急診醫師資深度對急診臨床表現的影響

The Influence of Emergency Physician Seniority on Clinical Performance in the Emergency Department

李肇瑞(Chao-Jui Li)

指導教授 ： 李建宏

高雄醫學大學/健康科學院/公共衛生學系環境暨職業安全衛生博士班/博士(2016年)

摘要

背景： 一般來說，臨床醫師會隨著工作年資的增加累積臨床知識、技巧，因此也能提供較好的醫療照護品質；然而，在急診醫師龐大的工作壓力下，急診醫師是否能夠持續在急診室工作，一直存在著疑問。急診醫師負責處理急診大量的傷患，因此評估急診醫師的臨床能力，主要可由四個面向觀察：評估患者的效率、需要使用的醫療資源、患者的預後、患者動向安排的準確性；然而急診醫師資深度在這幾個面向上的相關性卻未被確定，本研究的第一個目的，希望了解，急診醫師的臨床表現與急診工作年資的相關性。
另一方面，透過良好的住院醫師訓練，醫師才有可能提供良好的醫療照護。急診住院醫師藉由在急診室第一線照護患者，同時接受主治醫師的指導，包括檢視病史詢問、理學檢查、調整治療計畫、以及討論患者動向安排、及協助完成侵入性醫療處置；住院醫師的訓練是否對急診作業造成影響，在最近幾年常被提出討論，本研究的第二個目的是在了解，不同資深度的住院醫師，是否造成急診臨床表現的差異；由於住院醫師在急診除了接收教育訓練之外，也同時被賦予了不同程度的醫療任務，了解此差異，可用做急診醫療任務分派的參考。
研究設計與方法： 為了瞭解急診醫師工作年資和急診臨床表現之間的關係，本研究針對台灣地區最大之醫療體系的北台灣三院區急診白班非外傷患者進行為期一年的回溯性世代研究(從2011年7月1日到2012年6月30日)，醫師依照主治醫師工作年資被分為五年以下的資淺醫師、六到十年的中等年資醫師、和超過十年的資深醫師；患者由掛號到完成醫囑開立，以及掛號到完成動向安排的時間被用作醫師看診效率的指標，急診醫療資源使用評估包括心電圖、X光、檢驗室檢查、以及電腦斷層等診斷工具，患者的出院或死亡被用作患者預後的評估，患者動向的正確性評估，包括醫師下班時患者的動向、患者的最終動向、以及患者是否有72小時返回急診。
為了探究不同職級住院醫師對臨床表現的影響，我們在同一時段針對台灣地區最大之醫療體系的五院區急診白班非外傷患者進行另一個回溯性世代研究，來診患者被分成在主治醫師指導下由住院醫師看診，和主治醫師直接看診兩組，住院醫師進一步區分為資淺住院醫師(畢業後一年住院醫師、第一年住院醫師)、中等年資住院醫師(第二年、第三年住院醫師)、資深住院醫師(第四年、第五年住院醫師)；決策時間(患者由掛號到完成醫囑開立，以及掛號到完成動向安排的時間)，患者動向安排、診斷工具使用評估(包括檢驗室檢查、以及電腦斷層)，被用作急診表現指標，用來評估不同職級住院醫師在主治醫師指導下看診，和主治醫師單獨看診之間的差異。
結果： 資深急診主治醫師花費較長的時間完成急症患者與非急症患者之醫囑開立 (11.3, 12.4 分鐘)以及動向決定(2, 1.7 小時)，(資淺主治醫師醫師，醫囑開立：9.4, 10.2分鐘，動向決定：1.7, 1.5小時; 中等年資主治醫師，醫囑開立：9.5, 10.7 min，動向決定：1.7, 1.5小時)；資深主治醫師在非急症患者使用較少的心電圖、X光、實驗室檢查和電腦斷層；在控制患者的年齡、性別、疾病嚴重度、和醫療單位後，資深主治醫師看診的患者有較低的死亡率(控制後勝算比分別為：1.5, 1.6)；資深急診醫師傾向讓較多的患者留滯急診觀察(相對於資淺主治醫師增加2.7%，相較於中等年資主治醫師增加2.3%)，患者需要較長的時間才能出院(相對於資淺主治醫師增加0.2小時，相較於中等年資主治醫師增加0.1小時)；資深主治醫師診視的患者，有較低的急診72小時返診率(相對於資淺主治醫師減少0.5%， 相較於中等年資主治醫師減少0.3%)。
另一方面，住院醫師在主治醫師指導下看診，所花費的醫囑開立時間和患者動向決定時間，會隨著住院醫師的資深度增加而縮短；但相對於主治醫師單獨看診，資淺住院醫師看診，將導致較多的患者急診留院觀察(控制後勝算比，1.1; 95% 信賴區間，1.07–1.20)，住院醫師看診，將導致較多的實驗室檢查使用(資遣住院醫師：控制後勝算比，1.1; 95% CI, 1.03–1.16；中等年資住院醫師：控制後勝算比，1.1, 95%信賴區間，1.04–1.15；資深住院醫師：控制後勝算比，1.1, 95%信賴區間，1.05–1.15)。

