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| DC 欄位 | 值 | 語言 |
|---|---|---|
| dc.contributor.advisor | 陳秀熙(Hsiu-Hsi Chen) | |
| dc.contributor.author | Felice Tien ODonnell | en |
| dc.contributor.author | 田知學 | zh_TW |
| dc.date.accessioned | 2023-03-19T22:32:40Z | - |
| dc.date.copyright | 2022-10-17 | |
| dc.date.issued | 2022 | |
| dc.date.submitted | 2022-09-27 | |
| dc.identifier.citation | 1.台灣急診醫學會Taiwan Society of Emergency Medicine。 https://www.sem.org.tw/ 2.台灣急診醫學會(2019)。急診醫學的價值。台灣急診醫學通訊，2(4) 3.衛生福利部中央健康保險署。檢傷分類民眾衛教版：https://www.nhi.gov.tw/Content_List.aspx?n=5E61169F8C735065&topn=5FE8C9FEAE863B46 4.FitzGerald G, Jelinek GA, Scott D, Gerdtz MF. Emergency department triage revisited. Emerg Med J. 2010 Feb;27(2):86-92. 5.Kathleen P Hartnett et al. Impact of the COVID-19 Pandemic on Emergency Department Visits - United States, January 1, 2019-May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020 Jun 12;69(23):699-704. 6.美國疾管局CDC (Centers of Disease Control and Prevention) COVID-19專區 https://www.cdc.gov/coronavirus/2019-ncov/index.html 7.Brad Boserup, Mark McKenney, MD, and Adel Elkbuli.The impact of the COVID-19 pandemic on emergency department visits and patient safety in the United States. Am J Emerg Med. 2020;38(9):1732-1736. 8.Molly M. Jeffery et al. Trends in Emergency Department Visits and Hospital Admissions in Health Care Systems in 5 States in the First Months of the COVID-19 Pandemic in the US. JAMA Intern Med. 2020;180(10):1328-1333 9.Sara Nourazari et al. Decreased hospital admissions through emergency departments during the COVID-19 pandemic. Am J Emerg Med. 2021 Apr; 42:203-210. 10.Yachung Jeng et al. Impact of COVID-19 Pandemic on Accessibility of Taiwanese Medical Care. Am J Manag Care. 2021;27(9) 11.David C. Roberts et al. Increasing Rates of Emergency Department Visits for Elderly Patients in the United States, 1993 to 2003. Ann Emerg Med. 2008 Jun;51(6):769-74. 12.Gilbert A et al. Management of emergency department inflows during the COVID-19 outbreak in the CHU of Liege : efficiency of an advanced triage center. Rev Med Liege. 2020 Sup;75(S1):11-17 13.Yuval Levy et al. Emergency Department Triage in the Era of COVID-19: The Sheba Medical Center Experience. Isr Med Assoc J. 2020 Aug;22(8):470-475. 14.Han Sol Chung et al. Revised Triage and Surveillance Protocols for Temporary Emergency Department Closures in Tertiary Hospitals as a Response to COVID-19 Crisis in Daegu Metropolitan City. JKMS 2020 May 18;35(19):e189 15.Chung-Hsien Chaou et al. Traffic Intensity of Patients and Physicians in the Emergency Department: A Queueing Approach for Physician Utilization. J Emerg Med 2018 Nov;55(5):718-725 16.Douglas W Wallace et al. An adapted emergency department triage algorithm for the COVID-19 pandemic. ACEP Open 2020;1:1374–1379 17.Edmond A Hooker, Peter J Mallow, Michelle M Oglesby. Characteristics and Trends of Emergency Department Visits in the United States (2010–2014). J Emerg Med. 2019 Mar;56(3):344-351. 18.Naouri D, et al. Factors associated with inappropriate use of emergency departments: findings from a cross-sectional national study in France. BMJ Qual Saf 2020;29:449–464 19.Asako Miyazawa et al. Inappropriate use of the emergency department for nonurgent conditions: Patient characteristics and associated factors at a Japanese hospital. J Gen Fam Med. 2019;20:146–153. | |
| dc.identifier.uri | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/84918 | - |
