during an MCI. Significant differences were tested with the chi square and Fisher exact test (p < 0.05).
The pDMR was used significantly more often 61 percent vs 89 percent (p = 0.001), especially in T1 and T2 patients. Quantitative documentation in the pDMR improved significantly on airway, breathing, breathing frequency, saturation, circulation, heart rate, blood pressure, Glasgow Coma Score, exposure, and medication given but not in cervical spine and temperature.
Significantly more primary survey forms were used and more data were documented using the pDMR, especially in the most critical patients. An MCI medical record should be simple and concise and should not deviate from daily routine.
改善大规模伤亡事件（MCI）期间的文档记录。
这是一项回顾性图表审查。
该图表审查在重大事件医院（MIH）进行。MIH是荷兰中部一家高度戒备的后备医院，可在重大事件发生时进行部署。
患者、参与者：直到最近，MIH使用的是一份详尽的纸质病历：特殊情况医院病历（HSCMR）。现已制定了一份简明的初步检查表，并附在HSCMR上，形成了试点灾难病历（pDMR）。在这项回顾性图表审查中，将HSCMR中记录的（在MCI期间）初步检查数据与pDMR（在演练期间）进行了比较。使用了三种分诊类别：T1，即刻；T2，紧急；T3，延迟。
MIH假设，一份专门、简明且实用的初步检查表可改善MCI期间患者的定量文档记录。采用卡方检验和Fisher精确检验来检验显著差异（p<0.05）。
pDMR的使用频率显著更高，分别为61%和89%（p=0.001），尤其是在T1和T2类患者中。pDMR在气道、呼吸、呼吸频率、血氧饱和度、循环、心率、血压、格拉斯哥昏迷评分、暴露情况和用药方面的定量记录有显著改善，但在颈椎和体温方面没有改善。
使用pDMR时，初步检查表的使用显著增多，记录的数据也更多，尤其是在最危急的患者中。MCI病历应简单明了，不应偏离日常常规。
