CN112233748B - Sepsis case screening system and method based on electronic medical record data - Google Patents
Sepsis case screening system and method based on electronic medical record data Download PDFInfo
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Abstract
The invention discloses a sepsis case screening system based on electronic medical record data and a screening method thereof, which belong to the field of medical information. The method is clear, various indexes are well defined, screening data are comprehensive, the design is simple, and the method can be popularized and used in the process of establishing a sepsis database by extracting data from electronic medical record data.
Description
Technical Field
The invention belongs to the field of medical information, and particularly relates to a sepsis case screening system and a sepsis case screening method based on electronic medical record data.
Background
The number of cases of sepsis worldwide is nearly 5000 tens of thousands per year, and sepsis is the leading cause of death in critically ill patients. Therefore, attention and research on sepsis is of vital importance. The construction of clinical databases is important for the occurrence, development, prevention, treatment and the like of diseases, but the present aspects of China are relatively deficient, especially the construction of severe disease databases represented by sepsis. At present, epidemiological investigation and clinical trials of sepsis in China cannot automatically capture data from an electronic medical record system and establish a database. Therefore, for conforming to the policy of national medical guidelines of 'health China' and 'Internet+', the automatic capturing and extracting of data are realized by utilizing the Internet technology based on the electronic medical record data, and a comprehensive sepsis database which comes from the real world and is based on the medical record data of Chinese crowd is established, so that the method has important significance for diagnosing, treating and preventing the sepsis of residents in China.
Sepsis definition, release 2016, third, suggests sepsis as a fatal organ dysfunction caused by an infection-induced deregulated host response. Thus, sepsis is a syndrome caused by infection in a strict sense, and although it has a higher degree of cognition in an Intensive Care Unit (ICU), the rate of missed diagnosis in an ordinary ward is higher, and patients of the ICU often go to an excessive ward for discharge after improvement, and thus, overall, the omission of sepsis in discharge diagnosis is very high. On the other hand, as concepts are updated, their diagnostic criteria change. So in terms of building a sepsis database, sepsis patients cannot be included by simply screening for patient discharge diagnosis.
In view of the foregoing, there is a need to provide a method for automatically capturing data from electronic medical records, screening sepsis cases, for building a sepsis database from the real world.
Disclosure of Invention
In order to solve the technical problems, the invention aims to provide a sepsis case screening system and a sepsis case screening method based on electronic medical record data.
A sepsis case screening system based on electronic medical record data comprising:
the infection case screening module is used for acquiring identity data and infection related data from electronic medical record data of a patient, and checking and repeating to determine whether the infection case is an infection case;
the automatic evaluation module of organ function is used for selecting organ function as evaluation index according to sepsis definition, and calculating the score sum of each organ function as the score of infection related sequence inertia organ function;
and the sepsis case automatic screening module is used for comparing the infection related order inertial organ function score with the pre-infection order inertial organ function score, and outputting the sepsis case when the difference value is more than or equal to 2.
Preferably, the organ functions include respiratory system, circulatory system, coagulation function, liver function, kidney function and nerve function.
Preferably, the organ function score ranges from 0 to 4 points, where function is normally 0 points, function is worst 4 points, and the score is full 15 points when neurological function is not recorded.
Preferably, the scores for all organ functions are selected to be the worst value over a prescribed period of time.
Preferably, the scores of the organ functions are the worst values of all indexes within 2 days before and after blood culture and examination.
In addition, the invention provides a sepsis case screening method based on electronic medical record data, which is realized by using the sepsis case screening system based on the electronic medical record data, and comprises the following steps:
step one, an infection case screening module screens cases from electronic medical record data of a patient, acquires identity data and infection related data of the patient, checks and overlaps the identity data and the infection related data, outputs overlapped cases as the infection patient, compares the infection related data for the cases without the overlapping, and judges whether the infection is an infection case or not;
step two, an organ function automatic evaluation module selects organ functions as evaluation indexes according to sepsis definitions, and automatically calculates the score sum of the organ functions as the score of the infection related sequence inertia organ functions;
and thirdly, for the patient determined to be the infection case, automatically comparing the function scores of the infection-related sequence inertial organs with the function scores of the pre-infection sequence inertial organs by the sepsis case automatic screening module, outputting a sepsis case when the difference value is more than or equal to 2, otherwise, outputting a non-sepsis case.
Preferably, the method for screening infection cases in the first step comprises two ways, one way is to culture the blood for examination and apply antibiotics intravenously within 2 days before and after the blood for examination, and the method is to screen the detection result of the blood for examination by applying antibiotics intravenously for not less than 3 days under the condition that the patient does not die or discharge in 3 days; and the other is to select all infection related diagnoses from international disease injury and death cause classification standards, and screen all infection diagnoses according to discharge diagnoses of patients in an electronic medical record system.