| dc.description.abstract | 背景 新冠肺炎大流行期間有全球有許多醫療照護體系發現：由於其快速傳播造成的醫療需求增加以及防疫措施造成醫療資源轉移使得醫療可近性受到衝擊。台灣緊急醫療照護於疫情期間受到的影響值得運用實證資料進行評估，可應用於未來新興傳染病之緊急照護應變發展應對策略。 研究目的 本研究目的主要在建立急診醫療佇列實證資料庫並對新冠肺炎疫情對於台灣緊急醫療照護之衝擊進行系統化實證評估。 研究方法 研究運用回溯式世代研究設計，運用振興醫院之急診數位病歷資料系統建立涵括未有疫情之2019年1月1日到2021年12月31期間急診佇列實證資料庫，評估新冠疫情對於急重症醫療照護系統之影響。本研究收集研究期間每日急診部病患就診、離部動向、心肺停止照護以及急性心肌梗塞照護等資料建立急診佇列系統評估實證資料庫。所收集之民眾對於急重症醫療照護需求訊息包含每日就診量以及各檢傷級別就診人數，並收集急重症需求在接受急診緊急療照護後依病情需求產生包含離部出院、病房住院、加護病房住院、死亡等處置後動向。本研究亦收集急診留觀超過24小時以及自動出院之處置後離部動向，以對於急診處置能量以及整體醫療照護能量進行評估。對於台灣新冠疫情之發展，本研究收集由台灣疾病管制署與指揮中心發布維護之每日確診數位公開資料，包含確診人數以及確診個案縣市別納入於疫情影響評估中。本研究運用所建立之急診實證資料庫結合佇列系統之到達率(arrival rate)以及移出率(departure rate)評估疫情期間相較於未有疫情的變化進行疫情衝擊評估。本研究發展對應於佇列系統到達率以及移出率之布瓦松迴規模式，以評估年別以及新冠肺炎通報個案數對於急診需求與照護之衝擊。本研究進一步發展多項式羅吉斯迴規模式，以對於急診檢傷級別以及不同急診離部動向同時進行評估。對急診品質指標本研究以心肺復甦循環回復率以及急性心肌梗塞之處置品質指標分別運用羅吉斯迴歸以及寇斯迴歸分析量化疫情之影響。 結果 相較於未有疫情之2019年，在考慮新冠肺炎通報個案數後，2020年(RR: 0.85，95%CI: 0.83-0.86)與2021年(RR: 0.84，95%CI: 0.83-0.85)之急診就診率相對降低，顯示除新冠肺炎個案對於醫療照護能量帶來之直接影響外，疫情中的防疫措施以及民眾對於防疫的作為對於急診醫療照護產生降低就診之影響。在考慮新冠肺炎通報個案數後，急診之急重症第一級(RR: 1.22，95% CI: 1.12-1.31，2020年；RR: 1.05，95%CI: 0.97-1.13，2021年)與第二級(RR: 1.20，95% CI: 1.15-1.26，2020年；RR: 1.38，95%CI: 1.32-1.44，2021年)就診率皆高於未有疫情的2019年。而輕症的第四級與第五級個案於疫情期間則少於未有疫情的2019年，顯示急診之醫療照護功能於疫情期間運用分流以及防疫措施下，維持急重症個案照護之主要功能。在納入新冠肺炎通報個案數之影響後，急診出院比率於疫情期間呈現顯著下降趨勢(RR: 0.95，95%CI: 0.92-0.97，2020年；RR: 0.94: 95%CI: 0.92-0.97)，而對應於中重症的一般病房住院(RR: 1.15，95%CI: 1.11-1.19，2020年; RR: 1.12，95%CI: 1.08-1.15，2021年)與加護病房住院(RR: 1.32，95%CI: 1.21-1.45，2020年; RR: 1.14，95%CI: 1.04-1.24，2021年)於疫情期間皆顯著上升。延長滯留率則顯著下降。於2020年間自動出院率明顯著上升。對於急重症照護品質密切相關的死亡則未有顯著變化。急診於心肺復甦之循環回復率於疫情期間未有顯著差異，仍得到維持。急性心肌梗塞病患相較於疫情期間之心電圖完成時間以及啟動治療小組時間相較於2019年未有顯著差異。 結論 新冠肺炎期間民眾緊急醫療利用率下降主要為檢傷第四級以及第五級之輕症個案，在醫療資源調派配置以及防疫措施運用下，急診對於中重症照護能量以及死亡、心肺復甦心率回復率，與急性心肌梗塞照護品質指標品質得到維持。 | zh_TW |
| dc.description.abstract | Background The rapid spread of the COVID-19 pandemic has caused great impact on the medical accessibility of many healthcare systems around the world because of the increased medical demand and the displacement of medical resources caused by prevention measures and health policies. The COVID-19 pandemic had a much later onset in Taiwan than any in other countries in the world. There are unique facts about Taiwan, including the National Health Insurance. It is worth evaluating the impact of COVID-19 pandemic on Emergency Departments (ED) of Taiwan and its response strategies. Purpose The purpose of this study is to establish the registry of the empirical data on queue process of emergent health care and to conduct a systematic analysis of the impact of the COVID-19 outbreak on the services of triage of ED. Methods This is a retrospective cohort study using the existing medical database of the ED of Cheng Hsin General Hospital (CHGH) to establish the registry of the empirical data on queue process covering the period from January 1, 2019 to December 31, 2021. This was done to evaluate the impact of the COVID-19 pandemic on the ED and its critical care system. This study collected data of visits, triage levels on arrival, departures, dispositions, and the critical care events such as cardiopulmonary arrest, myocardial infarction, etc. of the ED patients of CHGH on daily basis during the study period in order to establish the registry of the empirical data on queue process. This study also collected the data of prolonged stays at the ED and discharge against medical advice (DAMA) as associated parameter in the evaluation of the management and medical capacity of ED. Regarding to the progress of the COVID-19 pandemic in Taiwan, this study collected the daily confirmed cases released by the Taiwan Centers for Disease Control (CDC), including the number of New Taipei city and Taipei city, where CHGH is located. The registry of the empirical data on queue process was initiated to analyze the arrival and departure rates in order to evaluate the dynamic change and impact on ED during