抗震救灾医疗后送系统实证与建模研究

发布时间：2018-04-28 23:05

本文选题：抗震救灾 + 医疗后送　；参考：《第二军医大学》2012年博士论文

【摘要】：生命救援是抗震救灾的首要任务,医疗后送作为应急医学救援的核心内容,直接影响伤病员的救治效果。2008年汶川地震是过去10年中国际范围内发生的破坏性最强的灾害之一,2010玉树地震震区地处高原,是近年来救援难度最大的地震之一。通过汶川、玉树两次地震所积累的医疗后送经验、对后送规律的认识和后送能力的储备,应当固化为地震应急医学救援知识遗产,为全人类所共享。国际社会在应对地震导致的各种医学问题上已取得了许多显著进展。而抗震救灾医疗后送是一项复杂的系统工程,我们必须更加关注其宏观组织指挥,提高决策效率,以取得最佳的救援效果。从复杂系统科学的角度探讨抗震救灾医疗后送系统的结构与效率成为新兴热点问题。目前我国抗震救灾医疗后送仍然建立在传统战时医疗后送理论的基础上,依靠指挥者的经验判断进行决策,缺乏针对性的理论指导和基础性系统规律研究。因此,研究抗震救灾医疗后送复杂系统的特点与规律,创新抗震救灾医疗后送机制、提高抗震救灾医疗后送能力与指挥决策水平,对于提升抗震救灾医学救援整体效果具有重要的现实意义和理论意义。本课题是全军医药卫生科研基金课题《非战争军事行动卫勤保障理论研究》(09MA030)的深入,是国家科技支撑计划《严重战创伤救治组织与决策技术系统研究》(2009BA187805)和国家自然科学基金《城市地震应急医学救援多主体决策建模与效能评估研究》(71103194)的分课题,并受2011年度校博士创新基金军事类研究项目《地震伤病员医疗后送建模研究》资助。研究目的：本课题是在总课题研究理念指引下,针对抗震救灾应急医学救援循证决策的拓展研究。基于前期(1+n)医疗服务系统复杂模型体系与大型决策支持平台,结合课题组汶川、玉树地震应急医学救援外部评估进展,借鉴军队“非战争军事行动卫勤保障理论研究”成果,依据对汶川、玉树抗震救灾医疗后送的大规模现场调研数据,运用复杂适应性系统(Complex Adapting System, CAS)理论、系统动力学(System Dynamics, SD)建模技术,进行系统的抗震救灾医疗后送理论研究,明确抗震救灾医疗后送的定位、特点、原则；通过汶川、玉树抗震救灾医疗后送实证分析,获得医疗后送系统(Medical Evacuation System, MES)结构框架、主体行为特征与结构演化规律；进行抗震救灾MES的复杂性分析与问题诊断,抽象系统主体类别、属性,建立抗震救灾MES概念模型,确定系统内部因果反馈关系及与外部环境之间的主要回路,获得抗震救灾MES演化过程中主体的交互作用,在此基础上构建抗震救灾MES逻辑模型与SD模型,进行伤病员后送与救治效果与医疗后送资源利用效率的模拟,以及对医疗后送资源、伤病员后送决策值与组织指挥效率的政策干预实验,探讨抗震救灾MES动态行为特征和内部运行机制,发现影响系统效率的问题根源,并提出针对性的政策建议,研究成果能够辅助抗震救灾应急医学救援战略决策,为抗震救灾医疗后送政策试验提供平台。研究资料：研究资料来源包括3部分。一是现场调研资料。包括课题组于2008年6月赴汶川进行汶川抗震救灾应急医学救援现场调研的资料,2010年4月、8月、12月分别赴玉树、国家卫生部、青海省卫生厅进行玉树抗震救灾应急医学救援现场调研资料。二是搜集整理的各类文件、报表、日志等。包括汶川抗震救灾应急医学救援相关文件资料；玉树地震紧急医学救援的相关文件、报表等资料。三是从各类期刊数据库检索的抗震救灾医疗后送的相关文献资料140余篇。研究方法：包括文献法、专家访谈法、现场调研法、系统思考、复杂适应性系统理论、系统动力学建模方法等。应用文献归纳分析方法,对抗震救灾医疗后送进行定性分析和理论研究,应用现场调研、文献归纳、统计学方法,进行汶川和玉树抗震救灾医疗后送实证分析；应用文献法、现场调研法、专家访谈法、复杂适应性系统理论等方法进行抗震救灾医疗后送复杂性分析,进行抗震救灾MES结构性问题诊断；应用系统动力学的系统思考与系统分析、建模方法,对抗震救灾伤病员MES进行建模设计,筛选主回路与关键变量并进行量化,依次构建概念模型,逻辑模型与系统动力学模型；应用Vensim DSS软件进行抗震救灾伤病员医疗后送模拟与干预实验。主要研究结果和结论：本研究通过抗震救灾医疗后送理论研究,探讨了抗震救灾医疗后送在传统医疗后送理论基础上的定位转变、职能拓展、体系机制和特点原则；通过抗震救灾医疗后送实证分析,获得抗震救灾MES主体结构、行为特征与系统演化规律；通过构建抗震救灾MES动力学模型,为抗震救灾医疗后送政策实验提供工具方法；通过对抗震救灾医疗后送的政策干预模拟实验,获得了提高优化医疗后送体制和流程、提高抗震救灾医疗后送决策效率的政策靶点,明确了各项政策的后果和影响,据此提出了相应的政策建议。