INTRODUCTION

There is a considerable paucity with regards to the research available on the quality and quantity of clinical teaching in the national emergency department (ED)setups.[1] Medical Council of India (MCI) in July 2009 recognized Emergency medicine (EM) as a specialty.With the onset of the age of modern medicine, the outlook towards to the time worn tradition of triage and detailed medical evaluation must be revoked. Skilled physicians in the emergency department are vitalentity of the new healthcare system and their development is of utmost important task of capacity building in EM.[2]

A number of training programs, most affiliated with foreign universities and ranging from 1 to 3 years were approved by the various healthcare institutes all over the country. A majority of the load fell on to private institutions due to lack of an integrated centralized post graduate training program at the time.[2] It was found that of the majority of hospitals, with the help of private healthcare institutions, had a wide variation in terms of size and volume of patients. Despite many hospitals employing doctors and nursing staff with basic medical knowledge, no trained emergency personnel were available. This led to a poor outlook to Emergency departments as compared to the allocated resources and equipment.[3]

Integrating a formal change in the curriculum,especially in the age old training system of medicine in a country like India is anintricate process. The educational approach varies vastly from the point of view of learners and educators, and is highly impacted by teaching methods, material and instructors’ perceptions and acceptability of educational resources among upcoming emergency physicians.[4]

Just being over half a century old specialty, EM is still in its early ages even in the American healthcare system.[5] So the evaluation of educational approaches by these international scenarios that has occurred after the implementation of many programs need to be evaluated in comparison with our own strategy.[5] As expected this is a long and tedious process and requires years of data collection and analysis for any substantial academia to be produced.

Despite the variety of programs being conducted in the country, a comparable entity common to all is patients’ clinical outcomes which can be measured using simple parameters which can be easily acquired compiling hospital registry entries.

This approach will lead to overall assessment of quality improvement and patient care after implementation of a specified curriculum in the training of young emergency physicians. Not only that, problems in the learning process and possible solutions can also be approached simultaneously.[5]

In the face of increasing emergency department(ED) crowding, balancing education and patient care is a trial of physicians. Multiple studies are being conducted to understand the evaluation of these programs by the physicians and students undergoing the training as well as the faculty conducting the training. These studies have till date shown a good progress when collated with previous data.[6]

Hence, lacking adequate evidence of any actual improvement in patient care and to evaluate the relative value of education of the Emergency doctors on clinical outcomes, a study was advocated which identified the factors to be assessed and compared so as to guide further development of the emergency medicine specialty in India.

METHODS

“药学研究的每一份付出，都能为百姓生命健康带来一丝希望。”王逸平曾说，他生前最大愿望是做出“世界各地临床医生首选的新药”。

The Emergency Medicine program in consideration was the Masters in emergency Medicine (MEM) Program affiliated with George Washington University, NY, USA.This was due to the lack of any central or government post graduate program in the country at the time of the study.

Patients of all age groups and gender registering in the Emergency Department and so were all the doctors working in the ED before and after initiation of the program.

Data was extracted from the hospital registers and compiled on a regular basis by hospital staff. Validity of the data was confirmed by visualized of the records personally by the investigators. Total number of patients visiting ED, total admission through ED per month,total no. of discharged through ED per month, average length of stay- admitted/discharge patients, No. of patient complaint, total no. of LAMA, total no. of patient expired per month data was collected.

No specific sample size was defined or allocated to any of the groups as the footfall of patients

6）对土方质量进行检测。无论是在土方填筑还是其他施工过程当中，都需要将质量检测工作做好。在土方施工之前，需要将施工过程中所需要的各项准备工作做好，并且符合照相关施工规定要求，同时在施工结束后还需要进行检查，严格把控作业质量。在施工过程当中，各相关单位应该重视对施工所用材料的抽查，保证施工不会因为材料而出现质量问题。除此之外，对于施工时的工程高度以及位置，也需要按照国家相关标准来进行检验。

Numerous parameters were considered as per mentioned above in the two groups and compared by applying multiple statistical tests. Minimum of 5% level of significance was considered to be adequate difference to register as any significant value.

All data was kept confidential and blinded statistical analysis conducted. Patient consent was wavered off as per ICMR guidelines as data was extrapolated from hospital registry.

RESULTS

The time frames that were considered included the periods before and after integrating a three-year structured program in emergency medicine. Comparative data in terms of number of patients was obtained when reviewing the total number of patients i.e., 36,145 patients with average patients of 1,642.95 (SD±368.29)per month for years 2009-2010 as compared to 36,440 patients with average per month of 1,656.36 (SD±295.2)for 2012-2013. Whilst the patient number stayed almost similar, the patient data suggests more complicated and critical patients in later years than in the earlier time periods, probably due to increased patient awareness and referral capabilities. Table 1, Figure 1.

