04-장동현

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1 대한응급의학회지제 25 권제 5 호 Volume 25, Number 5, October, 2014 원 저 Pediatrics 계획되지않은소아응급실재방문 : 환자의임상적특성과응급실과밀화와의관련성 서울대학교의과대학응급의학교실, 서울대학교병원권역응급의료센터응급간호팀 1 장동현 곽영호 김도균 정재윤 서동범 장익완 정재현 1 서혜향 1 김주원 1 추지혜 1 Unplanned Revisit to Pediatric Emergency Department: Patients Characteristics and Relationship with Overcrowding Dong-hyun Jang, M.D., Young Ho Kwak, M.D., Do Kyun Kim, M.D., Jae Yun Jung, M.D., Dong Bum Suh, M.D., Ikwan Chang, M.D., Je Hyun Jung, RN 1, Hye Hyang Seo, RN 1, Ju Won Kim, RN 1, Ji Hye Choo, RN 1 책임저자 : 김도균서울특별시종로구연건동 28 서울대학교의과대학응급의학교실 Tel: 02) , Fax: 02) birdbeak@snuh.org 접수일 : 2014년 6월 27일, 1차교정일 : 2014년 6월 27일게재승인일 : 2014년 8월 8일 529 Purpose: Revisit to the pediatric emergency department (ED) in the short-term period may be due to inadequate evaluation during the previous visit, which may indicate a problem with quality in emergency care. The aims of this study are to analyze the characteristics of patients who revisited the pediatric ED within 48 hours after discharge and to evaluate the relation between overcrowding and revisit rates. Methods: Retrospectively, we reviewed the charts of patients who returned within 48 hours after visiting a PED during a one-year period between June 1st, 2011 and December 31st, We determined the rate of return visits and review the characteristics of patients, emergency severity index (ESI) level at visits, cause of revisit, diagnosis, and crowding degree of the pediatric ED at the patient s first visit. Results: A total of 16,688 patients visited the pediatric ED and 13,716 patients were discharged from the PED during the period. Of these discharged patients, 534 patients revisited inevitably within 48 hours. The most common cause of revisit was relapse or worsened symptoms (70.0%). There was no significant difference in sex, severity of patient, and crowding degree of the pediatric ED at the first visit, however, patients who revisited were younger than those who did not (p=0.005). The ESI level at the return visit was significantly higher irrespective of admission after revisit (p<0.001). In diagnosis grouping, patients with gastrointestinal diseases, respiratory diseases, and neoplastic diseases showed a higher rate of revisit. Conclusion: Approximately 4% of our pediatric ED visits were for children returning within 48 hours. Patients who revisited were younger and patients with gastrointestinal diseases, neoplastic diseases, and respiratory diseases were more likely to revisit. Careful explanation of the possibility of worsened symptoms is necessary for these patients. Key Words: Overcrowding, Pediatric emergency department, Revisits Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea, Emergency Nursing & Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea 1 Article Summary What is already known in the previous study Unscheduled revisit to the emergency department (ED) in the short-term period is considered an indication that the initial evaluation or management was inadequate. Several factors can be possible causes of unscheduled emergency return visits. However, the relation between the revisit rates and crowding degree is unknown. What is new in the current study Approximately 4% of pediatric ED visits are for children returning within 48 hours. There was no difference in revisit rates according to crowding degree. Patients who revisited were younger and those with gastrointestinal diseases, neoplastic diseases, and respiratory diseases were more likely to revisit.

