臺灣博碩士論文加值系統

背景及目的：
爆發嚴重急性呼吸道症候群 (severe acute respiratory syndrome, SARS) 對急診部病患數和醫院收入的立即及長遠影響，尚未被詳細的探討。此回溯觀察型研究的目標是在研究嚴重急性呼吸道症候群的爆發，對一個委任SARS醫學中心的急診部病患和醫院收入的衝擊有多大。

方法：
收集2003年，也就是SARS流行那一年，所有急診部病患就診資料和費用明細。同時也收集SARS流行前一年 (2002) 同一時期的相關資料作為比較用。收集的資料包括急診部每日的病患數、就診科別、檢傷分類、總收入和每人平均總費用及各項費用。資料經由電腦擷取回來且統計比較SARS流行前後的差別。

結果：
在SARS流行期，流行尖峰期的急診部病患數比流行前期平均減少92.5位 (43.7%)，但是在就診的年齡和性別上並無差別。救護車運送、轉院和病情危急的病患數 (例如：到院前死亡、檢傷一類和住進加護病房的病患數) 並未因SARS流行而有所改變。但是，心血管疾病、功能性或發炎性腸炎、內分泌疾病、暈眩和外傷在SARS尖峰期與SARS前期和早期的病患數相比較結果，均呈現有統計學上意義的減少。
和2002年同時期相比較，在SARS流行尖峰期每天急診部病患數最多減少51.6%。 在服務科別方面，小兒科、外科和內科最多分別減少80.0%、57.6%和40.8%。在檢傷分類方面，一類、二類和三類病患數最多分別減少18.1%、55.9%和53.7%。在總收入方面，每天最多減少37.7%。在每位病患平均費用上，最多增加35.9%。在每人平均費用比例上，實驗室檢查增加31.4%、放射線檢查增加21.9%和藥費增加29.5%。

結論：
SARS爆發並不會消除危急病患對更高級醫療的需要。SARS爆發反而導致急診部病患明顯減少，且在流行期結束後還持續三個月之久。SARS期間，每位病患的平均總費用同步增加，但是急診部每天總收入卻明顯減少。每位病患平均總費用的增加可歸因於在急診部要篩檢SARS病患的流程增加。

Background and Purpose:
The immediate and long-term impact of severe acute respiratory syndrome (SARS) outbreak on emergency department (ED) visits and hospital expenditures for these visits has not been thoroughly investigated. The objectives of this retrospective observational study investigated the impact of SARS outbreak on the ED visits and the cost of these visits in a designed SARS medical center.

Methods:
Data related to total ED visits and their costs were collected for the SARS epidemic period in 2003 and the same period in the preceding year in 2002. Data collected included total ED visits, services provided, triage categories, and total expenditures for all patients. Data were retrieved and compared before and during the outbreak.

Results:
In demographic data, there is a significant decreases in patients attendances with a mean reduction of 92.5 ± 8.3 (43.7% ± 3.9% in reduction rate, P< 0.01) during peak- versus pre-epidemic stages, but without changes in patients’ age and gender. The numbers of patient with ambulance transport, inter-hospital referral, and critical illness, including dead on arrival, categorized to triage 1 or admitted to intensive care unit after ED visits, were not influenced by SARS epidemics. There are statistically significant decreases in mean attendances of patients with cardiovascular diseases, inflammatory or functional bowel disease, endocrine diseases, dizziness or vertigo, and trauma (P< 0.05), respectively, in peak- as compared to those in pre- and early-epidemic stages.
As compared with data from the same time in 2002, the reduction in daily ED visits reached 51.6% at the peak of SARS epidemic (p < 0.01). In pediatric, trauma and non-trauma patients, the maximum mean decreases in number of visits were 80.0% (p < 0.01), 57.6% (p < 0.01) and 40.8% (p < 0.01), respectively. In triage 1, 2 and 3 patients, the maximum mean decreases were 18.1% (p < 0.01), 55.9% (p < 0.01) and 53.7% (p < 0.01). The maximal decrease of total costs was 37.7% (p < 0.01). The maximum mean costs per patient increased 35.9% (p < 0.01). The proportions of increases in mean costs of each patient were attributed to laboratory investigations (31.4%), radiography (21.9%) and medications (29.5%).