抗震救灾医疗后送理论研究：抗震救灾医疗后送相对于传统医疗后送,呈现出阶梯简化、专科治疗靠前、军地协同的新特征。抗震救灾医疗后送的基本目的是降低地震伤死率与伤残率,提高治愈率。地震伤病员发生呈现增长期和稳定期的“两期”时间分布特征。医疗后送应以时效救治指导分级救治为原则,协调优化伤病员后送的组织形式与保障方式。国外应对特大灾难应急医学救援中亦呈现后送阶梯简化趋势。空运是大规模伤病员后送的主要方式,以海、空后送辅助陆地后送,形成伤病员立体后送体系。抗震救灾医疗后送实证分析：通过汶川、玉树抗震救灾医疗后送实证分析并与国外灾难医疗后送的点对点比较,发现早期后送和阶梯简化的医疗后送体系与伤病员救治需求相符；两次抗震救灾灾区一线的伤病员检伤分类的标准化程度不够,造成了卫生运力等稀缺资源的浪费,延误了专科治疗时间；后方医院收治能力评估方面尚待加强；伤病员中转站发挥重要作用,空运后送在远距离后送至具有优势作用,但后送飞机及后送医护人员存在安全隐患,不符合“送治结合”标准。抗震救灾MES复杂性分析：抗震救灾MES的供、需方主体和决策行为特征具有复杂适应性系统(CAS)的聚集特性、非线性、流特性与多样性四种特性,其复杂行为机制可以通过微观主体的“刺激-反应模型”、宏观系统的“回声模型”与系统内部结构演化的模块化“积木”机制进行分析,是典型的多主体复杂系统。基于系统复杂性分析进行问题诊断,发现抗震救灾MES的主要问题主要表现在抗震救灾MES机构资源结构障碍,抗震救灾MES主体行为障碍,子系统协调机制与等3个主要方面。抗震救灾MES逻辑模型构建：抗震救灾MES的系统边界由抗震救灾MES结构、抗震救灾MES主体和与系统相关的外部环境组成,系统的核心是伤病员在MES内的流动。抗震救灾MES包含抗震救灾总指挥部、各级医疗后送机构和伤病员三类主体组成。通过确定系统内部因果反馈关系、影响因素及与外部环境之间的主要回路,获得抗震救灾MES演化过程中主体的交互作用,构建抗震救灾医疗后送逻辑模型,归纳出建模时聚焦的主要问题为：抗震救灾MES各级资源利用率与伤病员有效救治率。抗震救灾医疗后送系统SD模型构建与模拟干预：将抗震救灾MES的目标设定为提高救治机构资源利用率,提高后送效率和伤病员有效救治率；以Vensim软件为平台构建抗震救灾医疗后送SD模型并进行检验。模拟研究发现抗震救灾MES在震后72h内的伤病员有效救治率低,支援力量部署效率低,而72h至震后2周内医疗力量的低效率损失居高不下。干预实验显示抗震救灾医疗后送的早期后送伤员、合适的伤病员后送比例有利于伤病员有效救治,同时发现早期开始灾区医疗力量的调整对提高支援医疗力量配置效率的作用明显,而提高需求判断、医疗后送计划、医疗后送决策及组织指挥效率,可以大幅提高伤病员有效救治率和医疗力量早期在灾区的饱和度。政策建议：通过以上对抗震救灾医疗后送理论研究、实证分析、建模与模拟干预研究,从创新抗震救灾医疗后送体制、提高医疗后送“送”、“治”连续性、加强抗震救灾医疗后送力量建设、促进抗震救灾医疗后送组织指挥能力提升四个方面提出优化医疗后送体制、提高医疗后送决策效率,提升医疗后送系统整体绩效的政策建议。本研究是复杂系统理论和系统动力学建模在抗震救灾伤病员医疗后送系统的首次尝试,由于系统涉及面广、影响因素多、相互关系复杂,难以全面描述,且缺少可借鉴的相关研究,研究建立的模型有待于进一步优化和细化,使之与实际更加贴合。
[Abstract]:Life rescue is the primary task of earthquake relief. As the core content of emergency medical rescue, medical evacuation directly affects the treatment effect of the wounded and sick people in the past 10 years is one of the most destructive disasters in the past 10 years. The 2010 Yushu earthquake area is located in the plateau, which is the most difficult earthquake in recent years. Through the medical evacuation experience accumulated in the two earthquake in Wenchuan and Yushu, the understanding of the law of evacuation and the reserve