新型冠狀病毒疫情對急診照護結果之影響及相關因素之探討

Abstract

研究背景與目的：2019 年年底爆發的新型冠狀病毒(COVID-19) 大流行嚴重地影響了全球的醫療服務，其中又以急診部門受創最為嚴重。當時急診室面臨著巨大的工作量，工作人員在嚴峻的條件下必須同時處理疑似新冠的個案和非新冠的患者。潛藏的「排擠效應」可能導致非新冠患者的治療照護有所延誤，而使健康結果惡化，特別是對於那些急診近期返診的高風險族群。儘管大流行期間急診就診人數減少，但急診病患的死亡率卻上升，這凸顯出了解疫情對急診影響的迫切性與重要性。本研究的主要目的在檢視COVID-19 爆發與外傷性成年患者、非外傷性成年患者以及高齡患者急診近期返診後之不良健康結果之間的關聯。透過分析疫情前後的患者和醫院系統性特徵，我們期待可以確定大流行是否加劇了這些高風險患者的健康風險，並確定影響其照護結果的各項因素，以便在類似疫情危機期間得以更好的擘劃醫療策略。此外，我們也調查了疑似COVID-19 病例的篩檢工作量與急診近期返診病患健康結果之間的關聯，以確定防疫工作量與急診照護品質之間是否存在潛在關聯。 研究方法：這是一項回溯性量性研究，重點在比較臺北榮民總醫院(TVGH) 在COVID-19 流行前後急診近期返診的成年人。2020 年1 月1 日至2020 年12月31 日的個案被歸類為研究組，而2019 年1 月1 日至2019 年12 月31 日的個案則被歸類為對照組。我們將研究族群分為外傷性、非外傷性和高齡次族群分別進行分析和討論。主要的依變項包括返診後入院、入住加護病房、住院期間死亡率、以及無生命跡象返診。再者，為了調查疑似新冠個案篩檢工作量與急診近期返診患者健康結果之間的關係，我們回溯性地收錄了自2020 年1 月27 日起北榮在急診室外正式設立發燒篩檢站以來的急診近期返診個案。我們應用羅吉斯迴歸分析模型來確定上述研究設計中影響健康結果的獨立預測因子。 研究結果：對於外傷性患者、非外傷性患者、及高齡患者族群而言，院外心臟驟停事件及入住加護病房的結果在疫情前後並無顯著差異。然而，在非外傷性患者及高齡患者中，疫情期間的院內死亡率顯著升高。另外透過羅吉斯迴歸分析顯示，新冠病毒疫情是非外傷性成人患者院內死亡率的獨立預測因子（aOR=2.371，p=0.015）。對於高齡患者，新冠病毒疫情同時是返診後住院（aOR=1.381，p=0.038）及院內死亡（aOR=2.620，p=0.032）的獨立預測因子。疫情期間每日疑似新冠案例數平均為9.4 ± 10.7，而每日疑似病例篩檢工作量在本篇研究中被確認為院內死亡的顯著預測因子（aOR=1.057，p=0.015）。 結論：本研究探討新型冠狀病毒疫情對急診近期返診患者健康結果的影響，我們發現疫情期間非外傷性患者與高齡患者的返診後死亡率顯著增加，防疫工作量也加劇了急診資源的排擠效應。本研究確認急診近期返診作為醫療品質指標的價值，並建議優化急診資源配置、加強高風險患者照護與出院後追蹤，以及提升急診系統韌性和醫療人員支持。未來應進一步研究疫情對長期健康結果的影響，為類似公共衛生危機中的醫療策略提供相關實證基礎。

Background and Objective: The coronavirus disease 2019 (COVID-19) pandemic, originating in December 2019, drastically impacted global healthcare, particularly in emergency departments (EDs). EDs faced overwhelming workloads, with staff managing both COVID-19 and non-COVID patients under severe conditions. This "crowding-out effect" led to delays in care for non-COVID patients, and worsening outcomes, especially for high-risk groups like those with frequent ED revisits. Despite reduced overall ED visits during the pandemic, mortality rates increased, highlighting the critical need to understand the pandemic's impact on emergency care. The primary objective of this study is to examine the association between the COVID-19 outbreak and adverse outcomes in traumatic adult patients, non-traumatic adult patients, and older patients who revisit the ED shortly after discharge. By analyzing patient and hospital characteristics before and after the pandemic, the research aims to determine whether the pandemic has exacerbated these high-risk patients' risks and identify factors influencing their outcomes to inform better healthcare strategies during such crises. Furthermore, we also investigate the association between the workload of screening for suspected COVID-19 cases and outcomes of ED revisiting patients to determine whether a potential link exists between the epidemic prevention workload and the quality of ED care.

Methods: This was a retrospective study to compare adults with short-term ED revisits before and after the COVID-19 epidemic in Taipei Veterans General Hospital (TVGH). The encounters from January 1, 2020, through December 31, 2020, were categorized as the study group, while from January 1, 2019, through December 31, 2019, as the control group. We categorized the study population into traumatic, nontraumatic, and elderly sub-groups for analysis and discussion respectively. The primary outcome was in-hospital mortality after short-term ED revisit and the secondary outcomes included subsequent hospital admission and intensive care unit (ICU) admission. In order to investigate the association between screening for suspected COVID-19 and outcomes of ED revisiting patients, furthermore, we retrospectively enrolled short-term ED revisit individuals since January 27, 2020, when a formal fever screening station was set up outside the ED in TVGH. The proportion of suspected COVID-19 cases was calculated and was investigated as one of the potential predictors. Logistic regression models were used to identify independent predictors for outcomes among the above mentioned study design.

Results: There was no significant difference in outcomes of out-of-hospital cardiac arrest, hospital admission, or ICU admission between two groups among traumatic, non-traumatic and older patients. However, significant higher in-hospital mortality in the study group was noticed among both non-traumatic and older patients. In logistic regression models, COVID-19 period was identified as the independent predictor for in-hospital mortality (aOR=2.371, p=0.015) among non-traumatic adults and both hospital admission (aOR=1.381, p=0.038) and in-hospital mortality (aOR=2.620, p=0.032) among older patients with short ED revisits. During COVID-19 period, daily suspected COVID-19 cases had a mean of 9.4 ± 10.7 and the volume of daily suspect COVID-19 cases was identified as one of the significant predictors for inhospital mortality (aOR=1.057, p=0.015) in the logistic regression model.

Conclusion: In conclusion, this study found that subsequent outcomes of individuals with 72-hour ED revisits were significantly poorer during COVID-19, and the COVID-19 period was an independent predictor for adverse consequences of nontraumatic and older patients with 72-hour ED revisits. Furthermore, we identified the impact of the workload on screening suspected COVID-19 in the ED, which can violate the outcome of short ED revisiting patients. Clarifying such an association could help patients, ED providers, and policymakers to make modifications regarding the optimal delivery of emergency services during the epidemic.