臺灣博碩士論文加值系統

目的： 急診是大眾健康照護的重要資源，整個社會對急診照護的需求正逐年增加。本研究著眼於探討不同類型的醫師（急診專科與非急診專科、資深與資淺、女性與男性、日班與夜班）在急診的看診品質是否存在差異，進而提供醫療行政單位及醫院管理階層有關促進醫療品質之參考。
方法： 本研究以病歷回顧方式，以中部地區一家500床區域教學醫院、每年服務量36000人次之急診室，在Jul 01, 2013~Dec 31, 2013期間來此急診之病人為研究對象，但排除婦產科及20歲以下病人。資料統計分析採用SPSS 17.0版套裝軟體進行。以卡方檢定比較72小時非預期性返回急診、急診住院診斷錯誤、24小時普通病房轉加護病房等三種看診品質之差異。再以羅吉斯迴歸分析探討各類別醫師因素對看診品質之影響。
結果： 急診專科看診組比非急診專科看診組在急診住院診斷錯誤較少（χ2=17.628 p＜0.001），在72小時非預期性返回急診與24小時普通病房轉加護病房，則無顯著差異。進一步以檢傷級數分層分析，檢傷級數二級、三級病人在急診住院診斷錯誤有顯著差異，檢傷級數四級、五級病人在急診住院診斷錯誤則無顯著差異。
以醫師年資分組的三組病人，在急診住院診斷錯誤有顯著差異（χ2=12.351 p=0.002）。在72小時非預期性返回急診與24小時普通病房轉加護病房，三組病人則無顯著差異。
以羅吉斯迴歸分析探討各類別醫師因素對看診品質之影響，發現在急診住院診斷錯誤，以急診專科組為參考組，非急診專科組之OR=2.679、p=0.021，有顯著差異。在72小時非預期性返回急診與24小時普通病房轉加護病房，各類別醫師因素對看診品質之影響，均無顯著差異。
結論： 本研究顯示急診專科醫師與資深醫師在急診住院診斷錯誤方面表現較好，建議在各類評鑑中要求急診專科醫師所佔比率逐步提高；醫院管理者應改善急診工作環境，以降低急診資深醫師的退出率。如此雙管齊下，以提昇各級醫院急診部門之臨床照護品質，實為刻不容緩。

Objectives:
Emergency health services play a crucial role in Taiwan’s public health care. The demand for emergency health care is growing at a fast pace in the Taiwanese society. The aim of this study is to analyze and examine clinical performance of physicians from different perspectives, (namely emergency vs. non-emergency specialists; senior vs. junior physicians; female vs. male physicians; and day-shift vs. night-shift physicians), and investigate whether there was a difference in the quality of their clinical performance in a highly stressful environment.
I hope that the findings of my research will become an important reference for hospital managements and health care policymakers in their decision making process.

Methods:
Medical records kept in the emergency department of a regional teaching hospital located in central-western Taiwan were examined and analyzed. Its emergency department treats around 36,000 patients per year. The period was limited between July 01, 2012 and December 31, 2012. Please note that obstetric patients and patients under 20 are not included in this study.
First, Statistical Package for Social Science 17.0 was applied to produce an in-depth quantitative analysis. Besides, Chi-Square Test was utilized to compare the quality of clinical performance. In this section, issues related to unplanned revisits within 72 hours, misdiagnosis of ED admission, and the occurrence of wrong disposition (Unplanned ICU transfers from regular wards within 24 hours) were examined. At last, Logistic Regression was used to investigate whether the quality of clinical performance had been affected by the factors of physicians.

Results:
The research suggests that the rate of misdiagnosis by emergency specialists was lower than the one caused by non-emergency specialists (χ2=17.628 p=0.000). However, in terms of the rates of unplanned revisits within 72 hours and wrong disposition, there is no significant difference between two groups.
When a further investigation was undertaken from the perspective of the triage scale, it shows that the rate of misdiagnosis that occurred to level 2 and level 3 patients show a noticeable difference. However, such a difference does not exist in level 4 and level 5 patients
Three groups of patients divided into regarding physician seniority showed significant difference in misdiagnosis of ED admission (χ2=12.351 p=0.002). In terms of the rates of unplanned revisits within 72 hours and wrong disposition, there is no significant difference between three groups.
Further analysis with Logistic regression of influencing factors on clinical performance revealed emergency specialist is the major factor influencing misdiagnosis of ED admission(OR=2.679 p=0.021). There are no significant factors influencing on unplanned revisits within 72 hours and wrong disposition.

Conclusions:
This study clearly shows that the ED misdiagnosis rates by emergency specialists and senior physicians are significantly lower. Therefore, I would like to make some suggestions here: the required percentage of emergency specialists engaged in the emergency health services should be gradually increased in hospital performance assessments. Moreover, we should invest more resources in improving the working environment of emergency departments, and lengthen the working lives of senior emergency physicians. I believe that these approaches are the quickest ways to improve the quality of emergency health services.

緒論
第一節 研究背景 01
第二節 研究動機 07
第三節 研究目的 09
第二章 文獻探討
第一節 健康照護品質的面向 10
第二節 急診室品質指標模型 12
第三節 72小時非預期性返回急診 15
第四節 急診住院診斷錯誤 17
第五節 24小時普通病房轉加護病房 18
第六節 不同類別急診醫師與臨床照護品質 19
第七節 文獻小結 22
第三章 研究設計與方法
第一節 研究流程與研究架構 23
第二節 研究假設 28
第三節 研究對象 29
第四節 研究變項與操作型定義 30
第五節 統計分析方法 31
第四章 研究結果
第一節 全體病人之基本資料及全體醫師之特徵 32
第二節 以卡方檢定探討分組病人之特徵與看診品質 36
第三節 以檢傷級數分層分析急診住院診斷錯誤之差異 43
第四節 以羅吉斯迴歸探討各種醫師因素對看診品質之影響 45
第五章 討論
第一節 急診專科醫師之看診品質 49
第二節 以檢傷級數分層再看急診專科醫師之看診品質 51
第三節 不同年資醫師之看診品質 52
第四節 看診品質之羅吉斯迴歸分析 54
第五節 研究限制 56
第六章 結論與建議
第一節 結論 58
第二節 建議 60
參考文獻 61

附錄：人體試驗研究計劃許可書 66

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