空中轉診病案之追蹤研究

1. 空中轉診病案之追蹤研究 • 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。

2. Follow up Study of Patients after aeromedical Transportation • 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.