Preferably, the evaluation index of organ function in the second step includes: the oxygenation index of the respiratory system, the mean arterial pressure and vasoactive drugs of the circulatory system, the platelets of the clotting function, the total bilirubin of the liver function, the creatinine of the kidney function, the glasgow coma score of the neurological function.
Preferably, the scores of all organ functions in the second step are the worst value of each index within 2 days before and after blood culture and examination.
Preferably, the organ failure occurs in the prior history of the infection case, and the organ function is not evaluated in consideration of the organ function score.
Compared with the prior art, the invention has the characteristics and beneficial effects that: the invention utilizes the infection case screening module to screen the electronic medical record data of the patient, determines whether the patient is an infection case, evaluates the functions of each organ through the organ function automatic evaluation module, and finally determines the sepsis patient through the sepsis case automatic screening module so as to ensure that the missed diagnosis rate of the patient is reduced to the greatest extent, and is used for establishing a sepsis database from the real world. The method is clear, various indexes are well defined, screening data are comprehensive, the design is simple, and the method can be popularized and used in the process of establishing a sepsis database by extracting data from electronic medical record data.
Drawings
FIG. 1 is a schematic diagram of an infection case screening procedure.
FIG. 2 is a schematic diagram of a sequential inertial organ function scoring production flow.
Fig. 3 is a schematic diagram of a sepsis case screening procedure.
Detailed Description
The technical solution of the present invention will be described in further detail with reference to the accompanying drawings, but the scope of the present invention is not limited to the following description. All of the features disclosed in this specification, or all of the steps in a method or process disclosed implicitly, may be combined in any combination, except for the mutually exclusive features and/or steps.
Any feature disclosed in this specification (including any accompanying claims, abstract and drawings), may be replaced by alternative features serving the same, equivalent or similar purpose, unless expressly stated otherwise. That is, each feature is one example only of a generic series of equivalent or similar features, unless expressly stated otherwise.
Specific embodiments of the invention will be described in detail below, it being noted that the embodiments described herein are for illustration only and are not intended to limit the invention. In the following description, numerous specific details are set forth in order to provide a thorough understanding of the present invention. However, it will be apparent to one of ordinary skill in the art that: no such specific details are necessary to practice the invention. In other instances, well-known circuits, software, or methods have not been described in detail in order not to obscure the invention.
The following description of the embodiments of the present invention will be made clearly and completely with reference to the accompanying drawings, in which it is apparent that the embodiments described are only some embodiments of the present invention, but not all embodiments. All other embodiments, which can be made by those skilled in the art based on the embodiments of the invention without making any inventive effort, are intended to be within the scope of the invention.
Before describing the embodiments, some necessary terms need to be explained. For example:
if the terms "first," "second," etc. are used herein to describe various elements, these elements should not be limited by these terms. These terms are only used to distinguish one element from another element. Accordingly, a "first" element discussed below could also be termed a "second" element without departing from the teachings of the present invention. It will be understood that when an element is referred to as being "connected" or "coupled" to another element, it can be directly connected or coupled to the other element or intervening elements may also be present. In contrast, when an element is referred to as being "directly connected" or "directly coupled" to another element, there are no intervening elements present.
The various terms presented in this application are used solely for the purpose of describing particular embodiments and are not intended to be limiting of the invention, as singular forms are intended to include plural forms as well, unless the context clearly indicates otherwise.
When the terms "comprises" and/or "comprising" are used in this specification, they specify the presence of stated features, integers, steps, operations, elements, and/or components, but do not preclude the presence and/or addition of one or more other features, integers, steps, operations, elements, components, and/or groups thereof.
The sepsis case screening system based on the electronic medical record data comprises an infection case screening module, an automatic organ function evaluation module and an automatic sepsis case screening module.
The infection case screening module is used for acquiring identity data and infection related data from the electronic medical record data of the patient, and checking and repeating the identity data and the infection related data to determine whether the infection case is the infection case.
The organ function automatic evaluation module is used for selecting organ functions according to sepsis definitions as evaluation indexes and calculating the score sum of the organ functions as infection related sequence inertia organ function scores (infection related SOFA scores). According to the third edition of sepsis definition, the method for assessing patient organ function is the sequential inertial organ function Score (SOFA). The score included 6 aspects of organ function, including respiratory system, circulatory system, clotting function, liver function, renal function, and neural function. Each system has a score range of 0-4 points, a normal function of 0 points and a worst function of 4 points according to the function condition. The sum of the scores of the 6 systems is the SOFA score. In consideration of the convenience of actual operation, the index selected by the respiratory system is an oxygenation index (oxygen partial pressure/inhaled oxygen concentration), the index selected by the circulatory system is Mean Arterial Pressure (MAP) and vasoactive drugs (dopamine, dobutamine, epinephrine and norepinephrine), the index selected by the blood coagulation function is platelets, the index selected by the liver function is total bilirubin, the index selected by the kidney function is creatinine, and the index selected by the nerve function is Glasgow Coma Score (GCS). Considering that GCS scores in electronic medical record data are generally recorded only when the mind is abnormal (the loss rate is high), the GCS scores are defaulted to be 15 points full when no numerical value exists. The scores for all organ functions are selected to be the worst value over a prescribed period of time. Preferably, the scores of the organ functions are the worst values of all indexes within 2 days before and after blood culture and examination.