The number of patients getting admitted through the emergency in 2009-2010 was 15,021 (mean 682.77 SD±145.731) and in 2012-2013 was 18,940 (mean 860.91 SD±140.307). This quite possibly suggests the improved patient disposition towards in-hospital care along with increased financial status of patients visiting the facility. Table 2, Figure 2.

The total number of patients provisionally diagnosed after evaluation and discharged with only Emergency department management was 20,476 (930.73±247.66)in 2009-2010 to 18,991 (863.23±189.054). This data possibly reflects improved patient diagnostics with improved conversion rates for further evaluation and appropriate management than only being discharged on symptomatic care. Table 3, Figure 3.

而业务人员的绩效工资挂靠于各个市场业绩任务达成，城市经理、区域经理等管理人员的绩效工资挂靠于整体市场业绩任务达成，都没有考虑到经销商撤销等异常情况，导致一旦某个市场经销商存在空缺，各级人员薪资水平均会受到较大影响，这催促着无论是领导层还是业务人员，都需要尽快寻找经销商来进行销量的补缺。但在较短的时间内，业务人员势必无法对当地市场的备选经销商做出详细了解和调研，多是走访几个经销商后，就仓促确定。此外，前期调研不充分也导致部分客户资质刚刚满足公司要求便设立为经销商，后期运营乏力，不利于产品在当地市场的拓展。

Similarly, the average length of stay of patients in the emergency prior to being discharged from the ED was 2:22:46 (±0:19:14) in 2009-2010 as compared to 3:58:10(±0:29:31). This too can be extrapolated similarly as to the admission times and additionally to the requisition ofpatients for thorough diagnostics in the emergency itself before discharge. Table 4, Figure 4.

Table 1. Total number of patient visiting ED

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Table 2. Total admission through ED per month

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Table 3. Total discharge ED month

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Table 4. The average length of stay of patients in ED

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Table 5. Return to emergency within 24 hours

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Figure 1. Total number of patient visiting ED.

Figure 2. Total admission through ED per month.

Figure 3. Total discharge from ED per month.

The number of patients returning to the emergency department within 24 hours of discharge or leaving against medical advice from the ED totaled at 72(mean of 3.27, SD 3.807) in 2009-2010 whilst in the time period of 2012 to 2013 the total number was 31(mean 1.41, SD 1.68). This data suggests the improved management of patients with appropriate discharge or referral advice. Table 5, Figure 5.

The number of patient complaints was 56 (mean 2.55, SD 1.565±0.334) in the period 2009-2010 and 35 (mean 1.59, SD 1.709±0.364) in the period 2012-2013. This represents the data reflecting better-quality of patient care as well patient outcomes and overall satisfaction of all the people visiting the emergency department. Table 6, Figure 6.

总之，搞好初中作文教学，培养初中生的写作能力，需要在提高作文教学效率上下功夫。作文教学始于“点”，也归于“点”，“点”上的功夫做扎实了，“面”上的文章必将呼之欲出。在作文教学中，切入的“点”找准了，作文教学的大门就会被轻轻开启；关键的“点”把握好了，作文里那个五彩纷呈、鲜活动人的世界就会为之呈现；把问题的“点”解决了，作文的整体面貌必将旧貌换新颜。

陆游还十分钦佩名士的“真”风度，此“真”在于名士性情的至纯至真。最突出的要数《任诞》第47则王子猷“雪夜访戴”一典，此典在陆游作品中出现达21次之多。关于此典与士人精神的关系，罗宗强先生有准确的理解和解释：“这是一则极美的文字，其中传达着一种千古士人为之神往的感情。后来的很多士人，都为这个故事所感动。它不仅表达一种真挚的友情，更重要的是传达士人的传统性格里那种忘情的趣味。这趣味蕴含高雅脱俗的情调，而且是纯情的，情来即兴，情尽即止。这是后来文人画传统的内在精神之一表现，也应该是属于士文化的一种成分。”[21](P238)

The number of patients getting admitted through the emergency increased in general and quite possibly suggests the improved patient disposition towards inhospital care along with increased financial status of patients visiting the facility.

The total number of patients provisionally diagnosed after evaluation and discharged with only Emergency department management was lowered. These figures in this study group re fl ect enhanced patient diagnostics with value-added conversion rates for further evaluation and appropriate management than only being discharged on symptomatic care.

Table 6. The number of patient complaints

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Table 7. Total number of LAMA

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Table 8. Patients expired ED month

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Figure 4. The average length of stay of patients in ED.

