- 學位論文
重大創傷患者的緊急醫療服務和醫院照護品質在非工作時間是否降低?
Are Emergency Medical Service & Hospital Care for Major Trauma Patients Inferior during Off-hours?
摘要
前言： 意外事故是台灣地區最重要的死亡原因之一，近年都一直排在第五位，同時更是四十歲以下的青壯族群的頭號殺手。對於創傷病患的即時且適切醫療，可以降低創傷病患整體的死亡率。這樣的治療需要創傷醫院的分級認證制度和良好的緊急醫療救護系統，進而將符合到院前重大創傷資格的病患運送到鄰近最適當的創傷醫院治療。在非工作時間，緊急醫療救護系統擁有的人力和資源相對缺乏，醫院的值班人員也多由資淺的工作人員擔任，發生錯誤的機會提高，可能造成緊急醫療救護系統的功能低下，因而對創傷病人造成傷害，使得創傷病人的死亡率上升。 目的： 本研究的目的在了解台北市的緊急醫療服務和醫院照護，對於重大創傷的患者，在非工作時間的品質是否降低？ 材料與方法： 本次研究回溯性蒐集從民國九十一年二月至民國九十二年一月中間，啟動台北市緊急醫療救護系統且符合台北市重大創傷指標的創傷病患，在到院前、急診部、手術室、以及加護病房各階段治療所花費時間，分析創傷病患在不同層級創傷醫院或醫學中心所利用之醫療資源的差異。對於非工作時間和工作時間的區分，工作時間定義為星期一至星期五的上午八時至下午五時，非工作時間定義為星期一至星期五的下午五時至上午八時、週末和國定假日。分析的結果則包含：醫療資源使用率(電腦斷層檢查比率、胸部X光檢查比率、超音波檢查比率、手術比率)、救護車出勤至到院時間、醫院流程品質(到院至手術房時間、 急診停留時間)、和病人的預後(加護病房住院日數、全部住院日數、死亡率)。 結果與討論： 本研究收集之啟動台北市緊急醫療救護系統之創傷病患，共計有13,022 人次。符合台北市到院前重大創傷指標者佔有4.9%，總共有648人次，其中有到院後之相關醫療紀錄638人次。在依存度方面在工作時間是58%，而在非工作時間是61%，P值為0.48。在工作時間，重大創傷患者的平均年齡是44歲，大於非工作時間的38歲，P值為0.0005。死亡率在非工作時間是13.5%，而工作時間則是14.1%，P值為0.77。創傷嚴重程度分數大於15的創傷病患和年齡大於55歲的病患有較高的死亡率(P值皆小於0.0001)。救護車出勤至到院時間在非工作時間和工作時間沒有差異。急診停留時間在創傷嚴重程度分數大於15和醫學中心較長(P值為0.001和0.006)。加護病房住院日數和全部住院日數於兩個時段皆相同。在醫療資源使用率上，醫學中心手術的比率大於非醫學中心為(33.1%和21.9%)。 在醫學中心，急診停留時間和到院至手術房時間在非工作時間和工作時間並沒有不同(P值為0.54和0.45)。但是在非創傷中心、創傷中心、和非醫學中心，非工作時間的到院至手術房時間皆高於工作時間(P值為0.19、0.17和0.13)，雖然尚未達統計上顯著差距，但是有顯現此一趨勢。 全部住院日數和急診停留時間的Pearson相關係數為-0.12而P值為0.88。加護病房住院日數和急診停留時間的Pearson相關係數為-0.18而P值為0.87。所以急診停留時間和加護病房住院日數及全部住院日數皆沒有相關性。 結論： 台北市的緊急醫療服務和醫院照護，對於重大創傷的患者，在非工作時間和工作時間相比，兩者的死亡率沒有差異，但是醫院照護的品質在非工作時間有低於工作時間的趨勢。但是這樣的趨勢在醫學中心層級不存在。
並列摘要
Introduction: Traumatic injury, one of the most important leading causes of mortality, is the 5th cause of mortality in Taiwan and the 1st cause of mortality for people under the age 40 in Taiwan. Appropriate immediate and definite care for traumatic patients can decrease the mortality. To achieve this goal, trauma hospital categorization and effective trauma care system need to be implemented to send traumatic patients to right hospital as soon as possible. During off-hours, the decreasing in manpower and resource and the lack of experience among medical team increase the opportunity of medical errors. These factors may decrease the quality of emergency medical service and hospital care, and increase the morbidity and mortality of major trauma patients. Objective: The goal of this study is to assess if the quality of emergency medical service and hospital care for major traumatic patients in Taipei are inferior during off-hours. Materials and Methods: This study retrospectively collected traumatic patients who activated emergency medical services in Taipei and met the major trauma triage rule between February 1, 2002 and January 31, 2003. The working-hours are defined as the interval from 8 AM to 5PM on weekdays and off-hour are defined as the interval from 5PM to 8 AM on weekdays and weekends. Outcomes analysis include: medical resource utilities (rate of CT study, rate of chest X-ray study, rate of ultrasound study, rate of operation), time of trauma to arrival at emergency department, hospital process quality (time to operation room, length of stay in emergency department), patients` outcomes (hospital length of stay, length of stay of intensive unit care, mortality). Results and Discussion: The study population was 638 patients from any a total 13,022 patients who activated emergency medical services in Taipei. There was no difference in the compliance with triage rule project between working-hours and off-hours (58% vs. 61%, p=0.48). The mean age was higher during working-hours (44 vs. 38, p=0.0005). During working-hours, the mortality was 13.5% compared with the 14.1% during off-hours (p=0.77). The mortality was highly correlated to the injury severity score>15 and age>55 (p<0.0001) but not the working-hours. Time of trauma to arrival at emergency department, hospital length of stay, and length of stay of intensive unit care are the same between working-hours and off-hours. For center levels, the time to operation room (214 min vs. 285 min, p=0. 45) and length of stay in emergency department (270 min vs. 232 min, p=0. 54) are not different among medical center between working-hours and off-hours. However, there is a trend that the time to operation room and length of stay in emergency department were higher during off-hours in non-trauma center or non-medical center. However this result was not statistically significant. The Pearson correlation coefficient was -0.12 and p-value was 0.88 between length of stay in emergency department and length of stay of intensive unit care. The Pearson correlation coefficient was -0.18 and p-value was 0.87 between length of stay in emergency department and hospital length of stay. Conclusion: The mortality of major trauma patients in Taipei was the same between work-hours and off-hours. However, there was a trend that the quality of emergency medical service and hospital care for major traumatic patients in Taipei was inferior during off-hours. This trend did not exist in medical center.