急診非緊急患者就醫行為

背景急診壅塞已經是存在於各大醫院的現況。學者對於急診資源的耗用，做了相當多的研究研究，卻鮮少以質性研究的方式深入急診了解緊急患者使用急診的相關研究。故本研究期待深入急診環境的方式，了解非緊急患者對於急診的使用情形，並探索急診第一線臨床工作人員又是用什麼樣的眼光看待這樣的現象。研究方法本研究以質性研究的方式，採半結構式一對一深入訪談(semi-structured in-depth interview)之方式蒐集資料。研究對象先以最大變異取樣(maximum variation sampling)與後以立意取樣(purposive sampling)的方法，以北部某人口密集地段之區域教學醫院急診部之醫師、護理師與社工師為受訪對象，探索其與非緊急病人直接接觸之經驗、想法與態度，樣本數以達到資料飽和為終點。結果經過2階段12次訪談(包含共12位受訪者中，醫師3位、護理師7位及社工師2位)與3層次之資料分析(撰寫逐字稿、分群、分群分析)，得到五個重要觀察結果— 第一、民眾的謬思：便利、便宜、他們不了解緊急資源的使用流程、相信大醫院、相信特色醫療、是對資源不熟悉的民眾、沒有地方棲身人的第一選擇；第二、急診醫師的矛盾：非緊急病人是急診醫師養成教育的必需、看輕症是很輕鬆的、經營或人力聘僱上的生態平衡；第三、護理人員的吶喊：第一線的面對衝突、人力缺乏、急診資源有限、沒有辦法滿足每一位病人的需求、專業不受尊重、必須同事面對外來和內部的壓力；第四、非危急病人的風險：硬軟體設備被非緊急病人占用，無法得到適當得評估；最後，不是大家都想要改變：制度與教育不能立即解決問題，只能嘗試科內部的協調來試圖改變現況。結論此「急診非緊急病人就醫行為」之質性研究中揭露出，原來我們總喊著改變不友善的醫療環境，醫護是站在同一陣線上，事實上，病人端不會改變，他們得到便宜、便利的就醫方式；醫師端雖然嚷嚷著改變，對於醫療環境的現況他們態度正向；叫苦連天的是護理人員，想改變環境卻使不上力，當中發現幾個有趣的問題：「理解的落差」、「醫、護角色感受不同」、「急診壅塞現況對於急診的意義」值得再繼續討論。急診壅塞的問題已經存在一段時間，現行可以改變的具體措施有：一、主管對於急診忙碌的了解。二、急診出入口的管控。三、保持急診檢查檢驗的流動性。四、落實衛教。

關鍵字

急診；壅塞；非緊急就醫；五級檢傷分類

並列摘要

Background : Emergency department over-crowding already exists in the current situation in most of medical centers. Scholars do quite a lot of studies in emergency resources consumption, but few in-depth qualitative research methods to understand how emergency patients visited emergency department. In this study, looking in depth emergency environment, to understand the use of non-emergency patients to emergency department, and to explore how the emergency first-line clinical staff feel about this phenomenon. Methods : In this study, qualitative research methods, using semi-structured one by one in-depth interview way of gathering information. Studied first with maximum variation sampling and then with the purposive sampling method. A densely populated metropolitan teaching hospital emergency department northern region of Taiwan , the emergency physician, nurse and social worker for the respondents to explore experience in direct contact with non-urgent patients, ideas and attitudes. The number of samples in order to achieve data saturation was the end. Conclusion : After two stages of 12 interviews (containing a total of 12 respondents, three emergency physicians, seven nurses and two social workers) and three levels of data analysis (written verbatim, clustering, cluster analysis) to obtain five important observations. First, people's muse: convenient, cheap, patients have no idea about the use of emergency resources processes, trust medical center, trust specialty medicine, and the first choice of patients who homeless or not familiar with public resources. Second, contradiction of emergency physicians: non-urgent patients are required to develop an emergency physician education, it is easy to handle simple disease, and the ecological balance on the business owner and employment. Third, shout of nurses: The first-line of facing impact, lack of manpower, limited emergency resources, there is no way to satisfy the needs of every patient, ignore professional, and facing the external and internal pressures simultaneously. Fourth, the risk of non-urgent patients: hardware and software devices are used by non-urgent patients, and unable to properly assess the patient. Finally, not everyone wants to change: institution and education unable to solve the problem immediately, the only we can do to change the status is try to internal coordination. Discussion : This "The medical behavior of non-urgent patients visited emergency department." qualitative research revealed that when we shouting to change unfriendly medical environment, physicians and nurses are on the same side. In fact, patients do not change their behavior because they get cheaper, convenient way for medical treatment. Although clamoring for change, physicians still has positive attitude about the status of the medical environment. The nurses work hardly but could do nothing to change the environment. We also found several interesting questions: "understanding gap", "different feelings of physicians and nurses", "the meaning of emergency department over-crowding" worthy to continue the discussion. The issue of emergency department over-crowding has existed for long time, the way we can change are: first, a leader understand the loading of emergency department. Second, the emergency department entrance control. Third, keep all the emergency inspections and examinations smoothly. Fourth, the implementation of health education.