臺灣急診室出院病人的重大不良事件之深入探討

The Study of Taiwanese Patients with a Major Adverse Events Discharged from the Emergency Room

陳啟華(Chi-Hwa Chern) ； 侯重光(Chorng-Kuang How) ； 王立敏(Lee-Min Wang)

《台灣急診專科醫師期刊》 5卷4期 (2013/12) Pp. 75-90

摘要

目標:透過急診診視醫師主觀推理和資深醫師客觀評價探討在急診臨床上出院病人重大不良事件。方法：採前瞻式問卷調查及立意取樣研究方式，研究對奉為已出院病人(不包含觀察室及自動出院病人);研究期間為一年(2005年9月1日~2006年7月31日)。研究含：「診視醫師對病人可出院的主觀認知」(研究組)及「資深醫師回溯性的客觀評估」(對照組)。研究分為看診醫師對病人可出院的主觀認知及資深醫師回溯性的客觀評估。結果測量以Office Excel輸入及儲存資料，統計分析使用卡方檢定及Fisher's的精確檢定方法。結果：20,512出院病例中，有1,370例(6.7%)是符合研究標竿的病例。醫師因素造成的重大不良事件(簡稱重大不良事件)數為165 (0.82%)。急診醫師對『出院理由』兩者比較為顯著差異(P ＜ 0.001)，而「病人想回家(出院)」及「醫師主觀認為可回家」兩者比較為顯著差異(P ＜ 0.001)；急診醫師對兩者『病人出院安全確定性』之待確定者為顯著差異(P ＜ 0.001)；急診醫師對兩者的『病情改善程度』之主觀認知的比較為無顯著差異。結論:本研究顯示，有重大不良事件的病人出院時，急診醫師主觀上認為大多數的病人可以出院(症狀明顯改善、病人是輕病及出院的安全性高)；但資深醫師客觀評估顯示，急診醫師在這些病人的處置上，絕大部份都有基本處置流程的缺陷。當病人不符合這基本要求時，急診醫師需要再審視臨床資料，從各種不同的觀點來考慮病人是否有其他可能(嚴重)問題或診斷，落實於未來不良事件的預防及教育訓練。

關鍵字

重大不良事件 ； 急診部門 ； 急診醫師

並列摘要

Objective: To study clinically significant adverse events (CSAEs) in the emergency department (ED) discharged patients through emergency physicians (EPs) subjective reasoning and senior EPs objective evaluation. Methods: This was a combined prospective follow-up and retrospective review study of consecutive adult non-traumatic patients who presented to a tertiary-care ED (annual census 82000) between September 1, 2005 to July 31, 2006.Data were extracted from ＂subjective reasoning of discharging patients with CSAEs＂ (control group) and ＂objective evaluation of CSAEs by senior EPs (study group). And the basic management process model in CSAEs, using clinical evidences as the guidelines. Comparisons of data, subjective reasons of discharging patients, improvement of symptoms, and the certainty of safety of discharging the patients were done between the study group and the controlled group using chi-square statistic or t-test. Results: Of 20,512 discharged cases, 1,370 (6.7%, 95% CI 6.3% to 7%) had returned visits and 165 physicians' factors of CSAEs (0.82%, with 95 CI 0.75% to 0.95%). Only 1 case (1/165, 0.6%) with CASEs was considered to be ''judgmental defect＂. Comparisons between the controlled group (regularly discharged patients) and the study group (patients of CSAEs) in physician and patient factors had significant difference. (P ＜ 0.001). Conclusion: A majority of patients with CSAEs through the analysis of the basic management process model were subjectively thought to have mild diseases/improved symptoms by EPs who discharged the patients. However, reviewing these cases, EPs had shortage of clinical follow-up and inadequacy in the basic parts of clinical evaluations in many cases.

並列關鍵字

clinically significant adverse events (CSAEs) ； emergency department (ED) ； emergency physicians (Eps)