2 530 / 대한응급의학회지 : 제 25 권제 5 호 2014 서론응급실을방문하여치료받고퇴원한환자중에서짧은시간내에다시응급실로재방문하는환자의비율은국내외의연구에따르면 1~5% 정도로보고되고있다 1-4). 응급실퇴원이후단기간내의재방문율은응급실에내원한환자의적절한진단및처치가이루어졌는지에대한평가지표가될수있으며, 더불어재방문의증가는응급실내과밀화와혼잡도증가에도악영향을줄수있는문제이다. 특히응급실과밀화와혼잡도증가는환자들의적절한처치를늦추고잠재적의료사고의위험성또한증가시킬수있는것으로알려져있다 5-7). 응급실을재방문하는환자의경우상당수는증상의재발이나새로운질환의발현으로불가피하게응급실을다시찾을수밖에없는경우도있지만, 첫방문후귀가시적절한설명의부족혹은향후경과에대한이해부족등으로불필요하게응급실을재방문하는경우도있다 2). 또한일부환자의경우첫방문당시응급실에서의진료및처치의미비등으로인하여방문이후증상이나상태의악화를보여재방문하게되기도한다. 이와같이, 재방문환자의재방문이유를분석하고재방문과관련된위험인자를찾아, 예측가능한재방문을감소시키기위해노력하는것은진료의적절성유지를비롯하여응급실과밀화를막는데에도도움이될것이다. 이전국내에서일반적인응급실의재방문관련연구는몇차례시행되었던바있으나, 소아응급실에서의재방문환자의특성이나요인분석연구는없었다 1-3). 또한외국의경우주로천식이나위장관염등특정증상혹은질환군에대한응급실재방문요인에대한연구가많이시행된바있는데이러한외국의사례를국내의응급의료상황에그대로적용하기에는어려움이있다 8-12). 본연구는권역응급의료센터소아응급실의재방문율및재방문환자의특성을파악하고예방가능한재방문에대한평가를통하여궁극적으로는소아응급실내원환자에대한적절한처치를통하여재방문환자감소를도모하고더불어응급실내과밀화와혼잡도를줄이기위한목적으로시행되었다. 대상과방법본연구는후향적서술적조사연구로, 서울대학교병원전자의무기록 (electronic medical record, EMR) 자료를통해권역응급의료센터소아응급실을이용하는환자중재방문환자의특성을분석하였다. 연구가시행된본소아응급실은연간내원환자 2만명규모로, 진료인력은전담소 아응급전문의 3명, 전임의 2명, 전공의 5명으로구성되어있다. 응급실진료는일반적으로지속적인활력징후의평가가필요하지않은경우진료실에서, 지속적활력징후평가가필요하다보이는환자의경우별도의소생실에서이루어지고있다. 환자의일차진료는응급의학과전공의 1명과소아청소년과전공의 2명이담당하고있으며, 소아청소년과외래추적관찰중인환자가기저질환에의한것으로의심되는문제로내원하였을때에만소아청소년과전공의에의한초진진료가이루어지고이외의환자에대하여서는응급의학과전공의에의한초진진료가이루어지고있다. 초진이후의진료에대하여서는 1~3년차전공의의경우전문의와함께이후처치에서의의사결정및퇴원결정을하고있으며전공의 4년차의경우에만단독으로의사결정및퇴원결정을하고있다. 2011년 1월 1일부터 2011년 12월 31일까지일개권역응급의료센터내소아응급실을이용한만 15세이하의환자중응급실퇴실시각기준으로 48시간이내에소아응급실로재방문한환자를대상으로하였고, 재방문환자중검사혹은치료등을예정후다시내원하였거나, 예정된재방문의경우는제외하였다. 연령기준에따라모든환자를만2세이하, 만2세에서만5세이하, 만6세에서만11세이하, 만 12세이상으로분류하였고, 의료보험에따라의료보험환자, 일반환자, 의료보호환자, 기타로분류하였다. 응급실재방문이유는, Kim 등 1) 의연구에서분류했던방법을참고하여상태악화및재발, 투약부작용, 진단의미비, 새로운질환발생, 환자에대한설명부족, 보호자의융통성부족, 입원목적, 검사, 치료목적, 기타로분류하였다. 방문당시의초기중증도는응급중증도지수 (emergency severity index, ESI) 수준에따라 level 1~5로분류하였고, 더불어재방문환자의중증도악화여부에대한평가를위하여첫방문과재방문당시의 ESI level에차이가있는지비교하였다 11). 과밀화지표에따른재방문환자수변화에대한평가를위하여소아응급실의시간별재원환자수를응급실전체병상수인 9로나누어응급실의시간별과밀화지표를구하였고, 과밀화지표의백분위를이용하여구간별로나누어각구간에따라재방문환자의비율변화가있는지를평가하였다 13). 응급실내재원환자가없을때를 0%, 응급실내재원환자가연중최대였을때를 100% 로하여 0~25% 에해당하는구간을구간 1, 25~50% 에해당하는구간을구간 2, 50~75% 에해당하는구간을구간 3, 75~100% 에해당하는구간을구간 4로정하였다. 그리고각방문환자의방문시각에해당하는과밀화구간을연결하여환자의응급실방문당시과밀화정도와재방문과의관련성을분석하였다. 응급실재방문환자의질병별분류에서는처음방문하였을때의퇴실주진단명을활용하였다. 같은기간동안응급

