探討中部某教學醫院非計畫性72小時重返兒童急診之相關因素

Exploring the Factors for the Unplanned Return Visits to a Hospital’s Pediatric Emergency Department Within 72 hours in Central Taiwan

目的：探討中部某教學醫院非計畫性72小時重返兒童急診之常見原因，進而探討急診照護結構與急診照護過程和非計畫72小時重返兒童急診之間的關係。
方法：本回溯性描述探索性研究以醫療成果研究（Medical Outcome Study）之照護品質理論為基礎，取自中部某教學醫院資料庫，納入517位非計畫性72小時重返兒童急診之病孩及其在照護結構及照護過程的相關資料做分析。
結果：研究對象多為學齡前期，重返急診常見健康問題有近半為症狀、徵象與臨床和檢驗值的異常發現（以發燒居多），另外近三分之一因呼吸系統疾病而重返。層次邏輯回歸分析顯示與非自動出院者相比，雖該模式不具統計學上的顯著意義，但能解釋自動出院者非計畫性72小時重返的20.8%（Nagelkerke R2）變異量；另外，照護結構中的主要照護者教育程度為大學以下、照護過程中的檢驗及檢查項目數一項以上者，是自動出院後非計劃性72小時重返的預測因子。
結論：過去文獻得知影響非計畫重返急診之因素，例如病孩的疾病嚴重度、醫病比、護病比、以及照護者之健康識能等在此研究中都不具統計學上之顯著意義。此可能受限於使用次級資料，變項無法精準操作有關，其他可能造成的原因及建議於本文亦有做探討。未來研究應以前瞻性之對照研究法，納入沒有重返之病孩資料一併探討其重返的源由。

Purpose: To explore the factors of unplanned 72- hour return to the pediatric emergency department in a teaching hospital in central Taiwan, and further, explored the associations between the structure and process of care and unplanned return to the pediatric emergency department.
Methods: This retrospective descriptive exploratory study was based on the quality of care theory of the Medical Outcome Study, and data were extracted from the database of a teaching hospital in central Taiwan. Data from 517 participants who were the unplanned return to a pediatric emergency within 72 hours were recruited and analyzed.
Results: Most of the pediatric patients were preschoolers. Nearly half of them returned to the emergency department due to common health problems or abnormal clinical test results (fever was most common), and nearly one-third returned with respiratory problems. Hierarchical logistic regression analysis showed that the model was not statistically significant; however, it explained 20.8% (Nagelkerke R2) of the variation in the unplanned return from automatic discharge compared with those non-automatically discharged. In addition, the primary caregiver’s education level was less than college, and patients who had more than one examination item were the predictors of unplanned return within 72 hours after the automatic discharge.
Conclusion: Related factors of unplanned return to the emergency department known in the previous literature such as the disease severity, doctor-to-patient ratio, nurse-to-patient ratio, and health literacy of the primary caregivers, were not statistically significant in this study. This might be limited using secondary data, and variables cannot be accurately manipulated; other relative factors and suggestions are also discussed in this article. Future research should adopt prospective longitudinal approaches and recruit data on children who did not return, to explore the reasons for their return.