11-13 김현수

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1 대한외상학회지 Vol. 23, No. 2, December, 2010 원 저 Six Sigma 활동을통한중증외상환자의응급실체류시간개선활동 차의과학대학교응급의학교실 김현수 김옥준 최성욱 김의중 박영태 고대이 1 조윤경 2 Abstract The Effect of Six Sigma Activity in Major Trauma Patients on the Time Spent in the Emergency Department Hyun Soo Kim, M.D., Ok Jun Kim, M.D., Ph.D,. Sung Wook Choi, M.D., Ph.D., Eui Chung Kim, M.D., Ph.D., Young Tae Park, M.D., Tae I Ko, M.D. 1, Yun Kyung Cho, M.D. 2 Department of Emergency Medicine, CHA Bundang Medical Center, CHA University, Department of Emergency Medicine, CHA Gumi Medical Center, CHA University 1 Division of Cardiology Department of Internal Medicine, CHA Gangnam Medical Center, CHA University 2 Purpose: This study was conducted to shorten the time spent at each stage of treatment and to reduce the total amount of time patients spend in the emergency department (ED) by applying Six Sigma in the treatment of major trauma patients. Methods: This is a comparative study encompassing 60 patients presenting to the ED of Bundang CHA Hospital from January 2008 to December 2008 and from July 2009 to March The stages of treatment for major trauma patients were divided into six categories (T1: total emergency department staying time, T2: duration of visit-radiologic evaluation time, T3: duration of visit-consult to department of admission, T4: duration of consultation-issue of hospital admissions time, T5: duration of visit-issue of hospital admissions time, T6: duration of issue of hospital admission-emergency department discharge time) and the total time patients spent in the ED was compared and analyzed for periods; before and after the application of Six Sigma. Results: After the application of Six Sigma, the numerical values in four of the six categories were significantly reduced; T2, T3, T4, and T5. However, the average of the total time patients spent in the ED did not show any remarkable change because the T6 increased highly. The level of Six Sigma increased 0.17σ. Conclusion: The application of Six Sigma for major trauma patients in the ED resulted in a significant improvement in the error rate for the total time patients spent in the ED. The Six Sigma activity has shown great potential. Therefore, the project is expected to bring better results in every stage of treatment if the levels