COVID-19 pandemic compared with pre-pandemic era, 2019. To evaluate the impact of the time (year) and media and pandemic (daily number of confirmed cases reported by the CDC) on the services of the ED, we combined the use of Poisson regression model. This study developed a polynomial Logistic regression model to further evaluate dynamic trends from arrival (triage levels) to departures (hospitalization, DAMA, ect.). As to the quality of critical care, this study used Logistic regression model and Cox regression model by analyzing the rate of return of spontaneous circulation (ROSC) for CPR and the management of acute myocardial infarction (AMI). Results After incorporating the effect of the number of reported cases of COVID-19 there were relatively lower rates of overall visits in the ED in 2020 (RR: 0.85, 95%CI: 0.83-0.86) and 2021 (RR: 0.84, 95%CI: 0.83-0.85), indicating not only the direct impact of COVID-19 pandemic on services of ED, but also the change of medical use of the public due to the health policies and personal decision making affected by the media and the pandemic. After incorporating the effect of the number of reported cases of COVID-19, the arrival rates of triage level 1 (RR: 1.22, 95% CI: 1.12-1.31, in 2020; RR: 1.05, 95% CI: 0.97-1.13, in 2021) and triag level 2 (RR:1.20, 95% CI: 1.15-1.26, in 2020; RR: 1.38, 95% CI: 1.32-1.44, in 2021) were higher than those in 2019. The number of cases with mild disease (triage level 4 and 5) was fewer than that in 2019, indicating that the ED care was spared and maintained for the acute and severe cases under the use of triage system in the combination of epidemic prevention measures. After incorporating the effect of the number of reported cases of COVID-19, the emergency discharge rate showed a significant downward trend (RR: 0.95, 95%CI: 0.92-0.97, 2020; RR: 0.94: 95%CI: 0.92-0.97) , whereas general ward hospitalizations (RR: 1.15, 95%CI: 1.11-1.19, 2020; RR: 1.12, 95%CI: 1.08-1.15, 2021) and intensive care unit(ICU) hospitalizations (RR: 1.32, 2021) 95%CI: 1.21-1.45, 2020; RR: 1.14, 95%CI: 1.04-1.24, 2021) increased significantly during the pandemic. The rate of prolonged stay at the ED dropped significantly. In 2020, the rate of DAMA had risen significantly. There was no significant change in mortality rate, the rate of ROSC from CPR, indicating a decent quality of acute and critical care. In addition, there was no significant difference in the management of patients with AMI before and during COVID-19 pandemic. Conclusions During the COVID-19 pandemic there’s been significant decrease in the arrival rate of ED, which was mainly due to the mild illness (triage level 4 5). With the allocation of medical resources and the application of epidemic prevention measures, the ED of CHGH was still able to maintain standard quality of care on the patients with moderate and critical conditions. | en |
| dc.description.provenance | Made available in DSpace on 2023-03-19T22:32:40Z (GMT). No. of bitstreams: 1 U0001-2209202222064600.pdf: 3859123 bytes, checksum: 9a8db9211fdc99a57ca4b2a60cbdd424 (MD5) Previous issue date: 2022 | en |
| dc.description.tableofcontents | 目錄 口試委員會審定書………………………………………………………………….... i 誌謝………………………………………………………………………… ……….. ii 中文摘要…………………………………………………………………………….. iii 英文摘要……………………………………………………………………………....v 目錄…………………………………………………………………………………….I 圖目錄………………………………………………………………………………..III 表目錄……………………………………………………………………………......IV 壹、前言……………………………………………………………………................1 1.1實習單位簡介……………………………………………...........................1 1.2研究背景…………………………………………………...........................1 1.3文獻探討………………………………………………………...................4 1.3.1急診檢傷分類原則……………………………………………............5 1.3.2台灣及其他國家急診受到新冠病毒疫情爆發的影響………............5 1.3.3其他國家急診因應新冠病毒疫情爆發的方式……………................6 1.3.4急診不當使用的爭議…………………………………………............8 贰、材料與方法………………………………………………………………............9 2.1 研究設計…………………………………………………………………....9 2.2 資料收集…………………………………………………………..............11 2.2.1急重症照護佇列系統數位實證資料庫………………………........11 2.2.2台灣新型冠狀病毒確診人數。