季瑋珠臺灣大學：預防醫學研究所陳建榮Chen, Chien-JungChien-JungChen2007-11-282018-06-292007-11-282018-06-292004http://ntur.lib.ntu.edu.tw//handle/246246/59213背景： 過去針對緊急醫療救護系統所做的研究，未討論偏遠地區建立緊急醫療救護站對於急症病人的效益。 目標： 本研究主要目的在探討緊急醫療救護站，以及緊急醫療救護站計畫對於偏遠地區急症病人死亡率之影響。 病人與方法： 本研究是以不同醫院前照護系統的急症病人族群為基礎的回溯性流行病研究。比較三個鄉鎮、兩種不同的醫院前照護系統：貢寮鄉和雙溪鄉為緊急醫療救護站計畫的鄉鎮，平溪鄉只有傳統的到院前救護系統。研究對象為1031名台北縣貢寮鄉、雙溪鄉和平溪鄉使用台北縣緊急醫療救護系統轉診至後送醫院的急症病人，資料收集期間為2001年3月1日至2003年3月31日。同時獲得上述三個鄉鎮的死亡登記以了解死亡情形。以邏輯式迴歸分析，探討在控制可能之干擾因子估計緊急醫療救護站介入與否，及緊急醫療救護站涵蓋與否鄉鎮的死亡危險比。 結果： 控制相關變因後，對於緊急醫療救護系統轉診的急症病人經緊急醫療救護站的介入，死亡危險比為0.26(95% CI:0.09-0.7)；緊急醫療救護站計畫涵蓋的鄉鎮，並未能證明對於存活有較佳的效益。 結論： 本研究發現緊急醫療救護站的介入對於死亡是有改善，緊急醫療救護站計畫涵蓋的鄉鎮並未顯示出有較佳的效益。Background Previous studies addressing the impact of the emergency medical service system did not assess the effectiveness of the Physician-Operated Emergency Medical Station (POEMS) installed in a rural area. Objectives To evaluate the effectiveness on the acutely ill mortality of the Physician-Operated Emergency Medical Station (POEMS) and the Physician-Operated Emergency Medical Station plan in a rural area. Patients and Methods This retrospective cohort study compared two types of prehospital care systems : Gongliao Township and Shuangsi Township; where Physician-Operated Emergency Medical Station plan implanted ; Pingsi Township ; where was conducted traditional emergency medical service without the Physician-Operated Emergency Medical Station plan implanted. A total of 1031 acutely ill patients who resided in Gongliao Township , Shuangsi Township and Pingsi Township and received Taipei County emergency medical service with transferal to hospital were included in this study between 1 March 2001 and 31 March 2003. These Townships mortality registry were obtained to assess the acute illness mortality. Logistic regression which to evaluate the effectiveness of the Physician-Operated Emergency Medical Station and the Physician-Operated Emergency Medical Station plan was used to calculate adjusted odds ratio of mortality after controlling for possible confounders. Results After controlling for confounding factors, the Physician-Operated Emergency Medical Station intervention can lead reduction of mortality (Adjusted OR: 0.26(95% CI: 0.09-0.7)). However, the Townships which the Physician-Operated Emergency Medical Station plan implanted didn’t have significantly better survival. Conclusions The retrospective cohort study revealed that the e the Physician-Operated Emergency Medical Station intervention can improve survival of the acutely ill patients in a rural area. The system with the Physician-Operated Emergency Medical Station plan can not obtain better survival on all cause of acutely ill patients in a rural area.摘要 i Abstract………………………………………………………………………….. iii Contents v Table List vii Figure List viii 1. Introduction 1 1-1. Emergency Medical Service System (EMSS) 1 1-2. Emergency Medical Service System for rural residents 2 1-3. Example of EMSS in Rural Taiwan 2 1-4. Inadequate Empirical Studies for Prehospital Care in Rural Areas 4 2. Literature Review 6 2-1. Effectiveness of Emergency Medical Service Systems 6 2-1-1. Mortality 6 2-1-2. Temporal Distribution of Deaths 8 2-1-3. Preventable death rate 10 2-2. “Scoop and Run” versus “Stay and Stabilize” 11 2-3. Studies Conducted in rural areas 18 2-4. Injury Severity 20 