of the hospital facilities are improved. (J Korean Soc Traumatol 2010;23: ) Key Words: Six Sigma, Emergency department, major trauma patients Address for Correspondence : Tae I Ko, M.D. Department of Emergency Medicine, CHA Gumi Medical Center, CHA University 855 Hyungkok-dong, Gumi , Korea Tel : , Fax : , 접수일 : 2010 년 5 월 7 일, 심사일 : 2010 년 6 월 23 일, 수정일 : 2010 년 7 월 19 일, 승인일 : 2010 년 9 월 15 일 119

2 대한외상학회지제 23 권제 2 호 I. 서론외상은심혈관질환, 암과함께우리나라에서가장흔한사망원인중하나로중증외상환자의발생뿐아니라, 그로인한사망역시점차증가하는추세를보이고있다.(1,2) 중증외상환자는다른질환과는달리빠른시간내에적절한치료가이루어지지않는경우사망에이르거나, 후유증으로인한영구적장애를초래할수있어진단및치료에있어서소요시간을단축시키는것이매우중요하다.(3) 이런중증외상환자의특성때문에정부에서도 2000 년응급의료에관한법률을전면개정하면서외상전문응급의료센터설립의근거를마련하였고, 2009년 4월중증외상환자에대한빠른치료가진행될수있도록수도권내본원을포함한 9개병원을 중증외상특성화후보센터 로지정하였다.(4) 본원에서도중증외상환자의사망률을감소시키기위한노력의일환으로, 중증외상환자가내원하여최종치료까지진행되는시간, 즉총응급의료센터체류시간을줄이고자하였다. 그러나본원은많은내원환자로인하여고질적인응급실과밀화가존재하여왔고, 이밖에다양한구조적, 시설적요인으로인하여외상환자의응급의료센터체류시간이증가하고있는실정이었다. 본원에서는이러한문제를해결하기위하여중증외상환자의진료프로세스에기업의품질경영개선시스템인 Six Sigma 개념을도입하는진료체계개선사업을계획하여진료프로세스의각단계에서의소요시간을증가시키는요인을분석하고, 이에대한개선안을고안하여, 이를실제적용하였다. Six Sigma 활동은생산과정의다양한문제를구체적으로정의하고, sigma라는통계척도를사용하여현재수준을계량화하고평가한후이를개선함으로서품질혁신과고객만족을달성하기위해전사적으로실행하는 21세기형기업경영전략으로, 1980년대말미국의모토롤라에서품질혁신운동으로시작된이후세계의여러초우량기업들이채택함으로써널리알려지게되었고, 국내에서도삼성그룹, LG그룹, 한국중공업등에서도입하여품질혁신에성공함으로써많은기업들이운용하고있다.(5) Sigma는원래정규분포에서표준편차를나타내는기호로, Six Sigma 활동은제조, 서비스등이이루어지는일련의체계의품질수준이제품 100만개당불량품이 3.4개이하가되는것, 즉 Six Sigma를달성하는것을목표로한다 (Table 1).(6) Sigma 수치가높아져서 6-sigma에가까워질수록불량률이개선됨을의미한다. Six Sigma 활동의여러방법론중기존체계를개선하는데효과적인 DMAIC는각각문제점을정의하고 (Define) 이에근거하여현재의상태를측정하며 (Measure) 문제점을분석하고 (Analysis) 이러한문제점을개선하고 (Improve) 개선된체계가의도한성과를얻을수있도록관리 (Control) 하는단계로구성된다. 이런방법론으로기존체계를개선한후, 개선전후의 Six Sigma 값을비교하여불량률감소가이루어졌는지를알아봄으로서개선의적절성을평가한다. 본원에서는기업에서상기와같은과정을통해제품의품질혁신을이루고자하는것처럼, 중증외상환자가응급의료센터에도착하여진료후응급의료센터에서퇴실하는시점까지의진료과정을제품생산공정처럼여러단계로구성된하나의흐름으로생각하고이를적용하였다. 먼저개선이필요한단계의불량의기준을정하였으며, 각단계에서소요되는시간을평가및계량화하였고, 각단계의문제점을찾아이를개선하였다. 그리고활동전후의 Six Sigma 값을비교함으로서목표했던기준에대한불량률의개선여부를알아보았으며통계적분석을통해체류시간의단축여부를검증하여이러한개선사업이총응급의료센터체류시간감소에미치는효과를분석하고자하였다. II. 대상및방법 1) 연구대상경기도지역내의 1개종합병원에서 Six Sigma 활동전인 2008년 1월부터동년 12월까지의기간에응급의료센터를통하여중환자실에입원한외상환자와 Six Sigma 활동후의 2009년 7월부터 2010년 3월까지의기간에응급의료센터에내원한외상환자들을조사대상으로하였다. 그리고이들중정부의 중증외상특성화센터외상전문응급의료센터평가설명서 에의거하여 ISS (Injury Severity Score) 가 15점이상이거나 RTS (Revised Trauma Score) 가 7점미만이었던환자들을중증외상환자로정의하였고본연구대상으로하였다.(2,7-9) 손상의원인이외상인지명확치 Table 1. Sigma level Sigma level Defect per million opportunities % 1Sigma 690, %0000 2Sigma 308, %0000 3Sigma 066, %0000 4Sigma 006, %0000 5Sigma %000 6Sigma % 120

