本帖最後由 goodcat1111 於 2009-5-16 10:29 編輯
作者：Neil Osterweil
出處：WebMD醫學新聞
May 6, 2009 — 儘管威脅已經不同，但建議仍然不變：確保急診室員工有正確的個人保護用具(personal protection equipment，PPE)，保證每個人知道自己的角色與定位，有兒童照護和餵食以及重要醫療人員家訪的應變計畫。
急診室員工指引之發展在於反應禽流感大流行的威脅，根據嚴重急性呼吸道症候群(SARS)的實務經驗而來，緊急登載在BMJ出版的線上版急診醫學期刊中。
Jeffrey W. Runge醫師表示，該建議偏向英國風格，美國急診醫學會在健康與人類服務部以及疾病控制預防中心的協助之下，目前正努力編纂類似的、更實用的建議，已經準備進行公佈。Runge醫師是美國急診醫學會的顧問，也是國家安全部健康事務的前任助理秘書暨醫療辦公室主任。
Runge醫師在Medscape Infectious Diseases的訪問中表示，目前，H5N1的議題和H1N1是一樣的，全都有傳染性和病毒性，目前看起來不像1918年流感大流行那麼嚴重，但是，醫院裡仍需要有提升準備的能力，而這不只有急診室需要而已。
EMJ 的文章描述了處理迅速形成之大流行的因應挑戰，也探究家庭顧慮、居家、餵食、員工士氣等議題，這些會影響急診員工的效率與耐受度。
英國劍橋Addenbrookes醫院急診的Susan Robinson醫師等人訪視香港的醫院，以研究他們的另一半如何因應2003年的SARS爆發，以及有關篩檢、隔離、員工訓練與配置、倫理議題、個別員工警訊等實務建議。
作者寫道，學到的最重要的一課是，在我們的職業生涯中，熬過這種大流行是最感性與挑戰性的經驗；急診部門緩和這個挑戰的最佳方法，是確保讓員工準備好他們的最佳能力。
【有關急診室的建議步驟】
作者建議急診室主任應採取準備步驟，總結如下：
1. 確保急診室有一定水準
急診室員工有能力聯繫與處置PPE、財務計畫、員工訓練等問題。
2. 與員工討論流感大流行
部門主管應與員工討論有關全國性及地區性的流感大流行計畫，討論如何處理此類問題，包括部門程序與常規事務的改變。
3. 建立檢測口罩、頭套等的步驟，適用所有員工；訓練員工適當使用他們的PPE；考量儲備足夠的保護設備，以因應擴大的需求。
口罩不是單一尺寸，所以部門需要儲備不同類型的口罩，以適合所有員工；此外，也應考量個人在緊急時的購買需求，口罩與其他保護設備可能會供應短缺，但仍應考量這類產品的保存期限，建立循環供應計畫，以便有即時的運用方法，且隨時可因應緊急之用。
4. 建立在急診室內被病患感染時的因應規範
作者寫道，假設每個發燒的病患都有傳染性，除非確定排除。否則需思考您的部門如何在這些發燒病患進到急診時的篩檢，且後續如何和其他非發燒病患隔離。
香港的急診部門建立了隔離與迅速評估病患的準則：發燒且四項準則之中有任何一項回答為「是」者，將啟動隔離與評估。(此準則適用於禽流感，但可調整為H1N1新型流感之用。)：
* 曾前往高風險區域旅行
* 有職業上的曝露病史
* 與其他發生患者有接觸史，特別是不明原因發燒者。
* 同一村莊、學校、工作場所、住地有多名病患群聚感染。
5. 醫院內與急診部門內員工的角色在大流行時可能改變
例如，其他單位的員工可能會被指派前往急診，原本處理擦傷撞傷或其他輕微問題者，可能會被要求協助處理更嚴重的案例。
6. 建立員工在大流行時的溝通系統
Robinson醫師等人寫道，討論員工希望接獲的資訊。或許是流感病患住院人數、發病同僚的處理或現有的PPE供應。指定資深醫師或管理者每天提供這些資訊。
7.思考改善員工士氣的方法
作者建議可以提供健康的食物、咖啡、點心等免費取用；協助洗衣；安排與家人和朋友的免費電話等。
8. 思考與討論員工可能需要面對的倫理決策
作者表示，大流行爆發時，不可能所有病患都可以住院。可能需要決定一些困難的決策。準備好建議單以發送給家中的病患和照護者。這應該包括避免交叉感染、需要後續醫療之症狀(此建議需依照流行爆發的程度)等建議，以及疾病可能病程的詳情。
【美國的反應】
Runge醫師表示，有分類上的議題，有員工出勤、個人保護設備的議題，有無足夠的負壓隔離病房和隔離機構的問題。即使是候診室都可能會發生問題，全都得在可以處理的程度下加以表達，且每個人都可以執行。
他指出，即將發生的大流行中我們會有三類病患。一類是鼻塞病患，因為擔憂H1N1新型流感而前來就醫，一類是有實際流感症狀，如發燒、肌痛、呼吸道症狀者，不論是否為流感，都可以返家照護，另一類是需要住院的嚴重案例，而這些人都同樣是前來急診就醫。
作者宣告沒有相關資金上的往來。
Emerg Med J. 線上發表於2009年4月22日。
Emergency Staff Need Protection, Training for Infectious Pandemic
By Neil Osterweil
Medscape Medical News
May 6, 2009 — The threat has changed, but the advice remains the same: make sure that emergency department (ED) staff have the right personal protection equipment (PPE), see to it that everyone knows their roles and where they are needed, and plan for contingencies such as childcare and feeding and housing of vital medical personnel.