The sepsis case automatic screening module is used for comparing the infection related order inertia organ function score with the order inertia organ function score before infection, and outputting the sepsis case when the difference value is more than or equal to 2. The SOFA score of the worst value of each index in 2 days before and after blood culture and examination of the selected infection cases is defined as the infection-related SOFA. If the blood is cultured for multiple times, the first time is the subject. Considering that many sepsis patients are admitted to the emergency department, the baseline data is missing from the electronic medical record data, and thus is reduced to chronic failure of any one of the 6 systems in the SOFA score described above in the prior medical history, the system will not take into account the score of the infected SOFA score, such as chronic respiratory failure, thrombocytopenia, liver failure, chronic renal failure, coma. This SOFA score corrected by baseline case data is defined as corrected infection-related SOFA score. The screened infection cases are screened as sepsis cases if the corrected infection-related SOFA score is greater than or equal to 2 points.
A sepsis case screening method based on electronic medical record data is realized by using the sepsis case screening system based on the electronic medical record data, and comprises the following steps:
step one, as shown in fig. 1, an infection case screening module screens cases from electronic medical record data of a patient, acquires identity data and infection related data of the patient, performs check and repeat, outputs overlapped cases as the infection patient, compares the infection related data for the cases without overlap, and determines whether the infection case is the infection case. The screening of infection cases includes two ways, one is to culture the blood for examination and apply the antibiotic intravenously for not less than 3 days without death or discharge of the patient within 3 days, and to apply the antibiotic intravenously within 2 days before and after the blood for examination, and to screen the examination result of the blood for examination. If the patient dies within 3 days or gives up treatment no more than 3 days. And the other is to select all infection related diagnoses from international disease injury and death cause classification standards, and screen all infection diagnoses according to discharge diagnoses of patients in an electronic medical record system. Specifically, all infection-related diagnoses were selected from the tenth edition of the international disease injury and death cause classification standard (ICD 10).
Step two, as shown in fig. 2, the automatic organ function evaluation module selects organ functions as evaluation indexes according to sepsis definitions, and automatically calculates the score sum of the organ functions as the infection related sequence inertial organ function score. The evaluation indexes of organ functions include: the oxygenation index of the respiratory system, the mean arterial pressure and vasoactive drugs of the circulatory system, the platelets of the clotting function, the total bilirubin of the liver function, the creatinine of the kidney function, the glasgow coma score of the neurological function. The scores of all organ functions were selected from the worst value of each index within 2 days before and after blood culture and examination.
Specifically, when the oxygenation index is greater than 400mmHg, the score of the respiratory system is 0 score; when the oxygenation index is 300-400 mmHg, the score of the respiratory system is 1 minute; when the oxygenation index is 200-300 mmHg, the score of the respiratory system is 2 minutes; when the oxygenation index is 100-200 mmHg, the score of the respiratory system is 3 minutes; when the oxygenation index is 100 mmHg or less, the score of the respiratory system is 4 points.
Platelets greater than 150 x 10 9 at/L, the blood coagulation function score is 0; platelets 100X 10 9 /L ～150×10 9 at/L, the blood clotting function was scored as 1 point; platelets 50X 10 9 /L ～100×10 9 at/L, the blood clotting function was scored as 2 points; platelets 20×10 9 /L ～50×10 9 at/L, the blood clotting function was scored 3 points; platelets less than or equal to 20 x 10 9 at/L, the blood clotting function was scored as 4 points.
When bilirubin is less than 20.5 mu mol/L, the score of liver function is 0 score; when bilirubin is 20.5-34.1. Mu. Mol/L, the liver function score is 1 score; when bilirubin is 34.1 mu mol/L-102.5 mu mol/L, the score of liver function is 2 points; when bilirubin is 102.5-205.1. Mu. Mol/L, the liver function score is 3 points; when bilirubin is greater than 205.1. Mu. Mol/L, the liver function score is 4 points.