3 김현수외 : Six Sigma 활동을통한중증외상환자의응급실체류시간개선활동 않은환자는연구대상에서제외하였고, Six Sigma 활동전과후의그룹들간의비교의용이성을위해타의료기관을경유하였거나본원에서진료후타의료기관으로전원된환자, 사망후병원에내원하였거나응급실내에서치료도중사망한환자는제외하여개선활동전후대상환자는각각 60명이었다. 2) 연구방법 Six Sigma 활동은외상팀 ( 신경외과, 흉부외과, 정형외과, 외과, 응급의학과, 영상의학과, 마취통증의학과 ) 의전문의및해당과의전공의, 응급실간호사와응급구조사, 응급의학과인턴이참여하였으며, 이에대한활동근거및단계를 DMAIC (Define, Measure, Analyse, Improve, Control) 과정을통해마련하였다.(2,8) DMAIC의각단계는다음과같다. 1 Define: 수차례의관련부서회의를통해서중증외상환자의총응급의료센터체류시간불량의정의를 180분이상된환자로하였고, 이외에총응급의료센터체류시간을구성하는세부단계를평가하기위해내원-방사선검 사시행시간과내원-입원장발부시간의불량을각각 20분, 150분이상된환자로정의하였다 (Table 2). 이는 2007 응급의료기능수행평가지표및의료기관평가 ( 보건복지가족부주최 ) 의항목을참고하였다.(11) 2 Measure: 2008년 1월부터동년 12월까지의기초자료수집기간동안본원응급의료센터에내원한후퇴실할때까지의진료과정을조사하여이를도표화하였고 (Fig. 1), 불량의기준을정의한 3단계를포함하여개선이필요한 6단계로세분화하였으며, 각단계의소요시간을측정하여분석하였다. 각단계는총응급의료센터체류시간 (T1), 내원-방사선검사시행시간 (T2), 내원-주협진과협진의뢰시간 (T3), 타과협진의뢰-입원장발부시간 (T4), 내원-입원장발부시간 (T5), 입원장발부-응급의료센터퇴실시간 (T6) 으로나누었고각각 T1-6로지정하였다. 3 Analysis: 수집된자료를분석하여시간이지연된단계와그원인을토의하였고소요시간증가에영향을줄수있는요소를 fishbone diagram 이라고불리는 Ishiakawa diagram으로구성하였다 (Fig. 2).(12,13) 4 Improve: 분석된자료를통해서각단계에서의소요 Table 2. Goal Time of Duration Stage Goal time (minutes) Total emergency department staying time (T1) < 180 Time after visit to radiologic evaluation (T3) < 200 Time after visit to the issue of hospital admissions (T6) < 150 Fig. 1. ED (Emergency Department) process map for major trauma patients 121

4 대한외상학회지제 23 권제 2 호 Fig. 2. Fish bone diagram and factors associated with longer emergency department staying time Table 3. Demography of patients Total Patients Before Improvement After Improvement Number Mean age (yr) Sex (M:F) 3.4:1 5:1 1.7:1 Emergency operation 시간단축을위한개선방안을만들었고, 이를각단계의구성원에게교육하였다. 5 Control: 개선안을본격적으로적용하기에앞서 2009 년 4월에서동년 6월까지의기간을예행기간으로하였다. 그기간동안 1개월마다각단계의구성원의대표들이모여당월 Six Sigma 활동의진행상황에대한토의를함으로써문제점을파악하여개선하고, 구성원이보다해당개선된진료체계에익숙해지고유기적인협진을할수있게유도하였다. 2009년 7월에서 2010년 3월까지개선된체계를적용하였다. 대상환자는 Six Sigma 활동이전과활동이후의각단계의소요시간을조사하여비교하였고, 그중불량률을정의한세단계의 Six Sigma 값을구하여개선여부를알아보았다. Six Sigma 활동이전의환자군은해당기간동안응급의료센터를통해중환자실에입원한환자들중중증외상환자의기준에부합되는환자를후향적으로조사하였 고, 활동이후의환자군은전향적으로조사하였다. 수집된자료의통계처리프로그램은 SPSS ver kor을사용하였고, Minitab을사용하여 Six Sigma 값을구하였다. 통계적인검증은독립표본 T-검정을사용하였고, p<0.05인경우에통계학적으로유의하다고정의하였다. III. 결과연구대상환자는총 120명으로 Six Sigma 활동이전 12 개월동안의환자가 60명이고, 활동후 8개월동안의환자역시 60명이었다 (Table 3). 외상의기전은활동전후모두교통사고에의한손상이가장많았고 (Fig. 3), 입원과는신경외과가가장많았다 (Fig. 4). 응급수술을시행한환자는활동전후각각 19명이었고중재적시술후중환자실에입원한환자는활동전 1명, 활동후에는없었다. Measure 단계에서조사된각단계의평균소요시간은 122

