| 摘要: | 前言：近代世界許多國家皆已面臨急診擁塞狀況，儼然已成為全球化的健康問題，許多因素皆會造成急診擁塞，喝酒受傷也是原因之一。2014年世界衛生組織全球酒精與健康報告 (WHO Global Status Report on Alcohol & Health 2014) 指出，2012年全球有330萬人死亡和酒精相關。受傷患者為急診就醫重要一環，一部分受傷和喝酒有關，常需於急診進一步檢查、留觀、住院、最嚴重死亡等。以上情況，皆會造成資源有限的急診及醫院更形擁塞，影響其他急診病人和住院病人處置時效。
目的：急診為重要的健康醫療照護資源的一隅，角色往往是醫療重要的中繼站，提供緊急傷病患第一線的緊急處置，處置後送至可確切治療的醫療場所後續治療或返家休養。本研究探討喝酒受傷輕症不需住院病人，於急診室留觀是否超過六小時因子及相關文獻回顧，期待能對喝酒受傷病人快速處置、診斷，儘快找出有問題病人、儘快後續處置，並讓輕症不需要過長急診滯留病人，在安全無虞、病人安全情況下，儘快出院，減少急診過長滯留造成的急診擁塞及醫療浪費，使急診動線流暢，增進急診醫療品質。
方法：這是一項回顧性研究，資料來源來自國軍高雄總醫院，收集2016年5月1日到2016年12月31日，所有喝酒受傷病人於急診室就醫情形，此期間看診醫師共四位輪班醫師，一位急診專科，三位外科專科。本研究探討酒後輕傷、不須住院病人於急診室是否留觀超過六小時因子，以統計分析找出關聯性加以後續分析討論。
結果：
1、 2016年05月01日到2016年12月31日間，共有201位與喝酒受傷有關病人送進急診室，無人小於18歲、排除2人因私人因素轉院、4人不願配合醫療，到院後不願意處置、掛號後立即要求離院，42人住院與住院後死亡，最後共153人納入酒後輕傷病人研究分析。
2、 喝酒受傷輕症病人急診室出院，和急診留觀大於六小時有統計學上顯著差異的有頭頸部外傷、腹部外傷、假日受傷、抽血液常規檢查、生化檢查、心電圖檢查、多處影像學檢查、腦部電腦斷層檢查；但和檢傷級數，就診時昏迷指數Glasgow coma scale （GCS）、創傷指數（ISS）、酒精濃度、月份、是否大夜、病人基本資料（性別、年紀、是否付款）、受傷機轉原因、顏面外傷、胸部外傷、四肢外傷無統計學上意義。
結論：
1. 血中酒精濃度高低，與是否急診觀超過六小時，並無統計學上意義，但考量病人出院安全性，當血液中酒精濃度>200mg/dL 時，須注意病人生命徵象，予以支持療法直至病人甦醒，始可離院，確保病人安全。
2. 抽血液常規檢查、生化檢查、心電圖檢查、多處影像學檢查、腦部電腦斷層檢查，和急診是否留觀超過六小時，有統計學上意義，代表多做耗時檢查會增加病人過長急診留滯機會，建議方法為醫師須即時追蹤報告發出狀況，給予病人接續處置與分流，減少急診滯留時間。
3. 頭部受傷和是否做腦部電腦斷層與急診留觀超過六小時皆有統計學上意義，單純頭部之年輕或中年外傷病人，若無重大疾病，來診昏迷指數15分，縱使病人抱怨受傷時有意識喪失、失憶，只要頭部電腦斷層正常，來診後意識清楚，無噁心、嘔吐，實不需過長滯留急診觀察，可讓病人離院，給予頭部受傷衛教單張，安排門診追蹤即可。
4. 檢傷檢傷三到五級、昏迷指數13-15分病人，若單純四肢肢體無合併嚴重組織受傷；到診時昏迷指數15分的頭部鈍傷病人，受傷過程雖有失憶、意識喪失，只要頭部電腦斷層、X光檢查無異常，傷口處置後，確定無其他隱性致命性部位受傷，無噁心、嘔吐，可盡速讓病人離院，給予衛教單張門診追蹤。若為腹部、胸部外傷，則照一般胸、腹部鈍傷處置流程，盡快找出是否有問題病人，分流至住院治留或返家休養，減少急診留觀大於六小時病人，減少急診擁塞，增進急診醫療品質
5. 對於年輕人和中年人，雖喝酒會造成意識不清，但若臨床看到昏迷指數嚴重喝酒受傷中年病人，其意識缺陷程度和酒精濃度是沒有相關性的，意識不好與頭部受傷程度或其他急重症較有相關性，因此不能因為病人酒後受傷、意識不清，單純懷疑酒精作用而去延遲病人檢查，必須依照重大外傷處置流程直到找到原因或排除重大傷病原因為止，須盡速處置病人，避免急診過長滯留導致醫療爭議。
Introduction： Emergency department (ED) crowding is a worldwide problem in recent years, many factors will be caused ED crowding, like alcohol-related injured patients. In 2014, World Health Organization (WHO) calls on governments to do more to prevent alcohol-related deaths and diseases because of 3.3 million deaths in 2012 were due to harmful use of alcohol. Management injured patients are important in the ED, whether or not drinking alcohol or not. Alcohol-related injured patients often need further examinations, observation, admission or the worse expired at ED. All of above situation will cause ED crowding and then influence other ED patients.