……………………………….........13 2.3 統計方法……………………………………………………………..........13 2.3.1佇列系統進入評估新冠疫情對急診就診率衝擊……………........13 2.3.2佇列系統移出評估新冠疫情對急診離部動向率影響………........14 2.3.3貝式動態佇列系統評估…………………………………................15 2.3.4急診急重症醫療照護品質評估……………………………............18 2.3.5貝氏分析演算方法……………………………………………........18 2.4資料來源與研究倫理…………………………………………………........19 叁、研究結果…………………………………………………………………..........20 3.1 振興醫院急診就診趨勢…………………………………………..............20 3.1.1急診就診趨勢……………………………………………..............20 3.1.2急診個案住院趨勢……………………………………..................25 3.1.3急診個案延長等候時間個案趨勢………………………..............27 3.1.43.1.4 到院前無心跳以及院內心跳停止個案趨勢……................27 3.2 以佇列模式評估疫情對急診就診與離部動向之衝擊…………..............29 3.2.1疫情對急診就診率影響: 佇列系統進入評估(Arrival rate)…......29 3.2.2疫情對急診離部動向率影響: 佇列系統移出評估(Departure rate)..34 3.3 疫情對急診重症處置品質影響評估: 以心肺復甦術與急性心肌梗塞為例…………………........................................................................................39 3.3.1急診心肺復甦回復循環評估…………………………..................39 3.3.2急性心肌梗塞急重症照護品質評估…………………………......40 肆、討論與結論……………………………..............................................................46 4.1 研究主要發現………………………………………...................................46 4.2 振興急診經驗分享………………………………………...........................51 4.3 研究限制…………………………………………………….......................57 4.4 結論與建議………………………………………………………...............57 伍、 參考資料………………………………………………………………….……58 圖目錄 圖1.1 2020~2021年疫情指揮中心公告每日台灣確診總人數...................................2 (a) 台北市與新北市新冠肺炎通報個案數，2020-2021..............................................2 (b) 台北市與新北市新冠肺炎通報個案數，2022......................................................3 圖2.1 疫情對於急重症照護評估研究設計與架構..................................................10 圖 2.2 急診多項式累積邏輯思迴歸分析模式貝式 DAG 模型............................15 圖 2.3 貝氏急重症動態佇列系統評估模式.............................................................17 圖 3.1 台北市與新北市新冠肺炎通報個案數，2020-2021.....................................20 圖 3.2 每日急診總來診量之比較，2019-2021.........................................................21 圖 3.3 急診每日來診量和疫情指揮中心報告每日全台確診人數，2020-2021.....21 圖3.4 就疫情嚴峻月份比較......................................................................................24 (a)重症(1級和2級)來診量，2019-2021...................................................................24 (b)相對輕症(4 級和 5 級)來診量，2019-2021........................................................24 圖 3.5 一般住院人數及入住加護病房人數，2019-2021........................................26 圖 3.6 急診留觀超過 72 小時的人數和 72 小時內再度返診的人數.................27 圖 3.7 到院前無心跳以及院內心跳停止人數.........................................................27 圖 3.8 急性心肌梗塞就診至接受心電圖時間年別趨勢.........................................40 圖 3.9 新冠肺炎通報個案數對急性心肌梗塞就診至接受心電圖時間影響評估.41 圖 3.10 急性心肌梗塞完成心電圖至啟動治療小組時間年別趨勢.......................43 圖 3.11 新冠肺炎通報個案數對急性心肌梗塞完成心電圖至啟動治療小組時間 影響評估......................................................................................................................44 圖 4.1 2019到2021年排除到院前心跳停止，在急診室突發心跳停止且接受 CPR 的病人分級來源。......................................................................................................48 圖 4.2 振興急診疫情期間戶外檢傷區.....................................................................51圖 4.3 振興急診疫情期間第一次本部空間規劃.....................................................52 圖 4.4 振興急診疫情期間第二次臨觀區空間規劃.................................................53 圖 4.5 振興急診疫情期間大致流程圖/分區防護原則............................................53 圖 4.6 振興急診戶外檢傷區第一次規劃之流程.....................................................54 