When the average arterial pressure is more than or equal to 70mmHg, the score of the circulatory system is 0 score; the mean arterial pressure was less than 70mmHg and the circulatory system score was 1 score without the use of a booster; the dosage of dopamine is less than or equal to 5 mug/kg.min, and the score of the circulatory system is 2 minutes at any dosage of dobutamine; when the dosage of epinephrine or norepinephrine is less than or equal to 0.1 mug/kg.min, the score of the circulatory system is 3 minutes; when the amount of epinephrine or norepinephrine is greater than 0.1 μg/kg.min, the circulatory system scores 4 points.
When creatinine is less than 106. Mu. Mol/L, the score of renal function is 0 points; when creatinine is 106-176 mu mol/L, the score of the kidney function is 1 score; when creatinine is 176-308 mu mol/L, the score of the kidney function is 2 points; when creatinine is 308-442 mu mol/L, the score of the kidney function is 3 points; when creatinine was greater than 442. Mu. Mol/L, the score for renal function was 4 points.
Step three, as shown in fig. 3, for the patient determined as the infection case, the sepsis case automatic screening module automatically compares the infection related order inertial organ function score with the order inertial organ function score before infection, and if the difference is greater than or equal to 2, the sepsis case is output, otherwise, the sepsis case is not sepsis case. The SOFA score of the worst value of each index in 2 days before and after blood culture and examination of the selected infection cases is defined as the infection-related SOFA. If the blood is cultured for multiple times, the first time is the subject. Considering that many sepsis patients are admitted to the emergency department, the baseline data is missing from the electronic medical record data, and thus is reduced to chronic failure of any one of the 6 systems in the SOFA score described above in the prior medical history, the system will not take into account the score of the infected SOFA score, such as chronic respiratory failure, thrombocytopenia, liver failure, chronic renal failure, coma. This SOFA score corrected by baseline case data is defined as corrected infection-related SOFA score. The screened infection cases are screened as sepsis cases if the corrected infection-related SOFA score is greater than or equal to 2 points.
The above examples are only illustrative of the preferred embodiments of the present invention and are not intended to limit the scope of the present invention, and various modifications and improvements made by those skilled in the art to the technical solution of the present invention should fall within the scope of protection defined by the claims of the present invention without departing from the spirit of the design of the present invention.
Claims (8)
1. The sepsis case screening method based on the electronic medical record data is characterized by comprising the following steps of:
step one, an infection case screening module screens cases from electronic medical record data of a patient, acquires identity data and infection related data of the patient, checks and overlaps the identity data and the infection related data, outputs overlapped cases as the infection patient, compares the infection related data for the cases without the overlapping, and judges whether the infection is an infection case or not; the method for screening infection cases comprises two ways, namely, culturing the blood for examination, applying antibiotics intravenously within 2 days before and after the blood for examination, and screening the detection result of the blood for examination by applying antibiotics intravenously for not less than 3 days under the condition that the patient does not die or discharge in 3 days; the other is to select all infection related diagnoses from international disease injury and death cause classification standards, and screen all infection diagnoses according to the discharge diagnoses of patients in the electronic medical record system;
step two, an organ function automatic evaluation module selects organ functions as evaluation indexes according to sepsis definitions, and automatically calculates the score sum of the organ functions as the score of the infection related sequence inertia organ functions;
and thirdly, for the patient determined to be the infection case, automatically comparing the function scores of the infection-related sequence inertial organs with the function scores of the pre-infection sequence inertial organs by the sepsis case automatic screening module, outputting a sepsis case when the difference value is more than or equal to 2, otherwise, outputting a non-sepsis case.
2. The method for screening sepsis cases based on electronic medical record data according to claim 1, wherein the evaluation index of organ function in the second step includes: the oxygenation index of the respiratory system, the mean arterial pressure and vasoactive drugs of the circulatory system, the platelets of the clotting function, the total bilirubin of the liver function, the creatinine of the kidney function, the glasgow coma score of the neurological function.
3. The method for screening sepsis cases based on electronic medical records according to claim 1, wherein the scores of all organ functions in the second step are the worst values of the indexes within 2 days before and after the blood culture and examination.
4. The method for sepsis case screening based on electronic medical records according to claim 1, characterized in that: organ failure occurs in the past history of infection cases, and the organ function evaluation index does not count into the organ function score.
5. The method for sepsis case screening based on electronic medical records according to claim 1, characterized in that: the organ functions include respiratory system, circulatory system, coagulation function, liver function, kidney function, and nerve function.
6. The method for sepsis case screening based on electronic medical records according to claim 5, wherein: the organ function score ranges from 0 to 4 points, where function is normally 0 points, function is worst 4 points, and the score is full 15 points when nerve function is not recorded.
7. The method for sepsis case screening based on electronic medical records according to claim 1, characterized in that: the scores for all organ functions are selected to be the worst value over a prescribed period of time.
8. The method for sepsis case screening based on electronic medical records according to claim 7, characterized in that: the scores of the organ functions are all the worst values of all indexes within 2 days before and after blood culture and examination.
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