5 김현수외 : Six Sigma 활동을통한중증외상환자의응급실체류시간개선활동 Fig. 3. Comparison of trauma mechanism before and after Six Sigma activity Fig. 4. Comparison of admission department before and after Six Sigma activity 모두 Define 단계에서정의한불량의기준을초과하였고 (Table 4). 개선활동전응급의료센터체류시간의 Six Sigma 값역시 0.85σ로 70% 이상의불량률을보였다 (Table 5). 따라서모든단계에서소요시간의단축이요구되는상태로, Analysis와 Improve 단계에서각단계에서의소요시 간증가의요소를분석하여개선하였다. 내원-방사선검사시행시각 (T2) 의단계에서는응급의료센터전용 CT실이부재하였고, 가용 CT실이동층에있지않아환자의이송에많은시간이소요되었으며, 환자가많은시간대에는엘리베이터를신속하게이용하기어려운 123

6 대한외상학회지제 23 권제 2 호 Table 4. Comparison of time interval (minutes) before and after Six Sigma activity Stage* Before improvement (minute±sd ) After improvement (minute±sd) p-value T ± ± T2 31.8± ± T3 53.5± ± T ± ±33.0 < T ± ±37.10 < T ± ± * T1: Total emergency department staying time T2: Duration of visit-radiologic evaluation time T3: Duration of visit-consult to department of admission T4: Duration of consultation-issue of hospital admissions time T5: Duration of visit-issue of hospital admissions time T6: Duration of issue of hospital admission-emergency department discharge time p-value is derived by Group t-test; Table 5. Comparison of sigma level (σ) before and after Six Sigma activity Stage Before improvement After improvement Difference Total emergency department staying time (T1) 0.85σ 1.02σ 0.17σ Duration of visit - radiologic evaluation time (T3) 1.07σ 1.36σ 0.29σ Duration of visit - the issue of hospital admissions time (T8) 1.17σ 2.75σ 1.58σ Fig. 5. Trauma call system 문제가있었다. 이를개선하기위해중증외상환자로의심되는환자가내원한경우검사실화면에중증외상환자임을알수있게하는별모양의표시를하고 (Fig. 5), CT 검사실에 cord yellow 라는신호를주면 CT 검사를시행하는모든과정이다른환자에우선하여최대한빨리진행될수있도록하였다. 그리고중증외상환자진료시 CT실로의빠른이송을위해안전요원이나간호보조원이미리엘리베이터를선점하도록하여즉각적으로환자를 CT실로이송할수있게하였다. 그결과이전의 31.8분소요되던시간이 Six Sigma 활동이후 22분으로 9.8분개선되었다. 내원-주협진과협진의뢰시간 (T3) 의단계에서는중증외상환자에대한의사의중증도파악및해결능력부족과영상검사결과가나온이후협진의뢰하는진료행태로 인해소요시간이증가하는문제가있었다. 그래서호주 New South Wales주의응급이송체계인 Ambulance service of New South Wales 의병원전단계에서의중증외상환자분류기준인 MIST (Mechanism, Injury, Sign, Transport and Treatment) 개념을도입하여응급의료센터각전공의에게숙지시킴으로서중증외상환자의분류를빠르고원활하게하였다 (Table 6).(14) 외상환자가 MIST의기준에부합하는경우즉시응급의학과의고년차전공의에게연락하여진료의첫단계부터적극적으로참여하게하였고, 응급의학과에서중증외상환자로판단하면외상팀에포함된모든과의당직의에게동시에협진의뢰를함으로써응급의학과와협진과들사이의의사소통뿐아니라, 협진과들사이의의사소통과정에서도불필요한단계를줄일수있도록하였다. 이러한개선안의시행후주협진과의협진시간이 53.5분에서 35분으로 18.5분감소하는효과를보였다. 주협진과협진의뢰-입원장발부시간 (T4) 의단계에서는입원결정권을가진해당과전문의및고년차전공의에게환자에대한정보가여러단계를거쳐보고되어입원장발부가늦어지는문제를해결하기위해응급의료센터전산프로그램에 TRAUMA CALL 이라고표기된버튼을신설하고내원환자가중증외상환자로판단되어응급의학과전공의가누르면 (Fig. 5), 외상팀의모든당직전문의및수석전공의에게문자메시지가자동으로전달되게함 124

