整合醫學科之成立對急診病人滯留時間之影響

The Influence of Hospitalist System on Length of Emergency Stay

急診滯留的問題一直是台灣大醫院的痛處，從衛生福利部中央健康保險署全民醫療保險品質資訊公開網得知台灣於106 年至108 年間，「急診轉住院暫留急診超過四十八小時案件比率」每季指標表現，19 家醫學中心僅5-6 間低於全國指標值。衛生福利部積極規劃一系列的制度試圖解決急診滯留的問題，包含宣導民眾就近就醫、加強適當轉診、要求醫學中心成立整合醫學科等等作為。本研究旨在探討整合醫學科成立前後急診滯留時間是否有顯著降低。研究對象為南部某醫學中心從2014 年8 月至2016 年7 月入急診之病人，排除20 歲以下之病人、兒科、外傷科與索取診斷證明之病人，計112,659 人次。研究結果發現整合醫學科成立可降低急診病人滯留時間，以整體滯留時間來看成立後為3.47 小時，相較成立前時間4 小時減少0.53 小時，具有統計學上之顯著意義(P=0.003)；以不需住院之病人其滯留時間來看減少0.25 小時，也有顯著意義(P=0.01)；惟需住院之病人而言無顯著意義滯留時間減少0.44 小時(P=0.308)。再依據性別、年齡分組、住院科別及檢傷分類做頻率配對，研究結果發現以整體滯留時間來看減少0.67 小時，具有統計學上之顯著意義(P=0.006)；以不需住院之病人其滯留時間來看，也有顯著意義滯留時間減少0.34 小時(P=0.020)；惟需住院之病人而言無顯著意義增加0.03 小時(P=0.638)。進一步探究不同檢傷分類之病人其急診滯留時間之差異情況，我們發現整合醫學科成立對於檢傷2 級與3 級病人減少0.81 小時有顯著差異(p=0.005)，特別是不需住院之檢傷2 級與3 級病人減少0.43 小時(p=0.004)。若能提升整合醫學科的病房周轉率，使病人住院天數降低，將有助於急診效能提升。降低急診滯留時間的議題主要仍攸關於待住院病人之等待病床時間長短。而未來如何讓病房運用發揮最大化，相信是需要所有醫療體系管理者可再更深入探究之議題。

The problem of emergency detention has always been a pain point for Taiwan's large hospitals. From the Universal Health Insurance Quality Information Portal provided by the Central Health Insurance Agency of the Ministry of Health and Welfare, it was revealed that only 5-6 of 19 medical centers had a ''rate of emergency admissions exceeding 48 hours after order placing” were lower than the national index value in 2017 to 2019 quarterly. The Ministry of Health and Welfare is actively testing a series of systems to try to solve the problems resulted from emergency detention, including promoting the public to seek medical treatment in the vicinity, strengthening appropriate referrals, and asking medical centers to set up sections of hospital medicine, etc. The aim of this study was to investigate whether there was a significant reduction in the time spent in emergency units before and after the establishment of the department of Hospitalist. Patients under 20 years of age, pediatric patients, trauma patients and patients who requested a certificate of diagnosis were excluded from the study. Total is 112,659 pieces of data. The results of the study found that the establishment of the Department of Hospitalist could reduce the stay time of emergency patients. In terms of the overall retention time, it was 3.47 hours after the establishment, which was 0.53 hours less than the 4 hours before the establishment, which was statistically significant (P=0.003). In terms of the length of stay of the patients who did not need hospitalization decreased by 0.25 hour, it was also significant (P=0.01). However, the patients who needed hospitalization decreased by 0.44 hour, it was no significant difference(P=0.308). According to gender, age group, inpatient department and Triage by frequency matching, the results showed that the overall length of stay was statistically significant decreased by 0.67 hour (P=0.006). In terms of the length of stay of patients who did not require hospitalization decreased by 0.34 hour, it was also significant (P=0.020). However, the patients requiring hospitalization increased 0.03 hours there was no significant difference (P=0.638). To further explore the differences in the emergency length of stay of patients with different triage classifications, we found that the establishment of the integrative medicine department had a significant difference decreased by 0.81 hour between triage level 2 and level 3 patients (p=0.005). In particular, triage grades 2 and 3 patients who did not require hospitalization decreased by 0.43 hour (p=0.004). If the ward turnover rate of the department of Hospitalist can be improved and the hospitalization days of patients can be reduced, it will help to improve the efficiency of emergency department. The issue of reducing emergency length of stay remains primarily about the length of the hospital bed waiting time for inpatients. ''How to maximize ward utilization in the future'' which is we believe an issue that all healthcare system administrators can explore more deeply.