【在线速递】应对2019-2020新型冠状病毒感染疫情：重症医学科准备之中国四川经验

Up to 31 January 2020, there have been 9811 officially reported confirmed cases of 2019-novel coronavirus (nCoV) infection in China since the epidemic began in December 2019 (updated data available at https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6).

自2019年12月疫情开始以来，截至2020年1月31日，中国已有9811例官方报告的2019年新型冠状病毒（nCoV）感染确诊病例（更新数据可在https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6 获取）。

With the rapid transmission, the epidemic has spread throughout the country, and 177 cases have been reported in Sichuan Province. As nCoV infection is a highly contagious disease with high mortality (3–15%) [1–3] and West China Hospital (WCH) is the largest hospital in the southwest of China and the referral medical center in Sichuan Province, it is our responsibility to prepare for admission of additional critically ill patients as a matter of emergency. We have held several expert meetings and have reviewed the related literature to develop a plan to respond to the epidemic [4, 5]. The purpose of the plan is to enable us to provide the maximum level of care to critically ill patients while ensuring the protection of medical staff.

随着快速的传播，疫情蔓延至全国，四川省已报告177例。由于新型冠状病毒感染传染性强、死亡率高（3-15%），华西医院（WCH）作为中国西南地区最大的医院以及四川省的转诊医疗中心，我们有责任为紧急情况下收治更多重症患者做好准备。为了制定应对疫情的计划，我们召开了几次专家会议并再次学习了相关文献，以确保我们能够在为重症患者提供最大程度护理的同时确保对医护人员的保护。

We set up a special emergency multi-disciplinary intensive care team to discuss the problems that we might encounter and countermeasures. Team members include intensive care unit (ICU) physician, infectious disease physician, nurse, respiratory therapist, nosocomial infection control expert, and administrative staff. We first evaluated the isolation conditions and the capacity of our department to admit a larger number of patients. Second, we specified the protection levels for different types of health care activities. Third, we assigned special work such as patient screening, consultation, and transfer to designated staff to minimize the number of health workers who had contact with patients with nCoV infection.

我们成立了一个专门的紧急多学科重症小组来讨论我们可能遇到的问题及相应的对策。团队成员包括重症医学科（ICU）医生、传染科医生、护士、呼吸治疗师、医院感染控制专家及行政人员。首先，我们评估了我们部门的隔离条件和接纳更多患者的能力。其次，我们为不同类型的医疗卫生活动制定了不同的保护级别。第三，对于患者筛查、会诊和转运等特殊工作我们都分配给指定人员，以最大程度减少与新型冠状病毒感染患者接触的卫生工作者的数量。

WCH is a teaching hospital with 4300 total beds and 8 ICUs of total 206 ICU beds. Under normal conditions, the ICU bed usage is always above 90%. It was not appropriate to treat 2019-nCoV-infected patients in the central area because the large stream of people would have a negative impact on infection control measures to curb the spread of the infection. Te hospital authorities decided to vacate 402 beds belonging to the Center of Infectious Disease and the adjacent Fifth Inpatient Building so that both are separated from the rest of the inpatient buildings in WCH (Supplementary Figure 1). Based on the initial data [1, 2] and taking into consideration the surge of critically ill patients, we plan to equip 50 ICU beds initially and adjust on the number of patients, as necessary. We made a list of requirements for other special medical equipment, such as ventilators, bronchoscopes , hemodialysis machines, ultrasound machines, standard personal protective equipment (PPE), and sterilizing equipment. During this epidemic period, a large amount of certified PPE, including medical masks, goggles, face shields, and waterproof isolation gowns, is required. Manufactures of the items on the requirement list were contracted and we drew up an advertisement to the society calling for donations to ensure sufcient supplies.

WCH是一家教学医院，共有4300张病床，其中包括8个ICU单元共206张ICU病床。在正常情况下，这些ICU病床的使用率一直在90%以上。在医院中央地区治疗新型冠状病毒感染的患者是不合适的，因为巨大的人流量会给这些地区遏制感染蔓延的措施带来负面影响。医院决定腾出属于传染病中心的402张病床以及临近的第五住院大楼，以使这两个区域与WCH其余的住院大楼分开（补充图1）。基于初始数据并将重症患者的激增考虑在内，我们计划最初配备50张ICU病床，如果有需要再调整ICU病床数来适应患者的数量。我们列出了其他特殊医疗设备的需求清单，比如呼吸机、支气管镜、血液透析机、超声机、标准个人防护设备（PPE），以及消毒设备。在此次疾病流行期间，我们需要大量认证过的个人防护设备，包括医用口罩、护目镜、面罩和防水隔离服。我们已经和需求清单上物品的制造商签约，同时我们向社会发出了公告，呼吁捐赠来确保足够的物品供应。

It is very important to make all staff aware of the public health significance of the epidemic, and of potential challenges in achieving disease control. Strict isolation and protection measures are a top priority. Training content includes hand and respiratory hygiene, use of PPE, safe waste management, environmental cleaning, and sterilization of patient-care equipment [6]. We educate and train staff by means of presentations, short videos, WeChat, and supervision to ensure that staff are following the correct procedures.