of the ability to send back should be solidified into the knowledge heritage of earthquake emergency medical rescue and shared by all mankind. The international community has made a lot of remarkable progress in dealing with the various medical problems caused by the earthquake. Medical evacuation is a complex system project. We must pay more attention to its macro organization and command, improve the efficiency of decision making, and obtain the best rescue effect. From the perspective of complex system science, the structure and efficiency of medical evacuation system in earthquake relief and disaster relief have become a new hot issue. On the basis of the theory of medical evacuation in United Front, we rely on the experience judgment of the commanders to make decisions, lack of pertinent theoretical guidance and basic systematic law research. Therefore, we study the characteristics and laws of the complex system in the earthquake relief medical evacuation system, innovate the medical evacuation machine system for earthquake relief and disaster relief, and improve the ability and command of medical evacuation in earthquake relief and disaster relief. The level of strategy has important practical significance and theoretical significance for improving the overall effect of medical rescue in earthquake relief.
This topic is the depth of the research foundation of the military medical scientific research fund of the whole army, the theoretical research of medical service support for non war military operations (09MA030). It is the national science and technology support program < serious trauma treatment organization and decision-making technology system > Research > (2009BA187805) and National Natural Science Fund < urban earthquake emergency medical rescue multi-agent decision-making modeling and effectiveness. The sub topics of evaluation study > (71103194) were funded by the 2011 year's doctoral innovation fund military research project, medical evacuation modeling for earthquake victims.
