新型冠狀病毒疫情流行對急診檢傷的衝擊

背景新冠肺炎大流行期間有全球有許多醫療照護體系發現：由於其快速傳播造成的醫療需求增加以及防疫措施造成醫療資源轉移使得醫療可近性受到衝擊。台灣緊急醫療照護於疫情期間受到的影響值得運用實證資料進行評估，可應用於未來新興傳染病之緊急照護應變發展應對策略。研究目的本研究目的主要在建立急診醫療佇列實證資料庫並對新冠肺炎疫情對於台灣緊急醫療照護之衝擊進行系統化實證評估。研究方法研究運用回溯式世代研究設計，運用振興醫院之急診數位病歷資料系統建立涵括未有疫情之2019年1月1日到2021年12月31期間急診佇列實證資料庫，評估新冠疫情對於急重症醫療照護系統之影響。本研究收集研究期間每日急診部病患就診、離部動向、心肺停止照護以及急性心肌梗塞照護等資料建立急診佇列系統評估實證資料庫。所收集之民眾對於急重症醫療照護需求訊息包含每日就診量以及各檢傷級別就診人數，並收集急重症需求在接受急診緊急療照護後依病情需求產生包含離部出院、病房住院、加護病房住院、死亡等處置後動向。本研究亦收集急診留觀超過24小時以及自動出院之處置後離部動向，以對於急診處置能量以及整體醫療照護能量進行評估。對於台灣新冠疫情之發展，本研究收集由台灣疾病管制署與指揮中心發布維護之每日確診數位公開資料，包含確診人數以及確診個案縣市別納入於疫情影響評估中。本研究運用所建立之急診實證資料庫結合佇列系統之到達率(arrival rate)以及移出率(departure rate)評估疫情期間相較於未有疫情的變化進行疫情衝擊評估。本研究發展對應於佇列系統到達率以及移出率之布瓦松迴規模式，以評估年別以及新冠肺炎通報個案數對於急診需求與照護之衝擊。本研究進一步發展多項式羅吉斯迴規模式，以對於急診檢傷級別以及不同急診離部動向同時進行評估。對急診品質指標本研究以心肺復甦循環回復率以及急性心肌梗塞之處置品質指標分別運用羅吉斯迴歸以及寇斯迴歸分析量化疫情之影響。結果相較於未有疫情之2019年，在考慮新冠肺炎通報個案數後，2020年(RR: 0.85，95%CI: 0.83-0.86)與2021年(RR: 0.84，95%CI: 0.83-0.85)之急診就診率相對降低，顯示除新冠肺炎個案對於醫療照護能量帶來之直接影響外，疫情中的防疫措施以及民眾對於防疫的作為對於急診醫療照護產生降低就診之影響。在考慮新冠肺炎通報個案數後，急診之急重症第一級(RR: 1.22，95% CI: 1.12-1.31，2020年；RR: 1.05，95%CI: 0.97-1.13，2021年)與第二級(RR: 1.20，95% CI: 1.15-1.26，2020年；RR: 1.38，95%CI: 1.32-1.44，2021年)就診率皆高於未有疫情的2019年。而輕症的第四級與第五級個案於疫情期間則少於未有疫情的2019年，顯示急診之醫療照護功能於疫情期間運用分流以及防疫措施下，維持急重症個案照護之主要功能。在納入新冠肺炎通報個案數之影響後，急診出院比率於疫情期間呈現顯著下降趨勢(RR: 0.95，95%CI: 0.92-0.97，2020年；RR: 0.94: 95%CI: 0.92-0.97)，而對應於中重症的一般病房住院(RR: 1.15，95%CI: 1.11-1.19，2020年; RR: 1.12，95%CI: 1.08-1.15，2021年)與加護病房住院(RR: 1.32，95%CI: 1.21-1.45，2020年; RR: 1.14，95%CI: 1.04-1.24，2021年)於疫情期間皆顯著上升。延長滯留率則顯著下降。於2020年間自動出院率明顯著上升。對於急重症照護品質密切相關的死亡則未有顯著變化。急診於心肺復甦之循環回復率於疫情期間未有顯著差異，仍得到維持。急性心肌梗塞病患相較於疫情期間之心電圖完成時間以及啟動治療小組時間相較於2019年未有顯著差異。結論新冠肺炎期間民眾緊急醫療利用率下降主要為檢傷第四級以及第五級之輕症個案，在醫療資源調派配置以及防疫措施運用下，急診對於中重症照護能量以及死亡、心肺復甦心率回復率，與急性心肌梗塞照護品質指標品質得到維持。