7 김현수외 : Six Sigma 활동을통한중증외상환자의응급실체류시간개선활동 으로써종래의응급의학과전공의-협진과저년차전공의- 협진과고년차전공의-협진과전문의로이어지는단계를개선하여소요시간을 132.6분에서 68.2분으로줄였다. 입원장발부-응급의료센터퇴실시간 (T6) 의단계에서는중환자실을포함한병실의부족이가장큰요인으로판단되었다. 그리고중재적시술이나응급수술이계획된경우해당시술실및수술실의준비가응급실보다상대적으로늦어지면서체류시간이증가하는경우도있었다. 그래서 중증외상환자의경우중환자실입실에관련해서우선순위를부여하였고외과계중환자실에여유가없는경우, 내과계중환자실에여유가있다면우선적으로병실을배정하기로하였다. 그리고중증외상환자전용수술실을배정하여응급수술이이루어지기까지의준비시간을단축하고자하였고, 중재적시술이필요할가능성이있는환자는미리중재적시술팀에게시술의가능성을알려서시술준비가갖추어지게하였다. 그러나이러한개선안의시행에도불구하고 Table 6. Major trauma triage tool (MIST) Mechanism of Injury Injuries Signs and Symptom Transport Incident: Death in same vehicle Intrusion into occupant compartment > 30 cm Steering wheel deformity Patient side impact Vehicle vs pedestrian/cyclist/motor Bicycle collision Ejection from vehicle Entrapment with compression Focal blunt trauma to head or torso Falls > 3 m or paediatrics twice the child s height High voltage injury Crush injury excluding fingers/toes Any rapid deceleration mechanism that results in a large inertia change at impact * Patients <16 & >65 years of age, Obstetric patients >20 weeks gestation, patients on antico agulants and patients with pre-existing diseases are at greater risk and require a high index of suspicion for serious injury. * All penetrating injury Head: Minor head injury with loss of consciousness or amnesic to event with - 2 or more vomits or a seizure - on anticoagulants Open, depressed skull or signs of base of skull. A decreased loss of consciousness is due to traumatic injury, until proven otherwise. Face: Injury with potential airway risk; severe haemorrhage. Neck: Swelling, bruising, hoarseness or stridor. Chest: Severe pain, paradoxical breathing, restrain abrasion Abdomen: Severe pain, rigidity, swelling, pelvic tenderness, restraint/abrasion/ contusion. Limbs: 2 or more proximal long bone #, amputation proximal to digits, ischemia, degloving injury. Spinal/Back: Visible deformity. Burns: Partial or full thickness burns Adults > 20% Children > 10%, or Burns involving head /neck/face/hands/feet/groin or inhalation