Guidelines for ED staff developed in response to the threat of an avian influenza pandemic and based on real-world experience with the severe acute respiratory syndrome (SARS) were rushed to print in the online edition of the Emergency Medicine Journal, a BMJ publication.
The recommendations have a British flavor, but similar, more practical recommendations are currently in the works from the American College of Emergency Physicians, with the help of the Department of Health and Human Services and the Centers for Disease Control and Prevention, and should be ready for promulgation, says Jeffrey W. Runge, MD. Dr. Runge is a consultant to the American College of Emergency Physicians and is the former assistant secretary for health affairs and chief medical officer of the Department of Homeland Security.
"Certainly, the issues for H5N1 are the same for H1N1," Dr. Runge said in an interview with Medscape Infectious Diseases. "This all comes down to transmissibility and virulence. This looks like it will be a less virulent flu than the 1918 flu epidemic, but still, there needs to be some preparation for surge capacity in the hospital, and not just in the emergency room."
The EMJ article describes the logistical challenges of coping with a rapidly evolving pandemic and also delves into issues such as family concerns, housing, feeding, and staff morale that could detract from the efficient running of EDs that are likely to bear the brunt.
Susan Robinson, MD, from the ED at Addenbrookes Hospital, in Cambridge, United Kingdom, and colleagues visited hospitals in Hong Kong to study how their counterparts there coped with the SARS outbreak in 2003 and came away with both practical advice about screening, isolation procedures, staff training and allocation, and ethical issues, and cautions about the effects on individual staff members.
"[T] he most important lesson learnt was that living through an epidemic or pandemic would be one of the most emotive and challenging experiences of our professional lives," the authors write. "The best method of mitigating against this is for emergency departments to ensure they have prepared their staff for such an eventuality to the best of their ability."
Recommended Steps for EDs
The authors recommend steps that ED directors should take to prepare the ED. The steps are summarized as follows:
1. Make sure that the department is represented at the institutional level
An ED staff liaison can lobby management/ownership for issues such as stocking up on PPE, financial planning, and staff training.
2. Discuss pandemic flu with staff
Department management should discuss national and regional planning for flu pandemics and discuss how coping with such an episode may involve changes in departmental procedures and routines.
3. Establish a process for testing that masks, gowns, etc, properly fit all staff; train staff in the proper use in the use of PPE; and consider stocking enough protective equipment to cope with an extended emergency
Masks are not one-size-fits-all, so the department may need to stock several different mask types to accommodate all of the staff. Personnel in charge of purchasing supplies should also consider that during an emergency, masks and other protective equipment are likely to be in short supply, but must also take into account the shelf life of such products and establish a plan for rotating supplies so that they are used in a timely fashion but are always on hand for emergencies.
4. Establish protocols for managing potentially infected patients within the ED
"Assume every febrile patient could be infectious until you know otherwise. Consider how your department will screen for these febrile patients at the point of entry to the ED and subsequently isolate them from other non-febrile patients," the authors write.
The EDs in Hong Kong established criteria for isolation and rapid assessment of patients. Fever and the answer of "yes" to any 1 of 4 criteria will trigger isolation and assessment. (The criteria apply to avian flu, but could easily apply to swine flu.):
‧ Travel to high-risk areas
‧ Occupational history of exposure
‧ Contact history of exposure to other persons with febrile illness, particularly those with known disease
‧ Clustering or the presence of multiple patients from the same village, school, workplace, or residence
5. Consider that staff roles in the hospital and within the ED may change during a pandemic
Staff from other areas may need to be reassigned to the ED, for example, or staff such as those who routinely handle bumps, bruises, and other minor problems might be called on to aid in more severe cases.
6. Establish systems for communicating with staff during a pandemic
"Discuss what information staff would wish to receive," Dr. Robinson and colleagues write. "This may be the numbers of patients admitted with flu, the progress of sick colleagues or available supplies of PPE. Assign this role to a senior clinician or manager who is able to produce this information on a daily basis."
7.Consider methods for improving staff morale
The authors recommend steps such as making healthy food, coffee, and snack freely available; laundry facilities; arranging for free calls to family and friends; etc.
8. Consider and discuss the ethical decisions that staff may be required to make
"It will not be possible to admit all patients with flu during a pandemic outbreak. Difficult decisions will need to be made," the authors caution. "Advice sheets may be prepared in advance to be distributed to patients and to caregivers at home. This should include advice on avoidance of cross-infection, symptoms which should lead to a further consultation with medical services (this advice may vary depending on the level of pandemic outbreak) and details of the likely course of the illness."
The US Response
"There are issues of triage, there are issues of staff attendance, personal protective equipment, and physical facilities like sufficient negative-pressure rooms and isolation facilities," Dr. Runge says. "Even the waiting room can be a potentially problematic thing, and all of these things need to be addressed at an operational level, and nobody's done that yet."
"What's going to happen here [in the event of a pandemic] is that we'll have 3 classes of patients," he adds. "One will be patients who have sniffles and come in because they're worried about the swine flu, you'll have another group that has bona fide flu symptoms with fevers, myalgia, and respiratory symptoms who either have or don't have the flu and can go home and take care of it there, or there will be some people who have a severe case and need hospitalization, and all those people are going to show up through that common pathway, the emergency department."
The authors have disclosed no relevant financial relationships.
Emerg Med J. Published online April 22, 2009. |
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