Conclusions:
The SARS outbreak did not eliminate the need of critical illness patients for advanced medical supports but resulted in a marked reduction of ED visits which persisted for 3 months after the end of the epidemic. Total cost of treating individual patients showed a simultaneous marked increase, while overall operational costs in the ED showed a marked decrease. The increased total cost of each patient was attributed to the increased number of diagnostic procedures to screen for the possible SARS in the ED.

目錄 起始頁碼
中文摘要 1
英文摘要 5
前言 9
第一章 文獻回顧 11
第一節 SARS的簡介 12
第二節 世界衛生組織如何定義SARS 13
第三節 SARS爆發院內感染的國外經驗 14
第四節 SARS爆發流行和院內感染的台灣經驗 17
第五節 SARS的傳染物質是冠狀病毒的確認 18
第六節 SARS對台灣醫療經濟影響 20
第二章 研究的動機與目的 21
第一節 研究動機 22
第二節 研究目的 23
第三章 研究材料與方法 24
第四章 研究結果 30
第一節 SARS流行對急診部門就診人數的影響 31
第二節 SARS流行前後共5期間病患就診基本資料之比較 32
第三節 SARS流行前後共5期就診病患的疾病種類 37
第四節 SARS流行對2003年急診部就診科別和檢傷分類的影響 40
第五節 SARS流行對2003年急診部門收入和病人費用的影響 44
第五章 討論 47
第一節 SARS流行對急診部門就診人數的影響 48
第二節 SARS流行前後共5期間病患就診基本資料之比較 50
第三節 SARS流行前後共5期就診病患的疾病種類 52
第四節 SARS流行對2003年急診部就診科別和檢傷分類的影響 53
第五節 SARS流行對2003年急診部門收入和病人費用的影響 54
第六章 總結 55
文獻參考 61
圖表 67
刊登通知 110
刊登論文 111

