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研究生:張馨尹
研究生(外文):Hsin-Yin Chang
論文名稱:空中轉診病案之追蹤研究
論文名稱(外文):Follow up Study of Patients after aeromedical Transportation
指導教授:蔡行瀚蔡行瀚引用關係
學位類別:碩士
校院名稱:臺北醫學大學
系所名稱:傷害防治學研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2008
畢業學年度:96
語文別:中文
論文頁數:112
中文關鍵詞:離島偏遠地區空中轉送轉診後續追蹤
外文關鍵詞:emergency air medical transportfollow up study
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背景:「行政院衛生署空中轉診審核中心」於91年10月1日成立,已建置完成空中轉診遠距醫療視訊系統和審查標準,不僅可以立刻執行空中緊急醫療轉送而且改善過去濫用空中轉診之缺失,成效顯著。病案空中轉送後的診斷及病情演變亦非常重要,目前尚欠缺詳細追蹤研究,故自民國95年1月1日針對偏遠離島地區空中轉診所有案件進行轉診後14天之後續臨床病況追蹤。本研究的目的是比較空中轉診前後病患罹病之嚴重度、檢視診斷的差異性與病情之後續變化,用以評估空中醫療轉送的適當性及迫切性,並提升空中轉診之品質。

材料與方法:本研究採回溯法,調閱民國95年1月1日至96年12月31日行政院衛生署空中轉診審核中心資料,由審核中心醫師電話追蹤至接受醫院14天,將結果以SPSS 14.0版本進行敘述性統計分析。

結果;空中緊急醫療轉診共447件。研究結果以男性居多295位(66%),全部轉診病案平均年齡52.5±22.1歲。病患之昏迷指數(Glasgow Coma Scale),轉送前離島醫師評估為重度佔16.3%(73位)、中度佔13.2%(59位)、輕度佔70.5%(315位);轉送後醫師評估昏迷指數重度佔20.4%(91位)、中度佔10.9%(49位)、輕度佔68.7%(307位),統計學上有顯著差異(P<0.05);其中78位(17.4%)在轉送前即予呼吸道插管治療,轉送後呼吸道插管者增加19位(4.3%),顯示空中轉診後嚴重度增加。追蹤兩週內轉診患者之死亡率為5.4%(24位),其中到院前死亡為3位(0.7%);24小時內死亡為7位(1.6%);48小時內死亡為1位(0.2%)。轉診疾病分類以心臟內科89件(19.9%)最多。離島醫院和本島接受醫院醫師疾病診斷一致性為96.4%,其中16位(3.6%)出現ICD-CODE診斷碼不相同情形 (P<0.05),以衛生所轉出之病患為多(共11件)。追蹤澎湖地區九十五年度轉診84件,九十六年度轉診114件,兩年內申請轉診件數共增加30件(35.7%),其轉診至本島後有五成以上病患僅以藥物或症狀治療,研究顯示其中有部分轉診患者是可以在離島偏遠地區轉出院所治療。

結論:本研究針對空中轉診個案進行病情追蹤14天之研究分析,轉診前和轉診後的醫師疾病診斷一致性達96.4%,顯示由空中轉診審核中心之專業審查與遠距視訊系統介入可以減少疾病診斷的誤判。另外,空中轉診後之嚴重度增加,有10位(2.3%)到院前及到院後一天內死亡,兩週內之死亡率為24位(5.4%),顯示空中轉診之急迫性及必要性。在轉診量方面澎湖一年內增加35.7%,較四年前增加209%,研究結果發現三軍總醫院調往澎湖分院之醫師大部分為剛完成住院醫師訓練之資淺主治醫師,經驗及能力有限,又以補服隊勤之心態,缺乏努力在地耕耘之工作士氣,且該院對全民健保給付的總額預算及核刪極為不滿,特別是急重症病人收治住院反而虧損,故將病人空中轉診至本島。
Background: National Aeromedical Approval Center ( NAAC ) in Taiwan was established in October 2002. Our previous study demonstrated the effectiveness of NAAC by reducing the frequency of unnecessary air medical transports. However, the outcomes of patients after aeromedical transportation have not yet been studied. In this study, we followed up patients for 14 days and performed further investigation about changes in the severity of disease, consistency of diagnosis, and trends situation. We will assess the appropriateness and level of urgency of aeromedical transportation, which to enhance the quality.

Material and Method: This study is a retrospectively study. Medical records of patients transported from the Remote Islands to Taiwan were collected from January 2006 to December 2007. The follow up study included clinical condition of patients in receiving hospitals, obtained by the doctor in NAAC using telephone survey. Information from the 14 days follow up was collected on numbers of patient’s demography, disease classification and patient’s outcome. We used SPSS 14.0 for statistical analysis.

