影響急診嚴重頭部外傷病患存活相關因素與醫療資源耗用情形之探討
—以南部某醫學中心為例

目的本研究主要在探討醫學中心的急診在處置嚴重頭部外傷病患其存活相關因素及醫療資源耗用情形，以瞭解不同病患特性及醫療處置對病患存活結果及醫療資源耗用是否有差異。方法本研究以南部某醫學中心急診嚴重頭部外傷病患為研究對象，採回溯性縱貫式次級資料分析。以醫院的病患資訊系統及健保申報費用進行資料蒐集。蒐集期間為2005年~2009年，符合研究分析之樣本數共206人。主要針對GCS ＜8分病患進行分析。本研究以病患特性及醫療處置為自變項，急診期間存活狀態及醫療資源耗用為依變項，以SPSS for Windows 14.0版套裝軟體進行資料之統計分析，以次數分配、百分比、平均值、標準差做描述性統計分析，再以二項對數迴歸分析及複迴歸分析做推論性統計。結果研究結果顯示，探討急診嚴重頭部外傷病患特性及醫療處置與急診期間存活之關係，急診嚴重頭部外傷病患在病患特性中死亡病患昏迷指數平均值3.8分、存活病患昏迷指數平均值5分（P=0.001）；有使用鎮靜劑存活人數高於死亡人數（P=0.001），皆具有顯著性差異。探討病患特性、醫療處置及急診期間存活狀態在醫療資源耗用的差異，女性病患，昏迷指數低，無使用鎮靜劑、高滲透性利尿劑，有留置氣管內管且執行腦部電腦斷層時間越長，其醫療費用有顯著增加。死亡病患急診總醫療費用平均花費19,281元高於存活病患急診總醫療費用平均花費1,874元（P<0.0001），是具有顯著性差異。以對數及複迴歸分析，探討急診嚴重頭部外傷病患特性、醫療資源耗用與急診期間存活狀態及醫療資源耗用交互作用，有使用鎮靜劑的病患存活是沒有使用鎮靜劑病患的0.374倍（OR 95％CI 0.143~0.978；P＝0.045）。昏迷指數每增加1分，病患存活機率便增加47.7%（OR 95％CI 1.086~2.009；P＝0.013）。執行腦部電腦斷層時間每增加1分，急診總醫療費用就增加80.84元，急診期間死亡病患比存活病患急診總醫療費用多17,178元。結論與建議本研究證實急診嚴重頭部外傷病患昏迷指數、鎮靜使用情形與急診期間存活狀態有顯著的相關，而與性別、年齡、複雜度及其他醫療處置(高滲透性利尿劑、氣管內管、執行腦部電腦斷層時間)並無顯著性相關。而女性病患，昏迷指數低，無使用鎮靜劑、高滲透性利尿劑，有留置氣管內管且執行腦部電腦斷層時間越長，其醫療費用有顯著性相關。因此建議做為日後急診處理嚴重頭部外傷病患重要參考依據，以增加頭部外傷病患存活率，並避免不必要之醫療資源浪費。

關鍵字

嚴重頭部外傷；存活狀態；醫療資源耗用

並列摘要

Objective This study focuses on the medical center's emergency department in the disposition of severe head injury patients and their survival in the case of medical resource utilization, in order to understand the different patient characteristics and medical management on patient survival results and whether there are differences in consumption of medical resources . Methods In this study, a medical center emergency department with severe head injury patients as research subjects and retrospective longitudinal secondary data analysis. Patients to the hospital information system and National Health Insurance costs of data collection. Were collected from 2005 to 2009, consistent with analysis of samples of 206 people.Mainly for GCS <8 hours patients were analyzed.In this study, patient characteristics and medical treatment as independent variables, survival during the state of emergency and medical resource utilization as dependent variables to SPSS for Windows 14.0 software package for data statistical analysis, by frequency, percentage, mean standard deviation did the descriptive statistical analysis, then two pairs of regression analysis and multiple regression analysis to do inferential statistics. Results The results show that study characteristics of emergency patients with severe head trauma and emergency medical treatment and the relationship between the survival period, emergency patients with severe head injury patients in coma patients died characteristics of the average index 3.80 points, the survival index of patients with coma average of 5 minutes (P = 0.001); have to use higher than the number of deaths in the survival of sedatives (P = 0.001), both with significant differences.On patient characteristics, medical treatment and survival status during emergency medical resource utilization differences in female patients with low GCS, no use of tranquilizers, high osmotic diuretics, have indwelling endotracheal tube and the implementation of the time the brain CT The longer the medical costs have increased significantly.Deaths in patients with emergency medical costs total cost 19,281.00 yuan higher than the average survival of patients with emergency medical costs of the total average cost 1,874 dollars (P <0.0001), is a significant difference. Logarithmic and multiple regression analysis to explore the characteristics of emergency patients with severe head injury, and emergency medical resources consumed during the survival status and medical resource utilization interact with sedatives is not used for overall survival in patients with 0.374 times the sedative (OR 95% CI 0.143 ~ 0.978; P = 0.045).Execution time of brain CT was increased by 1 points, emergency medical expenses total increase of 80.84 yuan on the emergency room than the survival of patients died during emergency patients more than 17,178 yuan of total medical costs. Conclusion and Suggestions This study demonstrated that emergency department patients with severe head injury Glasgow Coma Scale, sedation used during emergency situations and survival status were significantly correlated, but not with sex, age, complexity, and other medical management (high osmotic diuretics, endotracheal tube, the implementation of Brain CT time) there is no significant correlation.The female patient, low GCS, no use of tranquilizers, high osmotic diuretics, have indwelling endotracheal tube and the implementation of the CT brain longer, their medical costs were significantly correlated.Therefore proposed as a future treatment of the severe head trauma patients an important reference in order to increase the survival rate of head injury patients, and to avoid unnecessary waste of medical resources.