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  • 學位論文

探討在超壅塞急診部的電腦斷層使用趨勢與臨床處置及預後的相關性

Association Between The Trends in Utilization of Computed Tomography in An Overcrowding Emergency Department and The Clinical Disposition and Outcome

指導教授 : 張耀仁 葉兆斌

摘要


研究目的:探討在病人超壅塞的急診部門之電腦斷層掃描的使用趨勢與臨床處置及預後間的相關性,包括病人特性、電腦斷層掃描的類型、急診滯留時間、費用、臨床處置(從急診出院或辦理住院接受進一步治療)與住院後的存活率。 研究設計:在台灣中部一家擁有1520張床位的公立醫學中心,進行一項為期五年的回顧性研究。 研究對象:收集2009年至2013年間,到急診就醫成人(≥18歲)的臨床資料,包含接受或不接受電腦斷層掃描之病人,皆做為本研究的對象。 研究指標:對於所有曾經至急診就醫的成人(≥18歲),進行五年的回顧性分析,分析的項目包含:(1)人口統計學的特徵,(2)檢傷分類的級數,(3)是否有接受電腦斷層掃描檢查、是否使用顯影劑和電腦斷層掃描的類型,(4)臨床處置(從急診出院或辦理住院接受進一步治療),(5)在急診滯留觀察時間,(6)在急診就醫之費用總和以及(7)住院的存活率。 研究方法:本研究向醫院人體試驗委員會提出申請,委員會審查核可(證書號碼:CE13233)後,才進行臨床研究,由醫院臨床資訊中心的數據資料庫,收集2009年至2013年間,急診就醫成人(≥18歲)的臨床資料,完成初步篩檢及核對,去除無效個案之後,以SAS 9.4版套裝軟體(SAS Institute Inc, Cary, North Carolina, USA)進行「敘述性分析」、「變異數分析」及「卡方檢定」。 研究結果:在五年的研究期間,共收集269,239人次的急診就醫成人(男性有148,613人次和女性有120,626人次),其中有接受電腦斷層掃描共38,609人次。電腦斷層掃描使用率,從2009年的11.1%增加到2013年的17.7%(趨勢檢定,p<0.001)。五種部位的電腦斷層掃描分類的四種(頭部、胸部、腹部和其他部位)之使用趨勢,呈現越來越多之現象。各年齡層的電腦斷層掃描使用趨勢,也逐年增加。儘管急診電腦斷層掃描的使用率有顯著增加,但每年急診就醫成人的人次,實際上並未隨著增加。此外,在急診接受電腦斷層掃描的成人,隨後辦理住院的比率,則呈現下降趨勢(2009年為59.9%,2013年為48.2%)。接受電腦斷層掃描後而住院的病人存活率,沒有顯著變化(2009年為89.7%,2013年為89.7%)。 研究結論:急診就醫成人接受電腦斷層掃描的使用率,從2009年至2013年,呈現顯著增加。急診醫師可能在執行急診臨床醫療時,會安排非緊急的電腦斷層掃描檢查,以確認或排除某些疾病。所以需要進一步研究,確定在急診之電腦斷層掃描使用率的增加,是否能提高臨床診斷效率、加速臨床處置、減少急診壅塞和降低成本效益。 研究建議:訂定符合醫療政策、實證醫學指引及臨床治療的路徑,讓急診醫師在急診執行臨床診療過程,可以更謹慎地使用電腦斷層掃描,除了能重視醫療效益,更要確保病人安全和醫療品質,包含臨床診斷和及時治療。

並列摘要


Objectives: To investigate the association between the trends of computed tomography utilisation in an emergency department and clinical disposition and outcome, including patients’ characteristics, types of computed tomography, length of stay, cost, clinical disposition (discharge from emergency department or admission for further treatment), and survival rate of hospitalized patients. Setting: A hospital-based retrospective study of a public 1520-bed referral medical center was carried out in central Taiwan. Participants: Adult emergency department visits (aged ≥18 years), who had received computed tomography and those without use of computed tomography, were enrolled as the study participants during 2009–2013. Main outcome measures: For all enrolled emergency department visits, we retrospectively analysed: (1) Demographic characteristics of patients, (2) Triage categories, (3) Whether computed tomography and contrast medium were performed and the types of computed tomography, (4) Further clinical disposition in emergency department, (5) Length of stay in emergency department , (6) Cost in emergency department, and (7) Survival rate of hospitalized patients. Results: In all, 269,239 adult emergency department visits (148,613 male visits and 120,626 female visits) were collected during the 5-year study period, comprising 38,609 computed tomography scans. Utilisation of computed tomography increased from 11.1% in 2009 to 17.7% in 2013 (Trend test, p<0.001). Four in 5 types of computed tomography scans (head, chest, abdomen and miscellaneous) were increasingly utilised during the study period. Also, computed tomography was increasingly ordered annually in all age groups. Although the utilisation of computed tomography in emergency department increased markedly, the annual visits of emergency department did not actually increase. Moreover, the subsequent admission rate, in whom had received computed tomography, declined (59.9% in 2009 to 48.2% in 2013). Survival rate of hospitalized patients, who had received computed tomography, showed no significant increase (89.7% in 2009 and 89.7% in 2013). Conclusions: Computed tomography utilisation in emergency department increased significantly during 2009–2013. Emergency physicians may be using computed tomography for non-emergent studies in the emergency department. Further investigation is needed to determine patient safety and medical quality whether increasing utilisation of computed tomography is efficient and cost-effective, including clinical diagnosis and timely treatment.

參考文獻


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