确保所有工作人员了解此次疫情对公共卫生的重要性及控制疫情面对的潜在挑战是非常重要的。严格的隔离和防护措施是最优先的。培训内容包括手卫生、呼吸道卫生、PPE的使用、安全废物管理、环境清洁以及患者护理设备的灭菌。我们通过演示、短片、微信和监督的方式对员工进行教育和培训，以确保员工遵循正确的程序。

A special access to patients was set up and a boundary between the ward in which the nCoV patients are being treated and the office and living area of medical staff was established. The aim was to minimize the number of medical staff that have contact with a patient at any time, including during daily care, treatment, and transfer; minimize the use of high transmission-risk procedures such as bronchoscopy, manual ventilation, non-invasive ventilation, and tracheotomy. We use airborne precautions if these operations are necessary. Diagnostic imaging procedures such as X-ray and ultrasound at the bedside are prioritized, restricting computed tomography (CT) scans, because they cannot be performed at the bedside.

我们建立了专门的患者通道，并在治疗新型冠状病毒感染患者的病房与医务人员的办公、生活区域之间建立了分隔。这些措施的目的是尽量减少在任何时候（包括日常护理、治疗及患者转运期间）与患者接触的医务人员的数量；尽量减少使用具有传播风险的医疗操作，例如支气管镜检查、手动通气、无创通气和气管切开术。如果需要这些操作，我们将采取空气防护措施。优先考虑在床边进行X射线和超声等诊断影像检查，计算机断层扫描（CT）则因无法在床边进行而受到了限制。

A physiological parameter-based warning score is used to facilitate early recognition of patients with severe infection and admission decisions according to the severity classifcation. Te score is a modified version of the National Early Warning Score (NEWS) with age ≥65 years added as an independent risk factor based on recent reports [7, 8] (Fig. 1). 

基于生理参数的警告评分可用于帮助早期识别严重感染的患者，根据疾病严重程度的分类就可以决定是否将其收入院。该评分是国家早期预警评分（NEWS）的改良版本，根据最近的报道，年龄≥65岁被新增为独立的危险因素。

Patients are divided into four risk categories based on the score: low, median, high, and exceptional. A specially assigned physician or the special critical care team decides which patients need to be treated in the ICU, taking into consideration the disease severity, opportunity to benefit, and sources of support (Fig. 1).

根据得分将患者分为四个风险类别：低、中、高和特殊情况。特别指派的医生或重症小组根据疾病的严重程度、获益的机会及支持资源来决定哪些患者需要在ICU中接受治疗。

 All staff are required to report any history of exposure, respiratory symptoms, and temperature before entering the building in which the nCoV patients are treated. Everyone must wear masks, isolation suits, and wash hands if need to be in the building. Family members and nonessential medical staff are strictly forbidden from entering the nCoV ward.

在进入治疗新型冠状病毒感染患者的病房大楼前，所有工作人员都必须报告任何暴露史、呼吸道症状和体温。如果需要在该病房大楼中停留，每个人都必须佩戴口罩、隔离服并洗手。严格禁止家庭成员及不必要的医务人员进入新型冠状病毒病房。  

As nCoV infection is a novel disease, knowledge about it is limited [9, 10], especially regarding the management of critically ill patients. We designed a case report form to collect clinical data, proceed with the ethics committee approval of research protocols, and contact with the laboratory that is qualifed to conduct research on highly infectious organisms.

由于新型冠状病毒感染是一种新型疾病，我们对其知识的了解还十分有限，特别是关于危重患者的管理方面更是如此。我们设计了一个病例报告表来收集临床数据，正在经过伦理委员会的研究方案批准并且已经与具有资质进行高传染性生物研究的实验室取得联系。

In conclusion, the 2019-nCoV epidemic is a threat, not only to China, but also to global health. As ICU physicians, our focus is on the management of the most severe patients. We are unable to predict how many critically ill patients we will receive but are doing the best that we can to be prepared and to work together to overcome the epidemic.

总之，2019-新型冠状病毒疫情对中国乃至全球健康都构成了威胁。作为ICU医生，我们的重点是管理最危重的患者。我们无法预测我们将接收多少危重患者，但是我们正尽我们所能做好准备，并共同努力战胜此次疫情。

翻译

栾庆浩  医学硕士

山东大学第二医院重症医学科住院医师，兼任山东省医师协会重症医学医师分会重症急救专业委员会秘书。