圖 4.7 用較踏車運送及增加運送頻次還所以檢體到檢驗室時間.........................56 表目錄 表1.1 以色列Yuval Levy等研究分區結果.................................................................7 表2.1 急診佇列系統監測數位資料庫......................................................................12 表 3.1 到診級別來診量與就診率分佈，2019-2021.................................................20 表 3.2 急診年來診量比較，2019-2021....................................................................21 表 3.3 各級來診量比較，2019-2021........................................................................22 (a)2019 年和 2020 年各級病人來診量................................................................22 (b)2019 年和 2021 年各級病人來診量................................................................22 表 3.4 急診總就診率、重症就診率、輕症就診率，2019-2021............................23 表 3.5 急診離部動向分佈.........................................................................................25 (a)急診離部動向人數與該動向率............................................................................25 (b)離部動向率比值....................................................................................................25 表 3.6 到院前心跳停止以及院內心跳停止個案.....................................................28 表 3.7 年別與新冠肺炎個案數對急診就診率分析結果.........................................29 表 3.8 年別與新冠肺炎個案數對急診重症就診率單變項分析.............................30 表 3.9 年別與新冠肺炎個案數對急診輕中症就診率單變項分析結果.................31 表 3.10 年別與新冠肺炎個案數對急診各檢傷分級到院分佈影響.......................32 (a)單變項分析............................................................................................................32 (b)多變相分析............................................................................................................33 表 3.11 年別與新冠肺炎個案數對急診離部一般病房與加護病房住院率影響...34 表 3.12 年別與新冠肺炎個案數對急診死亡率影響...............................................35 表 3.13 年別與新冠肺炎個案數對急診延長滯留率(超過 24 小時)影響............36 表 3.14 年別與新冠肺炎通報個案數對各離部動向分佈之影響...........................37 (a)單變項分析............................................................................................................37 (b)多變相分析............................................................................................................38 表 3.15 年別與新冠肺炎通報個案數對急診心肺復甦回復循環之影響...............39 表 3.16 年別與新冠肺炎通報個案數對急性心肌梗塞個案就診至接受心電圖時間多變項評估結果......................................................................................................42 表 3.17 年別與新冠肺炎通報個案數對急性心肌梗塞個案完成心電圖至啟動治療小組時間多變項評估結果......................................................................................45 表4.1 2019~2021在急診死亡者來院方式................................................................48 表4.2 比較檢傷後掛號到醫師看診時間..................................................................54 表 4.3 比較新機和舊機的效率.................................................................................55 | |
| dc.language.iso | zh-TW | |
| dc.title | 新型冠狀病毒疫情流行對急診檢傷的衝擊 | zh_TW |
| dc.title | The Impact of COVID-19 Pandemic on Services of Triage of Emergency Department | en |
| dc.type | Thesis | |
| dc.date.schoolyear | 110-2 | |
| dc.description.degree | 碩士 | |
| dc.contributor.coadvisor | 殷偉賢(Wei-Hsian Yin) | |
| dc.contributor.oralexamcommittee | 許辰陽(Chen Yang Hsu) | |
| dc.subject.keyword | 急診佇列實證資料,急診就診率,急診動向,心冠肺炎,佇列系統, | zh_TW |
| dc.subject.keyword | Registry of the empirical data on queue process of emergent health care,Arrival rate,Departure rate,COVID-19,Queue process, | en |
| dc.relation.page | 59 | |
| dc.identifier.doi | 10.6342/NTU202203852 | |
| dc.rights.note | 同意授權(限校園內公開) | |
| dc.date.accepted | 2022-09-28 | |
| dc.contributor.author-college | 公共衛生學院 | zh_TW |
| dc.contributor.author-dept | 公共衛生碩士學位學程 | zh_TW |
| dc.date.embargo-lift | 2022-10-17 | - |
| 顯示於系所單位： | 公共衛生碩士學位學程 | |
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