急診五級檢傷分類之分級、等候時間與預後相關性之探討

Abstract

前言:急診檢傷分類主要的目標就是把適當的人，在適當的時間內，將其安排在適當的地方，使用適當的資源。在台灣現行急診檢傷制度，使用台灣檢傷急迫度分級量表(Taiwan Triage and Acuity Scale,TTAS)來分級，分級標準規劃為五級，各級病患均設置應等候時間，最高級數(一級)需馬上處理，其中二級與三級之病人其等候時間各為10分鐘與30分鐘，四級、五級則可等候一至兩小時處理。就醫民眾的認知總是認為自己最危急，而導致急診人滿為患，急診過度壅塞可能導致候診時間延長以及死亡率增加之危險。 研究目的:探討北部某家醫學中心:(1) 一年內急診來診人數、五級分類人數與預後之相關性(2)了解是否因分級不同、等候時間不同而影響其預後(指病人急診就醫後之動向)包括:返家門診追蹤治療、自動出院、住院、轉院、死亡。 研究方法:此研究屬次級資料分析，以北部某醫學中心急診室之TTAS電腦報表為資料來源，分析2012/08/01 ~ 2013/07/31間之五級檢傷病人的報表資料，以描述性統計了解平均值之改變，而推論性統計方式，使用One-way ANOVA了解分級與等候時間之相關性，以決策樹統計方式分析了解級數、等候時間與預後之影響。 研究結果：急診五級檢傷病人整年急診來診人次高達85279人次，平均年齡為53.43歲，其中以檢傷三級佔的比例最高(58.5%)、檢傷二級次之(23%)。性別的分佈差異上，檢傷一、二級男性明顯多於女性，而檢傷三級至五級，女性明顯多於男性。整體而言，除了檢傷一級與五級的病人之外，其他級數急診暫留時間越長其預後越差，其中以檢傷分類二級的病人在急診暫留時間468分鐘(8小時)其死亡率最高，達6.3%；但檢傷時間與等候醫師看診時間的長短並未影響預後；而急診來診人數的多寡僅會影響檢傷分類二級病人之預後，當日來診人數多於347人次/每日時，檢傷二級病人之死亡率則會增加，亦即來診人數越多檢傷二級病人之預後越差。當疾病嚴重度越高，血氧濃度與收縮壓均越低，相對應的檢傷級數較高時，也會影響其預後。 結論:藉由此研究結果得知急診來診人數的增加對於檢傷二級的病人影響最大，包括每日來診人數越多則死亡率越高，而急診暫留時間越長也會造成住院率上升，在急診暫留8小時死亡率最高佔6.3%；其他檢傷分級則僅受急診暫留時間影響，當暫留時間越長住院率與死亡率都會上升。故希望能藉由此研究之結果，加強宣導非緊急醫療需求之民眾先至一般中小型醫院就診，以提升大型教學醫院緊急醫療救護的品質，也藉此提供實證依據，有效的促進急、重症病患就醫安全，以提升緊急醫療救護品質。 關鍵字:急診室、急診五級檢傷分類系統、等候時間、預後

Background: The aims of emergency triage were to care the appropriate patient at the right location within the appropriate time with the appropriate resources. The current emergency triage system in Taiwan is the five levels based on Taiwan Triage and Acuity Scale (TTAS). Patients in each level are assigned certain waiting time. Patients with the highest level (level 1) need to be processed immediately, patients with level 2 and level 3 may wait 10 minutes to 30 minutes, and for those who are level 4 and level 5 may wait 1 to 2 hours. People seeking medical treatment always regard themselves as the most critical, resulting in too many people visiting the emergency room. The overcrowded inpatients may cause prolonged waiting time which might cause an increasing mortality rate. Purposes: The aims of this secondary data analysis study at a medical center in northern Taiwan were to explore: (1) the correlation between the number of patients seeking emergency care every day, their assigned level categories, and their outcomes, and ; (2) understand whether assigning different levels, and different waiting periods to inpatients would influence their outcomes. The final outcomes are determined by the tracking of patients after emergency medical treatment which could be discharged, against medical advice, admission, transfer or death. Methods: This study was a secondary data analysis which regards the TTAS statistical data reporting a northern Taiwan medical center emergency room as its primary data resource. The collected time period was from 2012/08/01 to 2013/07/31. The data analysis was descriptive statistics and the inferential statistics with One-way ANOVA to explore the correlation between levels and waiting time. Decision tree was used to identify the correlation between assigned levels, waiting times and outcomes. Results: Five-levels in emergency triage system at the emergency clinic visits throughout the year up to 85,279 patients, with an average age of 53.43 years. The majority was triage level three with 58.5%, following by the triage level two (23%). Gender differences were found that more males were found in triage level one and two; whereas, more females were in levels three to five. In overall, those patients with longer emergency stay had the worse the outcomes, except triage level one and five. The longer emergency stay time of468 minutes (around eight hours) is the highest mortality rate with 6.3%; however, the times for triage and waiting to see a physician did not affect outcomes. The amount of patients per day only affected the outcomes of patients with triage level two; the number of people over than 347 /per day increased its hospitalization rates. It indicated that more numbers of patients in emergency room, and then the outcome of the patients with triage level two became worse. When the disease severity is worst with lower level of oxygenation and systolic blood pressure the higher level of triage system and the worst outcomes it became. Conclusion: With the results of this study that increasing the number of patients at emergency room will increase the mortality rate at triage level two. longer length of stay in emergency room will cause the worse outcomes with higher rate of hospitalization and mortality. . The length of stay of eight hours at emergency room is the highest mortality rate. Longer emergency stay had the worse the outcomes at other triage level , We hope that the results offer the important information for the public and we can persuade them to visit small and medium-level general hospital when the condition is not emergent. In order to improving the emergency medical care quality , the public should be well-educated how to access the emergent resources. . Key word: Emergency room，Five-level triage system，Waiting time，Outcome