Figure 5. Return to emergency within 24 hours.

Figure 6. The number of patient complaints.

Figure 7. Total number of LAMA.

Figure 8. Patients expired ED month.

DISCUSSION

The total data in review had the time periods that took into consideration the periods before and after integration of a three-year structured Academic Program in Emergency Medicine.

The comparative data in terms of number of patients,the total of whom visited the Emergency department,was sizably almost similar even though this data gives a deceptive picture of no change in patient presentation to the emergency department of our study center. However,detailed patient records show that more complicated and critical patients were managed in the ED in later years than in the earlier time periods, probably due to increased patient awareness and referral capabilities.

A retrospective observational study was conducted in the Emergency department of Max hospital, Saket,New Delhi. A period of 22 months prior to the start of the program and like-wise 22 months after initiation of the program was collected from the hospital registry.The period was chosen so as this was the maximum possible data collected prior to the program due to inadequacy of complete records and later period was kept similar to give a relative level of confidence in comparing the data.

The number of patient deaths in the Emergency department for the time period 2009-2010 was 18 (mean of 0.82, SD 0.907±0.193) and for 2012-2013 was 45(mean of 2.045, SD 3.645±0.777).

Considering the figures of the total and the averages,it can be said that the number of deaths more than doubled in the second time frame of consideration. However, a look at the graphs of the two data when compared gives an idea that there are only last 3 months in the second time period which account for the 31 deaths of the total 45 in this period and only 14 in the rest of the months. This evidently can be correlated with the dengue and H1N1 influenza epidemics in the country at the time and may represent the increased number of very critical patients’ presentation to the ED, either directly but more so on a referral basis from multiple small clinics and private setups located in the nearby surrounding areas. Table 8, Figure 8.

The average length of stay of patients in the emergency prior to being admitted to the hospital was 2:55:35 (SD 0:22:43) in 2009-2010 as compared to 4:40:08 (SD 0:57:28) in 2012-2013. The considerable increase in the duration spent in ED corroborates with the increasing number of inpatient occupancy, increased detailed diagnostics and procedures carried out primarily in the ED prior to appropriate disposition, and increased competency of ED personnel at providing more thorough care to critical as well as non-critical patients awaiting inpatient bed.

Similarly, the average length of stay of patients in the emergency prior to being discharged from the ED was 2:22:46 (±0:19:14) in 2009-2010 as compared to 3:58:10(±0:29:31). This too can be extrapolated similarly as to the admission times and additionally to the requisition of patients for thorough diagnostics in the emergency itself before discharge.

泵站设置在涝河渠道左岸，采用立式管道离心泵。涝河滩地片区与贤庄周围片区管线在泵站上游分开，两片区进行分组轮灌，各管道设置控制阀，以控制管道水流方向。两片区均采用一级干管布置，干管设给水管，田间为当地自备软管灌溉。

当学生习惯此项作业后，他们每天都会阅读《论语》中的相关句子，积累相关的文言字词，同时又极好地训练了他们针对材料作文的审题能力。为了把每天的片段式作文写好，他们还要在文学、史学、哲学、美学、社会学等典籍中爬罗剔抉、刮垢磨光，旧瓶装新酒，或者用以往所学的知识，根据文言意思侃侃而谈、自圆其说。

The number of patients returning to the emergency department within 24 hours of discharge or leaving against medical advice from the ED totaled at 72(mean of 3.27, SD 3.807) in 2009-2010 whilst in the time period of 2012 to 2013 the total number was 31(mean 1.41, SD 1.68). This data suggests the improved management of patients with appropriate discharge or referral advice.

Patients who left against medical advice from the emergency department surmounted to 2,248 (mean of 102.18, SD 19.331±4.121) from 2009-2010 and 2,246(mean of 102.09, SD 31.213±6.655) from 2012-2013.There seems to be no apparent change in the number of patients going LAMA. However, the reasons for the two periods vary and may include the availability of empaneled coverage and socio-economic reasons. Table 7, Figure 7.

The number of patient complaints was 56 (mean 2.55, SD 1.565±0.334) in the period 2009-2010 and 35 (mean 1.59, SD 1.709±0.364) in 2012-2013. This represents the data reflecting better-quality of patient care as well patient outcomes and overall satisfaction of all the people visiting the emergency department.

The average length of stay of patients in the emergency prior to being admitted to the hospital was 2:55:35 (SD 0:22:43) in 2009-2010 as compared to 4:40:08 (SD 0:57:28). The considerable increase in the duration spent in ER corroborates with the increasing number of inpatient occupancy, increased detailed diagnostics and procedures carried out primarily in the ER prior to appropriate disposition, and increased competency of ED personnel at providing more thorough care to critical as well as noncritical patients awaiting inpatient bed. Table 4, Figure 4.