1. Ksiazek TG, Erdman D, Goldsmith CS, et al: A novel coronavirus associated with severe acute respiratory syndrome. N Engl J Med 2003;348:1953-66.
2. Drosten C, Gunther S, Preiser W, et al: Identification of a novel coronavirus in patients with severe acute respiratory syndrome. N Engl J Med 2003;348:1967-76.
3. Varia M, Wilson S, Sarwal S, et al: Investigation of a nosocomial outbreak of severe acute respiratory syndrome (SARS) in Toronto, Canada. CMAJ 2003;169:285-92.
4. Seto WH, Tsang D, Yung RW, et al: Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet 2003;361:1519-20.
5. Poutanen SM, Low DE, Henry B, et al: Identification of severe acute respiratory syndrome in Canada. N Engl J Med 2003;348:1995-2005.
6. Ho AS, Sung JJ, Chan-Yeung M: An outbreak of severe acute respiratory syndrome among hospital workers in a community hospital in Hong Kong. Ann Intern Med 2003;139:564-7.
7. Hseuh PR, Yang PC. Severe acute respiratory syndrome (SARS)--- an emerging infection of the 21st century. J Formosan Med Assoc 2003;102:825-39.
8. Centers for Disease Control and Prevention: Severe acute respiratory syndrome—Taiwan, 2003. JAMA 2003;289:2930-2.
9. Man CY, Yeung RS, Chung JY, et al: Impact of SARS on an emergency department in Hong Kong. Emerg Med (Fremantle) 2003;15:418-22.
10. Peter MH, Sanjay B, Stephen HG, Severe acute respiratory syndrome (SARS): breath-taking progress. Journal of Medical Microbiology (2003), 52, 609-613.
11. Lee N, Hui D, Wu A & 11 other authors (2003). A major outbreak of severe acute respiratory syndrome in Hong Kong. N Engl J Med 348, 1986-1994.
12. Chen YC. Chen PJ. Chang SC. Kao CL. Wang SH. Wang LH. Yang PC. SARS Research Group of National Taiwan University College of Medicine and National Taiwan University Hospital. Infection control and SARS transmission among healthcare workers, Taiwan. Emerging Infectious Diseases. 2004, 10(5):895-8.
13. Chen YC. Huang LM. Chan CC. Su CP. Chang SC. Chang YY. Chen ML. Hung CC. Chen WJ. Lin FY. Lee YT. SARS Research Group of National Taiwan University College of Medicine and National Taiwan University Hospital. SARS in hospital emergency room. Emerging Infectious Diseases. 2004, 10(5):782-8.
14. Chen SY. Su CP. Ma MH. Chiang WC. Hsu CY. Ko PC. Tsai KC. Yen ZS. Shih FY. Chen SC. Chen WJ. Predictive model of diagnosing probable cases of severe acute respiratory syndrome in febrile patients with exposure risk. Annals of Emergency Medicine. 2004, 43(1):1-5.
15. Su CP. Chiang WC. Ma MH. Chen SY. Hsu CY. Ko PC. Tsai KC. Fan CM. Shih FY. Chen SC. Chen YC. Chang SC. Chen WJ. Validation of a novel severe acute respiratory syndrome scoring system. Annals of Emergency Medicine. 2004, 43(1):34-42.
16. Wang YH. Lin AS. Chao TY. Lu SN. Liu JW. Chen SS. Lin MC. A cluster of patients with severe acute respiratory syndrome in a chest ward in southern Taiwan. Intensive Care Medicine. 2004, 30(6):1228-31.
17. Anonymous. From the Centers for Disease Control and Prevention. Update: outbreak of severe acute respiratory syndrome--worldwide, 2003. JAMA. 2003, 289(15):1918-20.
18. Tsang KW, Ho PL, Ooi GC & 13 other authors (2003). A cluster of cases of severe respiratory syndrome in Hong Kong. N Engl J Med 348, 1977-1985.
19. Chang HJ, Huang N, Lee CH, et al: The impact of the SARS epidemic on the utilization of medical services: SARS and the fear of SARS. Am J Public Health 2004;94:562-4.
20. Twu SJ, Chen TJ, Chen CJ, et al: Control measures for severe acute respiratory syndrome (SARS) in Taiwan. Emerg Infect Dis 2003;9:718-20.
21. Hu SC, Yen D, Yu YC, et al: Elderly use of the ED in an Asian metropolis. Am J Emerg Med 1999;17:95-9.
22. Center for Disease Control, Department of Health, Executive Yuan, Taiwan. Memoir of severe respiratory syndrome control in Taiwan. 2003. Available from URL: http://www.cdc.gov.tw.
23. Lateef F: SARS changes the ED paradigm. Am J Emerg Med 2004;22:483-7.
24. Chen WK, Cheng YC, Chung YT, et al: The impact of the SARS outbreak on an urban emergency department in Taiwan. Med Care 2005:43:168-72.
25. Blendon RJ, Benson JM, DesRoches CM, Raleigh E, Taylor-Clark K. The public’s response to severe acute respiratory syndrome in Toronto and the United States. Clin Infect Dis 2004;38:925-31.
26. Lew TWK, Kwek TK, Tai D, Earnest A, Loo S, Singh K, Kwan KM, et al. Acute respiratory distress syndrome in critically ill patients with severe acute respiratory syndrome. JAMA 2003;290:374-80.
27. Tham KY. An emergency department response to severe acute respiratory syndrome: a prototype response to bioterrorism. Ann Emerg Med 2004;43:6-14.
28. Hay E, Bekerman L, Rosenberg G, et al: Quality assurance of nurse triage: consistency of results over three years. Am J Emerg Med 2001;19:113-7.
29. Nelson M, Waldrop RD, Jones J, et al: Critical care provided in an urban emergency department. Am J Emerg Med 1998;16:56-9