2-4-1. Injury Severity Score 21 2-4-2. Revised Trauma Score 22 2-4-3. Prehospital Index 22 3.Patients and Methods…………………………………………………………...23 3-1. Background 23 3-2. Patients 23 3-3. Study Design 24 3-3-1 Outcome and Exposure variables 24 3-3-2 Data Collection 25 3-4. Statistical analysis 25 4. Results 27 4-1. Descriptive Results 27 4-2. The Impact of Emergency Medical Station on Mortality 30 4-3 The Impact of Emergency Medical Station Plan on Mortality…………31 4-4. The Impact of Emergency Medical Station Plan on Time to Death 31 5. Discussion 34 6. Conclusion 39 7. Reference 40 Table 1-3 The Medical Resource in Gongliao, Shuangsi and Pingsi Townships 43 Table 2-1-1 Outcome---Mortality and Preventable death rate 44 Table 2-1-2 Outcome---Temporal distribution of deaths 45 Table 2-2-A ALS care vs. BLS care rationale 46 Table 2-2-B Scoop and Run versus Stay and Stabilize (1) 47 Table 2-2-C Scoop and Run versus Stay and Stabilize (2) 48 Table 2-3 Studies Conducted in Rural Areas 49 Table 2-4-1 AIS score 50 Table 2-4-2 Revised Trauma Score 51 Table 2-4-3 Pre-hospital index (PHI) 52 Table 2-4-4 Trauma Score - Injury Severity Score : TRISS methodology 53 Table 3-3-1 Definitions of Variables 54 Table 4-1-A The comparison of Base-line Characteristics by different townships 55 Table 4-1-B The Comparison of Base-line Characteristics by emergency medical station intervention status 56 Table 4-1-C The Comparison of Baseline Characteristics by emergency medical station intervention status --- Medical cause 57 Table 4-1-D The Comparison of Base-line Characteristics by emergency medical station intervention status --- Trauma cause 58 Table 4-1-E The Comparison of Base-line Characteristics by station-installed status 59 Table 4-1-F The Comparison of Baseline Characteristics by station-installed status --- Medical cause 60 Table 4-1-G The Comparison of Baseline Characteristics by station-installed status --- Trauma cause 61 Table 4-1-H Stratification Analysis of DOA on Mortality by intervention status 62 Table 4-1-I Stratification Analysis of DOA on Mortality by station-installed status 63 Table 4-2-A Logistic regression analysis---Intervention 64 Table 4-2-B Model selection for Intervention 65 Table 4-3-A Logistic regression analysis---station-installed status 66 Table 4-3-B Model selection for station-installed status 67 Table 4-4 Temporal distribution of death---station-installed status 68 Figure List Figure 1-3 The Map of Taipei County 69 Figure 2-1-2 Tri-model distribution 70 Figure 2-4-2 Survival Probability with Respect to Revised Trauma Score 71 Figure 3-2-A Study Framework 72 Figure 3-2-B Algorithm of the patients’ transport 73 Figure 3-4 Model Selection Framework 74 Figure 4-1-A Mortality of Different Townships 75 Figure 4-1-B Mortality of Different Pre-hospital Care Patterns 76 Figure 4-1-C Mortality of Different Pre-hospital Care Systems 77 Figure 4-4-A Temporal Distribution of Death for all Cause in Fatalities 78 Figure 4-4-B Temporal Distribution of Death for Medical Disease in Fatalities 79 Figure 4-4-C Temporal Distribution of Death for Trauma Disease in Fatalities 80 Figure 4-4-D Survival analysis for different system 81en-US緊急醫療救護系統醫院前照護偏遠地區緊急醫療救護站效益分析rural areaPhysician-Operated Emergency Medical Stationeffectivenessprehospital careemergency medical servicethesis