Results: A total of 447 transfers were included in this study. Males accounted for 295(66%)of the cases. The total mean age of patients was 52.5±22.1years. Before transfer, there were 315(70.5%),59(13.2%),and 73(16.3%)patients in the minor, moderate, and severe classification, respectively. After transfer, there were 307(68.7%),49(10.9%),and 91(20.4%)patients in the classification of minor, moderate, and severe, respectively. The Glasgow Coma Scale (GCS) assessed by physicians in both Remote Islands and Taiwan, shows a statistically significant difference (P<0.05). There were 82 patients (17%) which intubated before transfer and after the transfer of intubated to increase 19(4.3%),indicated that the clinical condition continuously deteriorated in interhospital transportation. The overall mortality rate was 5.4%(24 patients)within 14 days, include 3(0.7%)out of hospital cardiac arrest ,7(1.6%)died within 24 hours and 1(0.2%)died within 48 hours. The most classified disease category was Cardiology (19.9%).The consistence rate of diagnosis between physicians in Remote Islands and Taiwan was 96.4%. There are 16 (3.6%) revised their ICD-9 Codes (P <0.05), include 11(11/16,68.8%) diagnosis inconsistencies were made from the Island Clinic. In recent years, our study found that there were increase of aeromedical transportation in Penghu islands, of whom 84 in 2006 and 114 in 2007, within two years to increase the number of transfer for 30 (35.7%). After transported to destination hospital, more than half of all patients were receiving drug therapy or treatment of the main symptoms, showed that the treatment of cases in remote island hospital were unnecessary aeromedically transported.

Conclusions: In this study, we followed up patient’s condition for 14 days after aeromedical transportation. Most physicians made the correct diagnosis(96.4%). By NACC professional intervention and telemedicine, could be significantly decreased errors in prehospital diagnosis. There were severer outcomes after transportation , 10 cases (2.3%) died prior hospital arrival within a day, the mortality rate of patients died within two weeks after arrival was 24 cases (5.4%); showed aeromedical transportation was very urgent and necessary. In addition, the trend of transfer seems to be increasing 35.7% within a year in Penghu islands comparison with total increasing 209% four years ago. However, our study found that most of the physicians in Penghu hospitals which came from Triservice General Hospital just completed training of residency or junior attending physician. Maybe they were junior and less experienced, led to lack of confidence in treatment and control patient condition; and the lack of efforts in the hard work of morale. Because the total health care budget control, severe patients were increased the burden on local hospitals and they transported patients to Taiwan frequently.
中文摘要…...................................................................................................I
英文摘要….................................................................................................IV
第一章 前言................................................................................................1
第一節、研究背景分析......................................................................1
第二節、文獻探討..............................................................................6
第三節、目前現況…………………………………………………13
第四節、國內空中轉診問題探討…………………………………19
第五節、研究目的…………………………………………………21
第二章 材料與方法..................................................................................22
第一節、資料收集..............................................................................22
第二節、遠距視訊系統架構概述......................................................24
第三節、轉診流程.............................................................................27
第四節、名詞解釋.............................................................................30
第五節、飛行責任空域......................................................................32
第三章 結果..............................................................................................33
第一節、轉診基本資料之分布情形.................................................34
第二節、轉診前後診斷之一致性.....................................................39
第三節、罹病受傷嚴重度分析........................................................42
第四節、追蹤14天病患動向原因之探討......................................46
第五節、轉診航次增加原因之探討................................................51
第四章 討論..............................................................................................55
第五章 結論與建議………......................................................................62
第六章 參考資料………………………………………………………..66
附件一 網路視訊連線系統……………………………………………103
附件二 離島偏遠地區緊急空中後送案件標準作業流程圖…………104
附件三 案件通報紀錄…………………………………………………105
附件四 醫療轉送前評估紀錄…………………………………………106
附件五 醫療轉送後評估紀錄…………………………………………107
附件六 直昇機緊急傷病患醫療後送個案資料表……………………108
附件七 時序紀錄表……………………………………………………109
附件八 醫院專科醫師專任位數統計--按科別及縣市別分……….....110
附件九 醫療設備數—按縣市別分……………………………………112






圖目錄
圖2-1 離島地區遠距醫療視訊點……………………………………..73
圖2-2 飛行責任區域圖………………………………………………..77
圖3-1 離島地區轉診醫師和本島接受醫院昏迷指數比較…………..86
圖3-2 澎湖地區案件數(月平均)………………………………………99
圖3-3 金門地區案件數(月平均)………………………………………99
圖3-4 連江地區案件數(月平均)……………………………………..100
圖3-5 東部地區案件數(月平均)……………………………………..100
圖4-1 92~96年年齡趨勢……………………………………………..102




















表目錄
表2-1 Glasgow Coma Scale(GCS)受傷嚴重度評估標準……………74
表2-2 本研究離島轉診病患之ICD-9分類碼………………………….75
表3-1 轉診病案基本資料……………………………………………….78
表3-2申請醫院…………………………………………………………..79
表3-3 疾病次專科分類與年度位數交叉比對表……………………….80
表3-4 接受醫院………………………………………………………….81
表3-5 診斷相同、診斷不相同分析……………………………………82
表3-6 申請醫院與接受醫院交叉比對………………………………….83
表3-7 ICD-CODE診斷碼不相同分析………………………………..84
表3-8 離島地區轉診醫師和本島接受醫院醫師評估昏迷指數……...86
表3-9 病患追蹤14天結果及住院動向交叉分析………………………87
表3-10 死亡分析………………………………………………………...88
表3-11 追蹤14天死亡結果與疾病次專科分類做交叉比對…………..89
表3-12 死亡診斷原因分析……………………………………………...90
表3-13 自動出院分析…………………………………………………92
表3-14 追蹤14天自動出院結果與疾病次專科分類做交叉比對……93
表3-15 自動出院原因分析……………………………………………...94
表3-16 轉院分析………………………………………………………...96
表3-17 追蹤14天轉院結果與疾病次專科分類做交叉比對…………97
表3-18 轉院原因分析…………………………………………………..98
表4-1 病患年齡層與罹患疾病科別交叉比對表……………………...101
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