injury. All circumferential burns or burns in a patient with comorbidities or pregnancy Airway: at risk, hoarseness, stridor Breathing: RR < 10 or > 29, SpO 2 < 90% on air, cyanosis or respiratory difficulty Circulation: HR >120, SBP < 90 or severe haemorrhage Disability: GCS 13 or paralysis/sensory deficit Or any worsening trend in ABCD Transport and Treatment 125

8 대한외상학회지제 23 권제 2 호 소요시간은 118.1분에서 208.1분으로증가한결과를보였다. T2,3,4,5의각단계별로소요된시간의증감은통계학적으로도유의하였다 (Table 4). 내원-방사선검사시행시간 (T2) 은개선목표인 20분을만족시키진못하였으나 22분으로매우근접한수치를보였고, 내원-입원장발부시간 (T4) 은개선목표치인 150분을만족하였다. 그러나입원장발부-응급의료센터퇴실시간 (T6) 는오히려소요시간이 90 분증가하여 Six Sigma 활동으로도개선되지않은결과를보였고, 이로인해다른단계의소요시간의개선에도불구하고응급의료센터총체류시간 (T1) 은활동전 318.6분에서활동후 311.5분으로크게개선된수치를보이지않았다. 그러나불량률에있어서는총응급의료센터체류시간의 Six Sigma 값이 0.85σ에서 1.02σ로증가하여비록 6σ( 총응급실체류시간이 180분이상되는경우가환자 100만명당 3.4명 ) 에는여전히크게미치지못했으나 0.17σ만큼불량률이개선된결과를나타내어목표했던 180분이상되는환자가줄었음을보였다 (Table 5). 내원-방사선검사시간, 내원-입원장발부시간에대하여시행한 Six Sigma 값의측정결과역시 0.29σ, 1.58σ만큼개선된결과를보였다. IV. 고찰응급의료센터에서중증외상환자의진료에는외상팀을비롯한다양한부서와구성원이관여하게된다. 따라서어떤목표를설정하였을때, 체계적인계획과이에대한객관적인평가가없다면이를달성하기쉽지않다. Six Sigma 활동은문제점을파악하고개선할수있도록도와주며개선이필요한점을단순히추상적목표만으로나타내는것이아니라이를수치화시켜문제인식과해결에명확한기준점을만들어준다. 그리고개선의정도를통계적으로보여주어그적절성을평가하고관리할수있게도와준다는점에서응급의료센터에서의중증외상환자진료체계개선에매우적합한방법중하나로생각된다. 본원에서시행한 Six Sigma 활동결과총응급의료센터평균체류시간은유의한차이를보이지않았으나본활동의목표였던불량률은개선됨을보였다. 특히세부단계인내원-입원장발부시간 (T4) 은불량률의개선및소요시간의감소가현저하여 MIST 개념을통한 trauma triage의도입을비롯한중증외상환자분류체계와전산시스템에 TRAUMA CALL 버튼을신설한것을포함한환자정보전달체계의개선이매우효과적이었음을나타낸다. 이는중증외상환자의진료에있어전용 CT실이나병실증설과같은시간, 공간, 비용적으로개선에한계가있는병원시설의개선없이, 진료체계의혁신을통한 Six Sigma 개선활동만으로도어느정도목표를달성할수있음을시사한다. 따라서현재의개선안이잘적용될수있도록지 속적으로관리하고그결과에대한평가를하며더나은결과를얻기위한개선노력을계속해야할것이다. 특히원래 MIST는외상환자의사고기전 (Mechanism), 손상양상 (Injury), 활력증후 (Sign), 이송도중의치료 (Transport and Treatment) 를의미하는것으로, 본래중증외상의가능성을병원전단계에서타진할수있도록사고기전, 손상양상, 활력증후의기준을만들어중증외상가능성을타진하고, 병원의외상팀과의의사소통을위해고안된개념인데, 차후병원내단계에좀더적합하도록개선하고변용하는작업이필요할것으로생각된다.(15) 이러한성과에도불구하고내원-방사선검사시간, 내원-입원장발부시간의불량률개선에비해총응급의료센터체류시간의불량률의개선도가떨어지고, 내원에서입원장발부까지의소요시간이크게단축되었음에도입원장발부-응급의료센터퇴실시간은오히려통계적으로유의하게증가된결과를보임으로서총응급의료센터평균체류시간역시통계적으로의미있는개선을보이지못한점은본개선활동의한계를동시에나타낸다고볼수있다. 입원장발부-응급의료센터퇴실시간단계에서소요시간증가의요인으로생각되었던한정된병실과중환자실의문제에대한개선안은중증외상환자뿐아니라병원전체적인환자수증가로인하여중환자실의절대적요구량이증가함으로서그효과가상쇄되었다고생각된다. 이는 Six Sigma 활동을통한진료체계개선만으로는분명한계가있고, 중환자실부족문제등을비롯한시설적측면개선이병행될때 Six Sigma 활동이더효과적인결과를보일수있음을시사한다. 이밖에도추후총응급실체류시간단축을위해서는입원장발부-응급의료센터퇴실시간단계에서의시행한개선안의한계점과그해결방안에대한추가적인고찰및개선개선노력이필요하다. 본연구의한계는먼저연구대상과 Six Sigma 활동이일개병원에국한되었다는점을들수있다. 따라서본개선활동을그대로진료체계나응급의료센터의시설이다른타병원에적용하기엔한계가있다. 그러나 Six Sigma 활동자체로본다면이활동이하나의체계가아닌개선의방법론이기때문에각병원에맞게변형, 적용할수있을것으로사료된다. 이밖에 3개월간의예행기간을두었으나, Six Sigma 활동에참여한모든구성원이이시스템에적응함에있어다소부족한시간일수있었고, 연구기간과표본의수도충분히만족할만한규모는아니었다. V. 결론 Six Sigma 활동은기업경영의혁신을위한운동이지만, 병원내진료체계를개선하는부분에도매우적합하고효과적인방법으로판단된다. 126