Patients who left against medical advice from the emergency department surmounted to 2,248 (mean of 102.18, SD 19.331±4.121) from 2009-2010 and 2,246(mean of 102.09, SD 31.213±6.655) from 2012-2013.There seems to be no apparent change in the number of patients going LAMA. However, the reasons for the two periods vary and may include the availability of empaneled coverage and socio-economic reasons.

Considering the figures of the total and the averages,it can be said that the number of deaths more than doubled in the second time frame of consideration.However, a look at the graphs of the two data when compared gives an idea that there are only last 3 months in the second time period which account for the 31 deaths of the total 45 in this period and only 14 in the rest of the months. This evidently can be correlated with the dengue and H1N1 in fl uenza epidemics in the country at the time and may represent the increased number of very critical patients’ presentation to the ED, either directly but more so on a referral basis from multiple small clinics and private setups located in the nearby surrounding areas.

CONCLUSION

From the above discussion we can make a coherent conclusion that there is an improvement in the outcome of the entire patient related aspects in the Emergency Department considering the all two time frames included in the study. The difference can be very well attributed to the integration of the structural Academic Program in the development of the Emergency Physicians. This leads us to make a conclusive analysis regarding a positive impact of the Relative Value of Education of Emergency Physicians not only in patient outcome but also in physicians and administrative outlook towards an overall better emergency care.

因此，现代医学模式不仅仅是科学医学而是科学医学与社会学的综合，是一个系统工程。建立与完善现代医学模式需要结合中国国情，走中国特色之路[11]。坚持以人为本，不仅关注患者身体疾病的生物学治疗，更应关注患者的心理健康和社会环境、生活方式对健康的影响，关注人与环境的和谐统一[12-13]，根据疾病谱的变化和经济发展状况合理构建与完善医疗保健体系。

We are grateful to Dr.Sangram Shinde, Kalden Sherab and Sushant Chhabra for their contribution to part of the study.

Funding: This work was supported by Department of Emergency Medicine and Max Institute of Medical Excellence, Max Super Specialty Hospital, Saket, Delhi 110017, India.

Ethical approval: Not needed.

图1所设计的输液监护仪的系统结构图,功能比较齐全,尤其是考虑到有些输液的液体温度过低影响对病人的治疗效果或输液的舒适度。另一个大特色是输液的滴速控制,滴速控制跟监测病人的血压和心率结合起来,可以极大的减轻了因输液对病人产生的医疗风险。比如:病人对输液的液体有过敏反应或心脏反应过激,这时该输液就及时停止和报警。

Conflicts of interest: The authors hav e no competing interests relevant to the present study.

大头菜20株酵母分离菌株经28S r DNA D1/D2区测序后，将结果在NCBI用Blast进行比对，具体对比结果及序列相似性见表3。

Contributors: All authors read and approved the final version of the manuscript.

上式中，xk是第k个源节点发送的信号，g2k是的第k列向量，g1k是的G1的第k列向量.等式右边第1项为期望发送给目的用户k的信号，第2项为其他用户的干扰，第3项为目的节点发送人工噪声，第4项为中继节点发送的人工噪声，第5项为中继节点转发的信道噪声，最后一项为目的用户k接收到的信道噪声.而中继节点发送的人工噪声位于G2的零空间中，因此第4项为零.因此，第k个目的节点的接收信干噪比(Signal to Interference-Noise Ratio,SINR)为

REFERENCES

1 Hexom B, Seth Trueger N, Levene R, Ioannides KL, Cherkas D.The educational value of emergency department teaching: it is about time. Intern Emerg Med. 2016 Apr 8.

2 Pothiawala S, Anantharaman V. Academic emergency medicine in India. Emerg Med Australas. 2013;25(4):359-64.

3 Khadpe J, Thangalvadi T, Rajavelu P, Sinert R. Survey of the current state of emergency care in Chennai, India. World J Emerg Med. 2011;2(3):169-74.

4 Muller JH, Jain S, Loeser H, Irby DM. Lessons learned about integrating a medical school curriculum: perceptions of students,faculty and curriculum leaders. Med Educ. 2008;42(8):778-85.

5 Hollander H, Loeser H, Irby D. An anticipatory quality improvement process for curricular reform. Acad Med.2002;77(9):930.

6 Ahn J, Golden A, Bryant A, Babcock C. Impact of a dedicated emergency medicine teaching resident rotation at a large urban academic center. West J Emerg Med. 2016;17(2):143-8.