| 摘要: | 背景：急診室是接觸高齡病患的前哨站。根據2019年我國統計處資料顯示，65歲以上長者急診就診率為最高；醫療費用申報也是佔比最高。高齡患者與其他年齡族群相比，常伴隨多重共病、多重藥物使用、較長住院天數，且易導致不良結果發生。因此既有的醫療模式已無法符合高齡者需求，各國相繼推動高齡急性照護模式（Acute Care for Elders, ACE）及設置高齡急診室。目前我國除創造符合高齡患者就醫的環境外，也積極發展臺灣在地的高齡急性照護模式。此外，不良結果易發生於高齡患者，包括:急診返診、住院、死亡之情形。根據美國急診醫學會指引之建議，急診室應建立高齡患者初步風險篩選工具，給予高齡患者及早介入與有效的後續照護措施，延緩及預防不良結果的發生。
研究方法：本研究採取前瞻觀察性研究方法，使用長者風險識別篩檢工具（Identification of Seniors at Risk Screening Tool, ISAR），並進行翻譯及信效度檢定。以北部某醫學中心之急診室為研究場域，針對65歲以上病患評估，一共分析291名。利用ISAR評估分數分成兩組，0-1分為低風險，≥2分為高風險組，分析其ISAR預測急診返診、住院、死亡等不良結果之相關因素。
主要結果：本研究結果納入91位低風險病人（31.3%），及200位高風險病人(68.7%)。與ISAR高風險組有顯著相關之因素為年齡、長照機構居民、使用救護車、陪同就醫、跌倒經驗、抽菸習慣、（Age-Adjusted Charlson Comorbidity Index, ACCI）。在高風險組(ISAR≥2分)與不良結果相關分析中，急診返診（一個月內）達統計上顯著差異（P=0.034），其勝算比為2.142，95%，信賴區間為1.049到4.376，曲線下面積為0.574。高風險組住院（一個月內）之勝算比為1.792，95%信賴區間為0.914到3.514，曲線下面積為0.558。
結論：經本研究結果發現年齡、長照機構居民、使用救護車、陪同就醫、跌倒經驗、抽菸習慣、(ACCI)等因素會導致ISAR評估為高風險組機會較高。ISAR高風險組急診返診之風險顯著增加，可作為預測急診返診工具。
Background: The emergency department (ED) is often the first contact point for elderly patients. In accordance with the 2019 Taiwanese Department of Statistics data, the rate of emergency visits and medical expenditures for patients aged 65 and over were the highest. Compared with younger patients, elderly patients often complicated with multi-morbidities, polypharmacy, longer hospital stay, and poor prognosis. Therefore, existing medical system have not been able to meet the needs of the elderly. Many countries have established “Acute Care for Elders (ACE)” model and organized geriatric emergency department. At present, Taiwan authority is creating an environment that meets the medical needs of elderly patients, and developing the local acute care model of Taiwan. In addition, adverse events often happen to elderly patients, including emergency revisit, hospitalization, and death. The U.S. Emergency Medical Association guidelines recommend initial risk assessment with a screening tool in the ED for elderly patients. This allows early interventions and more effectively follow-up care strategies to decelerate and eventually prevent adverse events.
Methods: We conducted a prospective observational study to screen the high-risk geriatric patients by the Identification of Seniors at Risk Screening Tool (ISAR). This tool was translated in Traditional Chinese and its reliability/validity was exanimated. A total of 291 elderly patients were screened by this tool in the ED of a medical center in northern Taiwan. This study separated the patients into two groups, the low-risk (ISAR score was 0 or 1) and the high-risk (ISAR score was 2 or more). We analyzed the results to identify the predictors of ED revisit, hospitalization and mortality.
Results: There were 91 included patients in low-risk group (31.3%) and 200 in high-group (68.7%). Some characteristics had significant relation to the high-risk group, including age, long-term care institution, ambulance transferring, companion, falling, smoking, and Age-Adjusted Charlson Comorbidity Index (ACCI). The subgroup analysis of adverse events in the high-risk group demonstrated that ED revisit (1month) was statistically significant (P=0.034), and its OR= 2.142 (95% CI = 1.049 - 4.3763, AUC =0.574). Hospitalization (1month) of the high-risk group had OR= 1.792 (95%CI = 0.914 - 3.514, AUC =0.558).
Conclusion: Our study indicated that some characteristics contributed to high risk group by ISAR screening, including age, long-term care institution, ambulance transferring, companion, falling, smoking, and ACC. Because the potentiality of ED revisit in the high-risk group increased significantly, ISAR can be used as the screening tool of elderly patients in ED. |