9 김현수외 : Six Sigma 활동을통한중증외상환자의응급실체류시간개선활동 본연구에서중증외상환자에대한 Six Sigma 활동으로총응급의료센터체류시간의불량률이감소하였을뿐아니라진료과정의많은단계에서소요시간감소를보여중증외상환자진료의질향상에긍정적인효과를주었다고생각된다. 따라서이러한활동은지속적으로시행되어야할것이며, 더연구되고, 발전해야할것이다. 다만응급의료센터평균체류시간이개선되지않은점은이러한활동이진료체계개선에더하여더많은중증외상전용중환자실확보를비롯한병원시설적측면의개선이병행되어야함을나타낸다. 본원은상기와같은 Six Sigma 활동의결과 2010년 4월, 중증외상특성화센터로지정되었다. 추후 Six Sigma를통한지속적시스템의개선노력에병원시설의보강이더해진다면, Six Sigma 활동이중증외상환자의치료에보다많은역할을할수있을것이다. REFERENCES 01) Korea national statistical office. Annual report of cause of death in Korea Seoul: Korea national statistical office ) Kug Jong Lee. The Necessity for a Trauma Surgeon and the Trauma Surgeon s Role in the Trauma Care System. The Korean Soc of Traumatology 2008;21: ) Whan Sik Kim, Min Su Cho, Keum Seok Bae, Seong Joon Kang, Kang Hyun Lee, Keum Hwang. Clinical Analysis of Death in Trauma Patients. The Korean Soc of Traumatology 2007;20: ) Available at: jsp?par_menu_id=04&menu_id=0403&boar D_ID=140&BOARD_FLAG=00&CONT_SEQ= &page=1 05) Available at: 06) Jin Kun Bae, Ok Jun Kim, Sung Wook Choi. Reducing Length of Stay in Emergency Department through Six Sigma Improvement Process. The Journal of the Korean Society of Emergency Medicine 2008;19; ) Yates DW. Scoring systems for trauma. BMJ 1990;301: ) Champion HR, Sacco WJ, Caranazzo AJ, Cop-es W, Fauty WJ. Trauma Score. Crit Care Med 1981;9: ) Available at: jsp?par_menu_id=04&menu_id=040102&boa RD_ID=110&BOARD_FLAG=01&CONT_SEQ=41 343&page=1 10) Available at: DMAIC.pdf 11) Available at: _/down.jsp?file=nemc_2_ pdf&boardle ftmenuflag=7&sub_boardleftmenuflag=null 12) Hankins Judy. Infusion Therapy in Clinical Practice 2001;42. 13) Nancy R. Tague. Seven Basic Quality Tools, The Quality Toolbox. Milwaukee, Wisconsin : American Society for Quality 2004;15. 14) Available at: 20Trauma%20Triage%20Tool.pdf 15) S. K. D Amours, M. Sugrue, S. A. Deane. Initial Management of The Poly-Trauma Patient: A Practical Approach in Australian Major Trauma Service. Scandinavian Journal of Surgery 2002; 91:

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