醫院特性、急診網絡與急診停留時間相關性之探討

Abstract

研究背景：急診壅塞是許多國家醫療體系的重要問題，急診壅塞常導致病患在急診室停留時間過長，而急診停留時間長，將導致醫療照護品質降低，也會造成病情惡化甚至死亡。政府多年來持續投注資源及經費改善急診壅塞問題，從各種面向下手，然而造成急診壅塞之原因多重複雜，效果改善有限。由於醫院無法選擇病患，而由民眾就醫端解決急診壅塞問題需要長時間持續宣導及教育，醫院特性及網絡特性上是否有較多空間可改善急診壅塞值得探討。 研究目的：經由分析醫院及急診網絡特性與急診壅塞之關係，探討急診停留時間過長之重要影響因素。 研究方法：本研究以2013年至2016年急救責任醫院之急診就醫健保申報資料為主要研究對象，將所有就醫病患分為「急診後離院」及「急診後住院」兩群，以病患急診停留時間作為急診壅塞之主要測量指標，以多階層複迴歸模型，探討在控制病患特性，醫院及網絡特性對病患急診停留時間之影響。 研究結果：就醫時醫院急診人次、每一醫師照護人次、醫院門診與急診就醫人次比值、急診人次佔所屬網絡急診人次比率等變項數值越高，則病患急診停留時間較長，醫院相對壅塞程度也較高；相反地，若該時段醫院急診下轉比率較高、醫院急性住院來自急診比率較高，則急診停留時間較短。 結論：本研究結果顯示，急診病患停留時間與就醫當時的急診人次、醫院特性等因素有關。因此持續推動分級醫療，鼓勵輕重症病患分流，減少大醫院輕症門診及輕症住院，強化急診網絡功能，增加轉診合作關係，應能適度縮短病患急診停留時間，減少醫院急診壅塞。

Background: Emergency department congestion is an important issue for the medical systems of many countries. Congestion in emergency rooms often causes patients to stay in the emergency room for too long, and long-term emergency stays lead to a decline in the quality of medical care, which can result in a decline in health status or even death. Over the years, the government of Taiwan has continued to invest resources and funds to improve the problem of emergency department congestion. From various aspects, the causes of emergency congestion are complicated and the effect is limited. Since hospitals cannot select patients, a promising avenue for improvement is control of hospital and network characteristics. Objectives: This research aimed to analyze the relationship between hospital and network characteristics and emergency department congestion in order to determine factors necessary for the improvement of congestion at hospital and policy levels. Methods: The study focused on the emergency medical information of the first aid responsibility hospital from 2013 to 2016. Patient cases were divided into two groups: 'discharged after emergency' and 'hospitalized after emergency'. Length of stay in the emergency room was the primary measure of congestion. We discuss the influence of hospital and network characteristics on the emergency stay time of medical patients through application of a multi-level regression model under the control of patient characteristics. Results: When there were a high number of emergency patients and emergency visits for each doctor, and the ratios of hospital clinics to emergency visits and hospital emergency visits to network emergency visits were high, patients in emergency departments experienced longer stays, and the hospital’s relative congestion was higher. Conversely, emergency stay times reduced when the hospital transfer rate and acute hospitalization rate were higher. Conclusions: The results of this study show that the length of stay in the emergency department is related to hospital and network characteristics. Therefore, to reduce congestion in emergency departments, we make the following recommendations: (1) medical care should be graded, (2) patients should be carefully screened based on the severity of their disease or injury, (3) the number of clinics and minor hospitalizations at large hospitals should be reduced, (4) the network function of emergency departments should be strengthened, and (5) transfer cooperation relationships between hospitals should be improved.