近五年澎湖離島空中緊急醫療轉送趨勢與治療結果之分析 Analysis of Patient Outcome and Tendency of Emergency Air Medical Transportation from Penghu Islands to Taiwan: 5 Years Study
中文摘要
本論文是對於澎湖離島空中緊急醫療轉送系列性研究之一。先前探討重點是遠距 醫療視訊系統建制及配合專業審查制度如何減少空中緊急醫療轉送航次，其研 究結果顯示：（1）可以顯著減少飛行航次，（2）病患可轉送至最近且適當之 醫院，（3）所有案件均無發生醫療糾紛及飛安意外事件；在探討專科醫師團隊 介入對離島空中緊急醫療轉送之影響，其研究結果顯示：（1）急重症專科醫師 群長期進駐澎湖地區，確實讓空中緊急醫療轉送率明顯下降，（2）每年節省政 府巨額預算，（3）符合經濟效益並達成安全之空中醫療轉送。然此類研究僅針 對澎湖地區空中緊急醫療轉送之個案進行基本資料與病情分析。至於轉送率減少 後，地方居民對離島醫療卻不見得滿意！特別是民國95 年 7 月三軍總醫院團隊 主導澎湖急重症醫療介入後，空中轉診案件反而增加，轉送至本島病患之治療 結果值得分析與探討。
對象及方法
採用回溯法收集民國93 年 1 月 1 日至 97 年 12 月 31 日，所有澎湖地區經空中緊 急醫療轉送到高雄三家醫學中心（高雄榮民總醫院、高雄長庚紀念醫院、高雄醫 學大學附設中和紀念醫院）個案。收集澎湖地區轉診單、空勤總隊記錄、急診與 出入院病歷記載做為統計分析。比較執行轉送飛行航次、直接降落高雄榮民總醫 院停機坪或小港國際機場之差異；並深入了解轉送病患之性別、年齡、疾病分類 疾病嚴重程度、加護中心治療天數及總住院天數、治療結果等資料。統計方法使 用SPSS12.0 套裝軟體進行資料處理，以 Chi-square test 檢定變項(variables)間交 叉比對下所呈現之差異，t-test 檢定兩組間平均值之差異，P<0.05 視為有統計上 顯著意義。
研究結果
(1)後送比率假日與非假日無明顯不同，可見全民健康保險醫療 給付效益提升計畫(IDS)，整合醫院與急重症相關專科醫師假日支援
，有助改善離島地區醫療服務品質，但未能提升在地醫療水準，死亡 率無顯著下降(P=0.093)。(2)創傷嚴重度較高者 ISS≧16 (P=0.019)
、昏迷指數較低(GCS≦8)或有氣管插管者(P=0.028)當地醫師會選擇 直接轉送高雄榮民總醫院，降落於急診大樓屋頂之停機坪。然與降落 小港機場再由陸地救護車兩階段轉送（36.91±7.43 VS. 53.76±6.37）
僅相差16 分鐘，雖死亡率無明顯下降(P=0.310)，但減少繁複病人搬 運過程，可避免非預期傷害之產生。(3)三軍總醫院介入後轉診人數 由126 人遽增為 210 人，以夏季(6-8 月) 79 人比例最高(P<0.001)。
可能介入後每年醫師輪調頻繁，新到任主治醫師資淺及醫院成本效益 考量下，導致轉送率明顯上升。(4)夜航比率亦顯著增加，飛行安全 堪慮。(5)轉送人數以心臟血管疾病 109 人最多(32.44%)，轉送後 3 天內執行心導管或侵入性手術者62 人(56.88%)，顯示近半數病患可 考慮「在地醫療」。雖然轉診後病人死亡率有下降(P<0.001)，三軍總 醫院介入仍無法全面落實在地急重症醫療品質。
結論
澎湖離島需要長期且固定之醫學中心專科醫師群支援，以提升急
重症診斷時效性與處理能力，建議後續支援醫療團隊以高雄地區醫學中心為佳，
以符合「最近且適當」之策略並兼顧病人「照護之延續性」。其次，中央建保局應 規劃適當之財務政策，嘉惠偏遠離島醫療院所，若經費許可，於澎湖醫療大樓 增加急重症相關醫療設備，強化老人及小兒加護中心照護能力，提升至符合準 醫學中心水準，同時應聘請資深且願意落地生根的專科醫師提升在地急重症醫 療品質，才能更有效降低空中轉診後送率。然空中緊急醫療轉送仍有其需求性與 重要性，若能配合衛生署空中轉診審核中心的審核及協調機制，設置配備完善 之醫療專屬轉診直昇機或固定翼專機。積極訓練有能力護送急重症病患之人員，
以確保轉送過程安全無虞，使空中緊急醫療轉診服務更加完善，讓離島居民受 到高品質之醫療照護，並能達到以病人安全為目標，做為政府制定偏遠離島地 區急重症醫療政策之依據與參考。
英文摘要
Objective: Our previous studies have demonstrated that the physician -assisted preflight screening by video-telemedicine significantly reduced the frequency of emergency air medical transportation (EAMT), and dispatching specialist physicians from main island Taiwan to the remote Penghu islands could reduce the cost of emergency and critical care to some extent. Further cost-effective result was expected when the medical center got involved in localization of emergency and critical care for remote islands. However, after joint collaboration with Tri-Service General Hospital (TSGH) in 2006, the demand of EAMT in Penghu islands discrepantly increased. In this study, we investigated the outcomes of patients with emergency and critical diseases receiving EAMT services to have a better understanding on this issue.
Methods: This study is a retrospective survey that reviewed medical records of patients with emergency and critical diseases in Penghu islands transferred to three medical centers in Kaohsiung City by EAMT between January, 2004 and December, 2008. Data were analyzed by using SPSS 12.0. Differences between groups were evaluated by t-test and Chi-square test. All p values with two tailed, p < 0.05 was considered as statistical significance.
Results: During the study period, 336 patients were transferred to the three indicated
medical centers in Taiwan. No difference was found on mortality between weekday and weekend admissions (P=0.858). Patients with higher Injury Severity Score (ISS)≧16(P =0.019), lower Glasgow Coma Scores or intubation (P=0.028) tend to be taken directly to the hospital (primary landing site). Although it takes 16 more
minutes to transfer from Kaohsiung International airport to the hospital, mortality rates were not different between the landing sites (P=0.093). However, unpredictable injuries could be avoided with less complicated transportation procedures. The number of transferred patients significantly increased during the summer months (June to August; p=0.002) after the intervention of TSGH. One possible explanation is that the dispatched physicians from TSGH were less experienced. Another reason is that transferring severe illness and elderly patients to Taiwan could ease off the burden on local hospital. Night flights obviously increased. It raises the concern about the flight safety. Patients with cardiovascular disease (CVD) were the most reasons for EMAT, but only 62 patients (56.88%) received invasive procedures in the initial 3 days. Nearly half of CVD could have been treated at the local hospital. The over all mortality was reduced significantly after the intervention of TSGH (P<0.001), but the quality of emergent and critical medical service did not meet the expectation.
Conclusions: Our study suggested that in order to upgrade the local capacity of emergent and critical medical care, it is necessary to establish a sustainable medical support program for Penghu islands with senior specialist physicians from nearby medical centers in Kaohsiung City. The program should be under better financial scheme by the National Health Insurance. The numbers of EAMT and mortality rate could be reduced much more if the above efforts are cooperated with the guidelines for managing emergency and critical care medicine and monitored by National Aeromedical Approval Center under the Department of Health. This experience might provide a good model for similar remote islands