The purpose of the study is:
Under the guidance of the general topic research concept, this topic is based on the development of the evidence-based decision-making of emergency medical rescue in earthquake relief. Based on the complex model system of the early (1+n) medical service system and the large decision support platform, the development of the external assessment of the emergency medical rescue in Yushu earthquake is combined with the project group Wenchuan, and the military "non war military action" is used for reference. On the basis of the large-scale field survey data of Wenchuan and Yushu earthquake relief medical treatment in Wenchuan and Yushu, and using the complex adaptive system (Complex Adapting System, CAS) theory and the system dynamics (System Dynamics, SD) modeling technology, the theoretical research on the earthquake relief medical evacuation theory of the system is carried out to clarify the earthquake relief medicine. The positioning, characteristics and principles of the treatment after treatment; through the empirical analysis of Wenchuan and Yushu earthquake relief medical evacuation, the structure framework of Medical Evacuation System (MES), the main behavior characteristics and the structural evolution law, the complexity analysis and the problem diagnosis of the earthquake relief MES, the abstract system main body category, the attribute, and the establishment of the anti earthquake disaster relief MES are carried out. The MES concept model of earthquake relief, the internal cause and effect feedback relationship and the main circuit between the system and the external environment are determined, and the interaction of the main body in the process of earthquake relief MES evolution is obtained. On this basis, the MES logic model and the SD model for earthquake relief and disaster relief are constructed, and the results of the evacuation and rescue effect of the wounded and the utilization efficiency of the medical evacuation resources are simulated. As well as the policy intervention experiments on the medical evacuation resources, the casualty evacuation decision value and the organizational command efficiency, the dynamic behavior characteristics and internal operating mechanism of the earthquake relief MES are discussed, and the root of the problems affecting the efficiency of the system are found, and the pertinent policy suggestions are put forward, and the research results can help the emergency medical rescue strategy decision of the earthquake relief. It provides a platform for the earthquake relief medical evacuation policy test.
Research information:
The research data sources include 3 parts. One is the field survey data, including the data of the field research on the emergency medical rescue of Wenchuan earthquake relief in June 2008, in April 2010, August, December, Yushu, the Ministry of health and the Qinghai Department of health for emergency medical rescue in Yushu. All kinds of documents, reports, logs, etc., including the relevant documents of emergency medical rescue in Wenchuan earthquake relief, related documents and reports of emergency medical rescue of Yushu earthquake, three are more than 140 documents of relevant documents of earthquake relief medical treatment from various periodical databases.
Research methods:
It includes literature, expert interview, field investigation, systematic thinking, complex adaptive system theory, system dynamics modeling method and so on. It applies the method of literature induction to the qualitative analysis and theoretical study of earthquake relief medical evacuation, and applies the field investigation, literature induction and statistical method to carry out the earthquake relief medical treatment in Wenchuan and Yushu. An empirical analysis is carried out with the methods of literature, field investigation, expert interview, and complex adaptive system theory to carry out the complexity analysis of earthquake relief medical evacuation, and to diagnose the MES structural problems in earthquake relief. System dynamics and system analysis, modeling methods are applied to the construction of MES in earthquake relief and disaster relief. The model is designed, the main loop and the key variable are screened and quantized, and the conceptual model, the logical model and the system dynamics model are constructed in turn, and the Vensim DSS software is applied to the medical evacuation simulation and the intervention experiment of the earthquake relief and the sick and wounded.
The main results and conclusions are as follows:
Based on the theoretical research of earthquake relief medical evacuation, this paper discusses the positioning transformation, function expansion, system mechanism and characteristic principles on the basis of the traditional medical evacuation theory, and obtains the structure of the MES host, the behavior characteristics and the system evolution law through the earthquake relief medical evacuation. The MES dynamic model for earthquake relief and disaster relief is set up to provide a tool for the policy experiment of medical evacuation for earthquake relief. Through the policy intervention simulation experiment on the medical evacuation of earthquake relief, the policy targets are obtained to improve the system and process of medical evacuation and improve the efficiency of decision making in earthquake relief medical evacuation, and the consequences of various policies are clearly defined. Accordingly, the corresponding policy suggestions were put forward.
Research on medical evacuation of earthquake relief and disaster relief: in earthquake relief medical evacuation compared with traditional medical evacuation, it presents a new feature of simplified staircase, pre specialist treatment and military land coordination. The basic purpose of earthquake relief medical evacuation is to reduce the death rate and disability rate of earthquake injury and improve the cure rate. The "two phase" time distribution characteristics. Medical evacuation should be based on the principle of timed treatment and treatment guidance, coordinate and optimize the organizational form and guarantee mode of the injured patients. The foreign response to emergency medical rescue also presents the simplified trend of the evacuation ladder. Air transportation is the main way of the evacuation of the large wounded, with the sea and air evacuation auxiliary. It helps the land to be sent back to form the system of three-dimensional evacuation of the wounded and sick.
