旗美地區急診醫療業務探討以高雄縣急救責任醫院-某署立醫院為例

研究目的本研究主要目的為探討在2004年12月~2006年8月及2006年9月~2009年12月止，IDS計畫及醫療發展基金獎勵措施實施後，提高旗美地區民眾就醫可近性，是否也提昇急診醫療品質成效。研究方法本研究資料來源取自醫院急診病患就診系統資料，分為三部份，第一部分為2004年1月至2004年11月止急診室就醫的病患共10,621人次，第二部分為2004年12月至2006年8月急診室就醫病患共21,082人次，第三部分為2006年9月至2009年12月急診室就醫病患共44,740人次。並透過電腦系統取得所有就診名單與就診時間相關之各項變數因子、檢傷級數等資訊。統計方法以SPSS14.0統計軟體進行描述性分析、相關分析(Correlation)與迴歸分析(Regression)。研究結果 IDS計畫及醫療發展基金獎勵措施實施後急診就醫人次明顯增加，病患來源部分，以自行前來病患最多。年齡部分，以15-64歲病患最多；其次為65歲以上。男性對於急診醫療的需求高於女性。疾病嚴重度以檢傷分級第三級最多，其次為檢傷第二級。就診科別以內科最多，小兒科最少。創傷部份，以非創傷居多。在轉院部分，IDS計畫及醫療發展基金獎勵措施實施後，IDS計畫實施後轉院上升1.65％，醫療發展基金獎勵措施實施後較IDS計畫下降2.62％，在統計上有顯著差異。轉住院部分，IDS計畫實施後轉住院上升0.61％，醫療發展基金獎勵措施實施後較IDS計畫下降2.05％，在統計上有顯著差異。留置時間≧6小時部分，IDS計畫實施後留置時間≧6小時上升1.48％，醫療發展基金獎勵措施實施後較IDS計畫上升4.7％，在統計上有顯著差異。轉住院下降及留置時間≧6小時上升，兩者是否有連動關係需更進一步探討。24小時內返診部分，IDS計畫實施後上升0.04％，醫療發展基金獎勵措施實施後較IDS計畫下降0.27％，在統計上有顯著差異。死亡率部分，IDS計畫實施後就診後死亡下降0.3％，醫療發展基金獎勵措施實施後較IDS計畫下降0.07％，在統計上有顯著差異。討論與建議醫療發展基金獎勵措施實施後，需要轉診的比率相對較低，所以研究醫院目前以內、外科醫師共同提供社區急診醫療服務的模式，確實能達到大部分社區民眾需求，綜上所述，研究醫院如要再降低轉診比率，提高住院率，應從提供老年急重症病患更完善之醫療照護為主，分析這些病患轉出原因，來提高民眾對於地區醫院之信賴。另轉住院下降及留置時間≧6小時上升，兩者是否有連動關係需更進一步深入探討。地區醫院與大型醫學中心之特性不同，其主要功能在於對提供社區民眾之可近性醫療服務。社區化之地區醫院應為社區民眾就診之首要選擇，尤其當醫療需求有其急迫性時，所以地區醫院中急診室的病患人口學分布、疾病型態、醫療資源分布..等等，應可做為該社區醫療需求之評估依據。

關鍵字

緊急醫療； IDS計畫(整合性醫療服務) ；醫療發展基金獎勵措施

並列摘要

Objective The aim of this study is to explore if the quality of emergency medical service was improved when incentives and rewards were provided through Integrated Delivery Service (IDS) between December 2004 and August 2006 and through Medical Care Development Fund between September 2006 and December 2009. Research Methods The current study drew on data collected from the emergency medical care system of the subject hospital. The data collected was divided into three parts. The first part included information of 10,621 patients who were admitted to the emergency room from January 2004 to November 2004. The second part included information of 21,082 patients who were admitted to the emergency room from December 2004 to August 2006. The third part included information of 44,740 patients who were admitted to the emergency room from December 2006 to December 2009. The system also enabled collection of all variables related to patient lists, time of treatment and triage. Using SPSS 14.0, the collected data underwent descriptive analysis, correlation and regression analysis. Results The results of the analysis showed significant increase in the number of patients admitted to the emergency room when incentives and rewards were provided through IDS and through Medical Care Development Fund. Most patients visited the emergency room on their own. The biggest age group of patients was men and women from 15 to 64, followed by the over 65 age group. The number of male patients requiring emergency medical care was higher than female patients. In terms of acuity levels, most patients were diagnosed as level 3, followed by level 2. In terms of medical care needed, most patients required internal medicine and fewest patients require pediatricians. Most trauma patients were non-invasive trauma. After implementation of IDS, referral rates of the subject hospital increased by 1.65%. When Medical Care Development Fund was implemented, referral rates were 2.62% lower than the figure after IDS was implemented, which was statistically significant. As for the number of hospitalized patients, hospitalization rate increased by 0.61% after IDS was implemented. Compared with the figure of hospitalization rate after IDS was implemented, hospitalization rate after Medical Care Development Fund was implemented dropped by 2.50%, which was statistically significant. The number of patients who were retained for six hours or over (≧6 hours) increased by 1.48％ after IDS was implemented and there was another 4.7% increase after Medical Care Development Fund was implemented. This change was statistically significant. Further analysis is needed to determine if there is any correlation between the drop of hospitalization rate and the fact that more patients were retained for six hours or over. After IDS was implemented, the number of patients readmitted within 24 hours of discharge increased by 0.04%. After Medical Care Development Fund was implemented, the figure dropped by 0.27% from the figure after IDS was implemented and the number was statistically significant. After IDS was implemented, Deaths dropped by 0.3% and the figure dropped a further 0.07% after Medical Care Development Fund was implemented, which was statistically significant. Discussion and Suggestions After Medical Care Development Fund was implemented, the number of patients requiring referrals was relatively lower; hence it could be concluded that subject hospitals’ current practice of having both physicians and surgeons providing community emergency medical service could meet the needs of most residents in the community. Furthermore, the results of the analysis suggest that if the subject hospital wishes to decrease referral rates and increase hospitalization rate, they should concentrate on providing more comprehensive medical care for senior patients and critically ill patients and they need to analyze reasons why such patients chose to transfer to other hospitals. The subject hospital should work to improve community residents’ trust for local hospitals. On the other hand, further analysis is needed to determine if there is any correlation between the drop of hospitalization rate and the fact that more patients were retained for six hours or over. Local hospitals are different from large medical institutions because their main functions are to provide accessible medical services to local communities. Local hospitals should be the first choices for local communities, particularly when they require emergency medical service. Hence, information related to demographic distribution of patients in the emergency room, types of diseases and distribution of medical resources can be used to evaluate the medical needs of local communities.