台北市緊急救護派遣系統之評估研究

Abstract

背景：到院前高級救護（例如進階呼吸道處理、去顫術及靜脈給藥等等）的實施，可有效降低危急個案的死亡率和罹病率。然而，到院前高級救護同時也需要更多醫療及社會資源來支持。台北市自1999年四月開始，已實施雙軌制到院前救護。然而根據2000年的研究資料顯示，其成果並不盡理想。用當時的研究結果與國際上類似的到院前救護研究相比較，台北市的高級救護的派遣不足率和國際上的結果類似，但過度派遣率則遠高於國際水準。高級救護的過度派遣，一方面會造成資源的浪費，另一方面也可能會造成真正需要高級救護個案的延遲派遣。2006年七月之後，台北市更導入了電腦化輔助派遣系統來改善到院前緊急救護的效率。 目的：本研究的目的是統計和分析到院前高級救護近年來的需要和適當性，研究電腦化輔助派遣系統的使用，是否改善到院前緊急救護的派遣的適當性。另外則利用電腦化輔助派遣系統來進行派遣員遵從度的分析。 方法：第一部份研究是對台北市消防局從2005年和2008年的到院前緊急救護的救護記錄表進行回溯性的橫斷分析。分層抽樣並比較2005和2008年1月、4月、7月、10月的第二週所有的救護記錄表的結果。研究回顧所有ALS需要的要件如主訴、傷害/疾病機制、最初的生命徵象及所需的到院前醫療照護，並以百分比來表示ALS需要的比率。而ALS派遣的適當性則由該案件是不是符合ALS派遣的要件來決定。第二部份則是利用電腦程式設定，讀取派遣員進行線上派遣的操作時間，進行遵從度分析。 結果：本研究第一部份在2005年共抽樣7594份救護紀錄表，其中符合ALS標準的有664件，2008年共抽樣8279份救護紀錄表，符合ALS標準的有745件，由此得知台北市ALS需要比例，在2005年及2008年分別為8.74％與9％。在ALS需要時間性方面以季節而言，冬季需要最多，其他季節則無明顯差異，ALS需要在一週七日之間也無明顯的差異，而每日ALS的需要時段也大致上和人們為出活動的時間相關，休息時間ALS需要量較少，這些趨勢基本上這兩年份的資料一致。在ALS需要特性方面，這兩年的分析結果除主訴方面和及急救處置方面有差異外，其他大致上相同。值得注意的是，AED監視、鼻口咽呼吸道和進階呼吸道等進階急救技術的施行，2008年較2005年明顯高出許多（P<0.0001）。 抽樣的ALS的實際派遣案例數各約佔該年份EMS的總案件數的3.06%及2.57%。而在ALS派遣適當性方面，扣除空跑及填寫不完全案例。2005年的ALS適當派遣率（即ALS需要案件正確派出ALS）為67.52％，而2008年電腦輔助派遣系統上線後，ALS適當派遣率上昇為95％。其他如ALS過度派遣率和BLS適當派遣率，也都有明顯提升（P<0.0001），但ALS派遣不足率則同樣為10％左右，並未因電腦系統的介入獲得改善。然而，無論是2005年或2008年，ALS派遣都有相當高的空跑率（32.33％ vs. 43.66%），2008年ALS空跑案件比例反而較2005年為高（P=0.0146）。 第二部分派遣員遵從度研究方面，共從系統下載45660筆資料，但是資料狀況與預期不同，無法利用派遣員操作的時間點來分析派遣員的遵從度。 結論：台北市在電腦輔助派遣系統上線前後，ALS需要比例上沒有明顯變化，皆為9％左右。但是在電腦系統上線之後，ALS適當派遣率、ALS過度派遣率和BLS適當派遣率都有明顯的提升。然而，ALS派遣不足率則無明顯變化，且ALS空跑率反而明顯上升。這表示目前的派遣作業雖有進步但仍有待改進，尤其是派遣準則和派遣員遵從度部分，需要更多的研究深入探討這部份的原因及研究如何進一步的改善。

Background: The implementation of the pre-hospital advanced life support (ALS) measures, such as advanced airway management, defibrillation and intravenous drugs administration, has been shown to reduce the mortality and morbidity to the critical causalities. However, the ALS services require more medical and social resources in both training and the equipment. The two-tiered EMS system took place since April 1999 in Taipei. According to the last study of 2000 in Taipei, the appropriateness of our EMS dispatch was suboptimal. Compared with the previous international studies, the last study showed similar under-triage rate but much higher over-triage rate. Over-triage of ALS dispatch may result in resource-wasting and delaying the cases that actually require ALS services. In July 2006, the computerized medical priority dispatch system was conducted to improve the efficiency of the EMS dispatch in Taipei. Objective: The first part of this study is sought to determine that ALS demand and the appropriateness after several years of the two-tiered EMS system implemented in Taipei, whether or not the computerized dispatch system improved the appropriateness of the EMS dispatch. The second part of study is try to use the computer program of the system to access and record the time periods during each stage of dispatch to check the compliance of dispatchers. Method: A retrospective, cross-sectional analysis of the EMS records of Taipei City Fire Department from January 2005 to December 2008 was conducted. Stratified random sampling of all EMS records in the second week of January, April, July and October of 2005 and 2008 were obtained. Retrospective ALS demand criteria, including the chief complaints, mechanisms of injury/illness, initial vital signs and types of care rendered, were developed to estimate the rate of ALS demand. ALS demand is expressed as the percentage of cases fulfilling ALS criteria over the total number of EMS cases. Appropriate ALS dispatches were those ALS dispatches determined as fulfilling the ALS demand criteria. Results: In the first part of study, 7594 and 8279 EMS cases were retrieved from year 2005 and 2008 database according to the sampling method. 664 (8.74%) and 745 (9%) cases were fulfilled the ALS criteria. Among the two groups, ALS demands were all higher in the cold climates and morning/evening rush hours. The characters of ALS demands between year 2005 and 2008 were similar but true ALS level procedures such as tracheal intubation were performed more often in 2008 (P<0.0001). Actually ALS dispatches were 232 (3.06%) and 213 (2.57%) of sampled EMS calls. Deducting ambulance non-transport and incomplete record cases, the proper triage rate (ALS dispatched to ALS cases) was 67.52% and 95%; and the over-triage rate (ALS dispatched to non-ALS cases) were 32.48% and 5%. The proper triage rate and over-triage rate were significant improved in year 2008(P<0.0001). However, the under-triage rate was not improved (around 10% both) and ALS non-transport rate was significant higher in 2008 (32.33% vs. 43.66%, P=0.0146). In the second part of study, 45660 cases were downloaded from the computer system but failure to determine the compliance of dispatchers. Conclusion: No significant change of ALS demands were found before and after computerized medical priority dispatch system conducted but proper triage rate, over-triage rate were significant better. However, the under-triage rate and non-transport rate were not improved. The compliance of dispatchers was also failure to determine. Further studies for accuracy improvement of dispatch codes and the compliance of dispatchers are recommended.