[ 摘要 ]

我國兒童急診利用約佔全部急診利用四分之ㄧ，且兒童容易因生理、心理因素影響對於疾病及外傷之感受，進而影響醫療照顧者的評估與治療。然而國內急診相關研究多以全年齡層為研究對象，尚無以全國資料針對兒童探討急診利用及品質之相關研究。

目的：

探討我國兒童急診利用情形，並進一步以病患層次探討影響兒童急診暫留時間、再急診、急診後死亡之因素，從醫院層次，校正病患風險後，探討醫院特質與急診照護品質之關聯性。

方法：

以2005年健保資料庫中申報急診之病患且年齡未滿18歲者為研究對象，並聯結「死因統計資料檔」、「戶籍登記檔」、「醫事機構年底現況檔」取得變項資料，以廣義估計方程式(generalized estimating equations，GEE)分析影響兒童急診暫留時間、再急診、急診死亡之因素。

結果：

我國兒童急診利用率為19.8%，平均每百人利用29.8次，其中因上呼吸道感染就醫佔20.1%為最多。急診品質指標中六小時以上暫留率為4.05%、超過一日暫留率為0.14%、三日內再急診率為5.29%、急診後三十日內死亡率為0.06%。在病患特質部分，女性、年齡愈大者、原住民、居住在山地離島地區、重大傷病者、共病情形嚴重、檢傷分類一級者暫留六小時以上機率較高；年齡較大者、原住民、共病情形次嚴重、檢傷二級、較容易暫留超過一日；而男性、年齡較小者、低收入戶、有重大傷病、共病情形嚴重、檢傷一級三日內再急診機率較高；年齡較小者、有重大傷病、共病情形嚴重、檢傷分類一級急診後三十日內的死亡率較高。而在醫院特質部分則發現醫學中心、服務量較高之醫院有較高急診暫留六小時以上之機率，而急診專科醫師數較高之醫院急診後三十日內的死亡率較低。在就醫日期部分則發現非假日有較高暫留六小時以上、暫留超過一日、三日內再急診之機率。

結論：

本研究發現病患特質、醫院特質、就醫日期會影響兒童急診照護品質。建議醫療院所改善急診作業流程，減少非必要的急診暫留，同時針對再急診風險較高之兒童，發展醫囑清單或加強兒科醫師會診功能，進而減少再急診之發生；衛生主管機關應加強評估醫療院所處置急症兒童之能力，並針對兒童急診照護品質較差之醫院加強輔導，進而提升我國兒童急診照護品質。



[ 英文摘要 ]

Background:

Nearly a quarter of all emergency department visit in our country are made by children.The physiological and emotional attributes of children impact not only their susceptibility to illness and injury,but also the ways in which providers need to assess and treat them.Nevertheless,there is no population based study in Taiwan to assess the ED utilization and quality of care for children.

Purpose:

TO assess ED utilization for children and to estimate the risk factors which effect ED length of stay, revisit, and the death after emergency department for children on patient and hospital levels.

Medthods:

All patients participate in National Health Insurance seen ED during 2005 and 0-17 years old.TO link claim databases(the mortality registry database, census registry database and registry for contracted medical facilities database) to get variables.The significance of risk factors for ED length of stay, revisit, and death after emergency department were assessed by Generalized estimating equations(GEE).

Results:

The utilization rate of ED for children was 19.8%.All ED visits per 100 children was 29.8 times.The common reasons for ED was “other upper respiratory infections ”(20.1%).The rate of ED length of stay over 6 hours was 4.05%. The rate of ED length of stay over 1 day was 0.14%.The revisit rate within 3 days was 5.29%.The mortality rate within 30 days was 0.06%.In the patients characteristics.The ED length of stay over 6 hours for children were associated with female,older age, aborigine,lower urbanization degree, Catastrophic Illness,severe co-morbidity and triageⅠ. The ED length of stay over 1 day for children were associated with order age, aborigine,sub-severe co-morbidity and triageⅡ.The ED revisit were associated with male,age younger, Catastrophic Illness,lower income,severe co-morbidity, and triageⅠ. The ED mortality rate within 30 days were associated with age younger, Catastrophic Illness,severe co-morbidity and triage. In the hospital characteristics.The ED length of stay over 6 hours were associated with medical center, high ED volume.The ED mortality rate within 30 days were associated with fewer ED doctors.There are relative high probability to stay in the ED beyond 6 hours or 1 days and revisit when visit ED in the non-holidays.

Conclusion:

ED quality of care for children were affected by patient and hospital characteristics and the time of visit.We suggest to improve the flow of ED sevices to reduce unnecessary ED length of stay.TO strengthen the consultations of pediatrician and preprinted order sheets for the high risk patient of revisit to ED. Furthermore, the administration should strengthen the ability of hospital to take care the urgent case and improve the quality of care for children.