急診壅塞的原因與改善策略

Emergency department overcrowding: an overview of critical issues and improvement strategies

本文以文獻回顧方式，就急診壅塞概況（包含台灣現況）、原因與機轉、對醫療品質之衝擊及相關的改善策略等各面向進行討論。作者搜尋1999至2019年急診壅塞的相關文獻，再挑選較具代表性的文章加以整理。文獻整理的結果發現輸入—處理效能—輸出的概念模型可用來分析急診壅塞的原因、所造成的影響及可能的解決辦法。作者另提出急診病人與其他類型的病人會共同競爭醫院的一般病床資源的生態，且以水庫的「水位」來說明急診壅塞如何形成的機轉。造成急診壅塞的成因非常複雜，主要發生在輸出端、醫院系統的問題、以及背後醫療體系與給付制度的生態等多重因素所造成。急診的壅塞的相關指標可由等候時間的延長及空間的擁擠情形分別來定義，其中急診留滯病人數能間接反應急診佔床率的概念。改善急診室壅塞的策略可以由急診流程、醫院管理、社區面等方面來討論。已經造成急診壅塞的醫院，必須注意維持照護品質與病人安全。急診壅塞未來將面臨新的挑戰，包含醫療環境的變化與急診生態與作業模式的改變，所以必須以新的思維面對急診壅塞的情形。醫院管理在處理急診壅塞時可能面臨財務上的阻力，因此政策的介入以提高誘因將更形重要。本文所整理急診壅塞各種相關問題的重要文獻，應對國內有志於進行急診壅塞相關研究的學者有所助益，進一步或可引導未來有效的政策之建議。

This study reviews emergency department (ED) crowding by focusing on the current situations in Taiwan, causes and mechanisms, the impact of ED crowding on health care quality, and improvement strategies. We searched studies addressing ED crowding between 1999 and 2019 and summarized the most representative articles. We found that the input-throughput-output model can help analyze the causes and effects of ED crowding and reveal potential solutions. ED patients must compete for medical resources, such as acute care beds, with non-ED patients, and reservoir level has been used to explain the mechanism of ED crowding. ED crowding stems from multiple complex factors, mainly including output factors, hospital operation systems, and the health care system overall. The indicators of ED crowding are prolonged waiting time and a crowded space. The number of patients in the ED is indirectly correlated with the ED occupancy rate, and is useful to reflect the situation of crowding. Strategies to solve ED crowding include changes in ED operations and hospital management and the use of a community network. ED crowding has been a critical issue for hospitals, and changes in the health care environment and operations have exacerbated this problem; every staff member has to expend considerable effort in dealing with it. Financial pressure might prevent decision-makers from implementing potential solutions; therefore, incentives and government support may be required. We hope that this study provides a useful overview for researchers and policymakers and guides them to make effective policies for addressing ED crowding. (Taiwan J Public Health. 2021;40(1):8-29)