結論： 相對於工作年資十年以下的主治醫師，資深主治醫師花費較長的時間完成醫囑開立、以及決定患者動向，但對於非急症患者使用較少的診斷工具，同時患者有較低的死亡率；資深主治醫師有最好的醫療照護品質(最低的死亡率，較少的72小時返診率)，但稍微延長了患者的急診滯留時間。住院醫師看診除了增加實驗室檢查的使用，也同時增延長患者動向安排所需要的時間。

關鍵字

急診醫師 ； 年資 ； 臨床表現

並列摘要

Background: It is generally believed that physicians who have more experience have also accumulated knowledge and skills during their years in practice, and are therefore able to deliver higher quality care. The ability of emergency physicians (EPs) to continue within the specialty has been called into question due to high stress in emergency departments (EDs). EPs see a large volume of cases of varying complexity. The major concerns for EP clinical performance can be divided into four areas: the efficiency of patient assessment, the resource usage for patient diagnosis, the outcomes of treated patients, and the accuracy of disposition decisions. However, the relationship between clinical performance and the seniority of EPs is not well established. The first purpose of this study was to evaluate the associations between the duration of EP experience and these aspects of clinical performance.
On the other hand, High quality patient care can only be provided if physicians are well prepared for this task through residency training. In the ED, residents are trained and educated via patient primary care under the supervision of attending physicians, who review histories and physical examinations, adjust treatment options, discuss disposition plans, and assist with procedures. Thus, the aim of the present study is also to clarify the influence of resident seniority on supervised practice in ED. It is believed that the results of this study will help in adjustment of supervision or rearrangement of clinical loading in the ED.
Research Design and Methods: To evaluate the associations between the duration of EP experience and these aspects of clinical performance, a retrospective, one-year, cohort study was conducted across three EDs in the largest healthcare system in Northern Taiwan. Participants included all day-shift non-traumatic adult patients. who presented to the EDs between 1 July 2011 and 30 June 2012. Physicians were categorized as junior, intermediate and senior EPs according to ≤5, 6–10 and >10 years of ED work experience. The door-to-order and door-to-disposition time were used to evaluate EP efficiency. ED resource use indicators included diagnostic investigations of electrocardiography, plain film radiography, laboratory tests and computed tomography scans. Discharge and mortality rates were used as patient outcomes. The outcome involves disposition accuracy included patient dispositions at the end of the shift, patient final dispositions and patient 72-hour ED return.
To investigate the influence of resident seniority on supervised clinical practice in the ED. Another retrospective, one-year cohort study was conducted in five EDs within the same healthcare system. All adult non-trauma visits presenting to the EDs during the day shift during the same period were included in the analysis. Visits were divided into supervised (i.e., treated by resident under attending physician’s supervision) and attending-alone. Supervised visits were further categorized by resident seniority (junior [PGY1, R1], intermediate [R2, R3], and senior [R4, R5]). The decision-making time (door-to-order and door-to-disposition time), patient dispositions (e.g., ED observation and hospital admission), and diagnostic tool use (laboratory examination or computed tomography [CT]) were selected as clinical performance indicators. The differences in clinical performance were determined between supervised visits (i.e., resident-seniority groups) and attending-alone visits.
Results: Senior EPs were found to have longer door-to-order (11.3, 12.4 min) and door-to-disposition (2, 1.7 hours) time than non-senior EPs in urgent and non-urgent patients (junior: 9.4, 10.2 min and 1.7, 1.5 hours; intermediate: 9.5, 10.7 min and 1.7, 1.5 hours). Senior EPs tended to order fewer electrocardiograms, radiographs and computed tomography scans in non-urgent patients. Adjusting for age, sex, disease acuity, and medical setting, patients treated by junior and intermediate EPs had higher mortality in the ED (adjusted-odd-ratios, 1.5 and 1.6, respectively). Senior EPs also kept more patients in the ED (2.7% more than junior EP, 2.3% more than intermediate EP); they took more time for patient discharge (0.2 more hour than junior EP, 0.1 more hour than intermediate EP); they had fewer patients return to the ED within 72 hours after discharge (0.5% fewer than junior EP, 0.3% fewer than intermediate EP).
On the other hand, increasing resident seniority led to decreasing door-to-order and door-to-disposition time among supervised visits. Furthermore, compared with attending-alone visits, supervised visits with junior residents had a greater odds of ED observation (adjusted odds ratio [aOR], 1.1; 95% CI, 1.07–1.20), while supervised visits with all three resident-seniority groups had significantly greater odds of laboratory examinations (junior: aOR, 1.1; 95% CI, 1.03–1.16; intermediate: aOR, 1.1; 95% CI, 1.04–1.15; senior: aOR, 1.1; 95% CI, 1.05–1.15).
Conclusions: Compared to EPs with ≤10 years of work experience, senior EPs take more time for order prescription and patient disposition, use fewer diagnostic investigations, particularly for non-urgent patients, and are associated with a lower ED mortality rate. Senior EPs had the best quality of care (lowest mortality, fewest 72 hour returns). This best quality of care is accompanied with a slightly longer length of stay. In addition, compared to attending-alone visits, supervised visits still resulted in greater use of laboratory examinations and delayed patient disposition.

並列關鍵字

Emeregency physician ； Seniority ； Clinical performance

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