Objective： ED is at the frontline of treating any people who suffering from acute illness. The impact of alcohol-related trauma influences not only patients themselves, but also consuming extra ED medical resource. Prolonged stay more than 6 hours is an important factor in ED crowding and will affect other patients who need emergency care, especially those with critical condition
The aim of this study was to investigate the variables about minimally alcohol-related injured patients that were observation at ED more than 6 hours and read more thesis. In hope of alleviating evaluation, management and then disposition minimally injury alcohol-related patients to appropriate position. Reduced prolong length of stay at ED to improved ED medical quality.
Methods：This study adopts a retrospective and statically approach. The author review all the injury patients associated with alcohol-related injury during 1 May 2016 and 31 Dec 2016. This study was conducted at Kaohsiung Armed Forces General hospital, a 500-bed local teaching hospital, around 4000 patients/per month called at emergent department, and around 20 percent of patients when presentations at ED because of trauma. Categorical variables were compared with groups with chi-squared test. Continuous variables were compared with groups with T-test. p-value < 0.05 was considered to demonstrate statistical significances. Data analysis were performed by using the Statistical Package for the Social Sciences, (SPSS statistics 18., Chicago, Illinois, USA).
Results：
Between May 2016 and Dec 2016, there were 201 patients who were suffered from alcohol-related injury. 6 patients were excluded because of transferring to other hospital and against-advise discharge. 195 patients were included to this study. 98 patients who were discharged from ED within 6 hours. 55 patients were observation at ED more than 6 hours and finally discharge at ED, 42 patients were finally admission, moreover expired. We finally exclude admission and expired patients because of not minimally alcohol-related injured patients. Totally, 153 patients were included to this study.
Compared with minimally alcohol-related injured patients whether observation at ED more than six hours or not. There were significant differences in head trauma, abdominal trauma, day (weekday vs. weekend), whether or not receiving blood examinations, multiple images study, electrocardiogram and computed tomography of brain. There were no significant difference in month , time (‘after hours’ 23:30 h to 07:29 vs. other hours 07:30 to 23:29 h), age, sex, paid or not, mechanism of injury (self-harm, conflict with other people, traffic accident, falling down), treatment urgency (triage category 1, 2, 3, 4, 5), Glasgow coma scale (GCS) status (minor:13-15;moderate:9-12; severe: less than 9), Injury Severity Score (ISS: minor<9;moderate:9-15; severe> 15) ,facial trauma, chest trauma, four limbs trauma, alcohol level and the result of blood examinations.
Discussion：
1. Although blood alcohol concentration (BAC) is not associated with minimally alcohol-related injured patients observation at ED more than six hours or not. In order to be left patient discharge from ED with safe condition, when BAC is more than 200mg/dL. Closely follow up clinical symptoms until to patients is alert is suggested even if ED prolong length of stay.
2. The treatment urgency (triage category 1, 2, 3, 4, 5), Glasgow coma scale (GCS) status (minor: 13-15； moderate：9-12； severe< 9) and Injury Severity Score (ISS: minor<9; moderate: 9-15; severe> 15) is not associated with minimally alcohol-related injured patients observation at ED more than six hours or not. That is because severely patients were almost admitted for further management and they were excluded from the study initially.
3. Time consuming examinations like blood examinations, computed tomography of brain, multiple images are associated with minimally alcohol-related injured patients observation at ED more than six hours or not. Real-time follow final results by doctors to reduce prolong length of stay at ED to improve ED quality was suggested.
4. Initial presented at ED with GCS level between 13-15 and triage category was classified into level 3 to level 5. Merely limbs trauma and blunt head trauma was told by patient clearly, even though loss of consciousness and amnesia at the time was told by the observer. As long as x-ray of limbs and computed tomography of brain revealed no abnormality and make sure no obscure injury under the patient GCS level is 15. If patients without nausea and vomiting at ED, no severely tissue injury of limbs was noted, arrange discharge and out-patients department follow up is recommended.
5. For younger and middle-aged patients, initial severely GCS category at ED were always not associated with alcohol consumption. Aggressive management of decline consciousness alcohol-related injured patients without delaying treatment is considered. |