Empirical analysis of earthquake relief medical evacuation: through the empirical analysis of Wenchuan, Yushu earthquake relief medical evacuation and comparison with foreign disaster medical evacuation point to point, it is found that the early evacuation and stepped simplified medical evacuation system coincide with the treatment needs of the injured and sick people; the standardization of the classification of the wounded and the wounded in the two earthquake disaster relief area Lack of degree, resulting in the waste of scarce resources such as health transportation, delay the specialist treatment time; the assessment of the capacity of the rear hospital is still to be strengthened; the transfer station of the wounded is playing an important role and the air transport is sent to the hospital with the advantages of a long distance, but the evacuation of the aircraft and the post delivery medical staff is not in accordance with the "delivery and treatment". Combined with the standard.
The MES complexity analysis of earthquake relief: the supply of earthquake relief MES, the main body and the decision behavior characteristics have four characteristics of complex adaptive system (CAS), nonlinear, flow characteristics and diversity, its complex behavior mechanism can pass the "stimulus counter model" of the micro body, and the "echo model" of the macro system and the system within the system The modular "block" mechanism of the structural evolution of the Ministry is a typical multi-agent complex system. Based on the system complexity analysis, the problem diagnosis is carried out. The main problems of the earthquake relief MES are mainly manifested in the barrier of the resources structure of the earthquake relief MES mechanism, the behavior obstacle of the MES host in the earthquake relief and disaster relief, the subsystem coordination mechanism and the other 3 main factors. On the side.
The construction of MES logic model for earthquake relief: the system boundary of the earthquake relief MES is composed of the earthquake relief MES structure, the earthquake relief MES main body and the external environment related to the system. The core of the system is the flow of the wounded in the MES. The earthquake relief MES includes the general command department of the earthquake relief and disaster relief, the three main types of medical evacuation agencies and the wounded and sick members. By determining the internal causal feedback relationship of the system, influencing factors and the main circuit between the environment and the external environment, the interaction of the main body in the MES evolution process of earthquake relief and disaster relief is obtained, and the logical model of the earthquake relief medical evacuation is constructed, and the main problems of the focus are summarized as follows: the utilization rate of the resources at all levels and the effective rescue of the wounded and the sick and wounded in the earthquake relief and disaster relief The rate of treatment.
SD model construction and simulation intervention for earthquake relief medical evacuation system: setting the target of earthquake relief MES to improve the utilization rate of resources of rescue organizations, improving the efficiency of evacuation and the effective cure rate of the wounded, constructing the SD model of earthquake relief medical evacuation with the Vensim software as the platform and testing it. The simulation study found that the earthquake relief MES in earthquake relief was in earthquake. The effective treatment rate of the injured patients in the post 72h was low, the efficiency of the support force was low, and the low efficiency of the medical force was high within 2 weeks after the earthquake. The intervention experiment showed that the early evacuation of the wounded in the earthquake relief medical evacuation, the proportion of the appropriate wounded and the sick and sick people were beneficial to the wounded and the medical force in the early disaster areas. The adjustment of quantity has a significant effect on improving the efficiency of supporting medical force allocation, and the improvement of demand judgment, medical evacuation plan, medical evacuation decision and organization command efficiency can greatly improve the effective cure rate of the wounded and the medical force in the early stage of the disaster area.
Policy recommendations:
Through the above analysis of medical evacuation theory, empirical analysis, modeling and simulation intervention research, from innovative earthquake relief medical evacuation system, improve medical evacuation "send", "treatment" continuity, strengthen the construction of medical evacuation force in earthquake relief, and promote four aspects of improving the ability of medical evacuation organization and command. The policy recommendations of improving the efficiency of medical evacuation and improving the overall performance of the medical evacuation system are put forward.
This study is the first attempt of the complex system theory and system dynamics modeling in the medical evacuation system of the wounded and wounded in earthquake relief. Because the system involves a wide range, many factors are involved, the relationship is complex, it is difficult to fully describe it, and the related research is short of reference. The model set up needs to be further optimized and refined to make it more practical. Add up.

【学位授予单位】：第二军医大学
【学位级别】：博士
【学位授予年份】：2012
【分类号】：R82

【参考文献】