關鍵字

急診佇列實證資料；急診就診率；急診動向；心冠肺炎；佇列系統

並列摘要

Background The rapid spread of the COVID-19 pandemic has caused great impact on the medical accessibility of many healthcare systems around the world because of the increased medical demand and the displacement of medical resources caused by prevention measures and health policies. The COVID-19 pandemic had a much later onset in Taiwan than any in other countries in the world. There are unique facts about Taiwan, including the National Health Insurance. It is worth evaluating the impact of COVID-19 pandemic on Emergency Departments (ED) of Taiwan and its response strategies. Purpose The purpose of this study is to establish the registry of the empirical data on queue process of emergent health care and to conduct a systematic analysis of the impact of the COVID-19 outbreak on the services of triage of ED. Methods This is a retrospective cohort study using the existing medical database of the ED of Cheng Hsin General Hospital (CHGH) to establish the registry of the empirical data on queue process covering the period from January 1, 2019 to December 31, 2021. This was done to evaluate the impact of the COVID-19 pandemic on the ED and its critical care system. This study collected data of visits, triage levels on arrival, departures, dispositions, and the critical care events such as cardiopulmonary arrest, myocardial infarction, etc. of the ED patients of CHGH on daily basis during the study period in order to establish the registry of the empirical data on queue process. This study also collected the data of prolonged stays at the ED and discharge against medical advice (DAMA) as associated parameter in the evaluation of the management and medical capacity of ED. Regarding to the progress of the COVID-19 pandemic in Taiwan, this study collected the daily confirmed cases released by the Taiwan Centers for Disease Control (CDC), including the number of New Taipei city and Taipei city, where CHGH is located. The registry of the empirical data on queue process was initiated to analyze the arrival and departure rates in order to evaluate the dynamic change and impact on ED during COVID-19 pandemic compared with pre-pandemic era, 2019. To evaluate the impact of the time (year) and media and pandemic (daily number of confirmed cases reported by the CDC) on the services of the ED, we combined the use of Poisson regression model. This study developed a polynomial Logistic regression model to further evaluate dynamic trends from arrival (triage levels) to departures (hospitalization, DAMA, ect.). As to the quality of critical care, this study used Logistic regression model and Cox regression model by analyzing the rate of return of spontaneous circulation (ROSC) for CPR and the management of acute myocardial infarction (AMI). Results After incorporating the effect of the number of reported cases of COVID-19 there were relatively lower rates of overall visits in the ED in 2020 (RR: 0.85, 95%CI: 0.83-0.86) and 2021 (RR: 0.84, 95%CI: 0.83-0.85), indicating not only the direct impact of COVID-19 pandemic on services of ED, but also the change of medical use of the public due to the health policies and personal decision making affected by the media and the pandemic. After incorporating the effect of the number of reported cases of COVID-19, the arrival rates of triage level 1 (RR: 1.22, 95% CI: 1.12-1.31, in 2020; RR: 1.05, 95% CI: 0.97-1.13, in 2021) and triag level 2 (RR:1.20, 95% CI: 1.15-1.26, in 2020; RR: 1.38, 95% CI: 1.32-1.44, in 2021) were higher than those in 2019. The number of cases with mild disease (triage level 4 and 5) was fewer than that in 2019, indicating that the ED care was spared and maintained for the acute and severe cases under the use of triage system in the combination of epidemic prevention measures. After incorporating the effect of the number of reported cases of COVID-19, the emergency discharge rate showed a significant downward trend (RR: 0.95, 95%CI: 0.92-0.97, 2020; RR: 0.94: 95%CI: 0.92-0.97) , whereas general ward hospitalizations (RR: 1.15, 95%CI: 1.11-1.19, 2020; RR: 1.12, 95%CI: 1.08-1.15, 2021) and intensive care unit(ICU) hospitalizations (RR: 1.32, 2021) 95%CI: 1.21-1.45, 2020; RR: 1.14, 95%CI: 1.04-1.24, 2021) increased significantly during the pandemic. The rate of prolonged stay at the ED dropped significantly. In 2020, the rate of DAMA had risen significantly. There was no significant change in mortality rate, the rate of ROSC from CPR, indicating a decent quality of acute and critical care. In addition, there was no significant difference in the management of patients with AMI before and during COVID-19 pandemic. Conclusions During the COVID-19 pandemic there’s been significant decrease in the arrival rate of ED, which was mainly due to the mild illness (triage level 4 5). With the allocation of medical resources and the application of epidemic prevention measures, the ED of CHGH was still able to maintain standard quality of care on the patients with moderate and critical conditions.

並列關鍵字

Registry of the empirical data on queue process of emergent health care ； Arrival rate ； Departure rate ； COVID-19 ； Queue process

參考文獻

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