3 장동현외 : 계획되지않은소아응급실재방문 : 환자의임상적특성과응급실과밀화와의관련성 / 531 실에방문후퇴원했던환자들중재방문하지않았던환자들의퇴실주진단명을재방문환자의퇴실주진단명과비교하였다. 환자들의퇴실당시진단분류는 Pediatric Emergency Care Applied Research Network (PECARN) 의 diagnosis grouping system (DGS) 연구결과를국내실정에맞게수정한한국형 DGS 방법에따라시행하였다 14,15). 알레르기, 면역및류마티스질환, 순환기및심혈관계질환, 눈질환, 이비인후과 / 치아및구강질환, 내분비 / 대사및영양문제, 체액및전해질문제, 소화기계질환, 생식기계질환, 혈액질환, 근골격계및결합조직질환, 신경계질환, 신생물질환, 정신행동질환, 호흡기계질환, 피부및연조직질환, 상세되지않는전신질환, 외상, 비뇨기계질환, 기타로분류하였고, 각진단분류에따라재방문율에유의한차이를보이는지를비교하였다. 수집된자료는 STATA 12.0 (StataCorp, TX, USA) 을이용하여분석하였고, 각군간의빈도분석은카이제곱검정을이용하였고유의수준은 p<0.05 로하였다. 결과 2011년 1월 1일부터 12월 31일까지 1년간권역응급의료센터소아응급실의총방문환자 16,688명중입원혹은전원된환자를제외하고응급실에서퇴원한환자는 13,716명이었다. 응급실퇴실시각으로부터 48시간이내에재방문한환자는 570명이었고, 그중예고된재방문환자 36명을제외한 534명이최종 48시간이내재방문환자였으며재방문비율은 3.9% 였다. 응급실재방문환자들의재방문이유로는상태악화및재발이 374명 (70.0%) 으로가장많았으며, 새로운질환의발생이 101명 (19.0%), 검사및치료목적이 41명 (7.7%) 으로다수를차지하였다. 이외에환자에대한설명부족 6 명 (1.2%), 입원목적 4명 (0.8%), 보호자의융통성부족 4 명 (0.8%), 투약부작용 2명 (0.4%), 진단미비 1명 (0.2%), 전자의무기록상에서정확한원인이파악되지않 는경우가 1명 (0.2%) 이었다. 특히재방문환자들의응급실첫방문당시 ESI level은 level 1이 1명 (0.2%), level 2가 38명 (7.1%), level 3가 421(78.8%), level 4가 66명 (12.4%), level 5가 8명 (1.5%) 이었으나, 재방문당시에는 level 1이 36명 (6.7%), level 2가 40명 (7.5%), level 3가 419(78.5%), level 4가 36명 (6.7%), level 5가 3명 (0.6%) 으로첫방문과재방문당시의 ESI level에차이를보였다 (p<0.001). 재방문당시 ESI level이상승한환자는총 127명 (23.8%) 이었고, ESI level이낮아진환자는총 53 명 (9.9%) 이었다 (Table 1). 또한재방문이후의입퇴원여부에따라분류한경우, 재방문후입원하였던환자 410 명중에서 ESI level이상승한환자는 102명 (24.9%), ESI level이낮아진환자는 42명 (10.2%), 퇴원하였던환자 124명중에서 ESI level이상승한환자는 25명 (20.2%), ESI level이낮아진환자는 11명 (8.9%) 으로재방문후입퇴원여부에따른 ESI level의차이는없었다. 총내원환자중재방문환자군및재방문환자중상태악화및재발로인한재방문환자군의인구학적및임상적특성을재방문하지않은군과비교하였다. 환자의성별, 보험여부, 방문당시의 ESI level은통계적으로유의한차이는없었으나재방문환자군의평균연령은 4.5±4.8세, 재방문하지않은환자군의평균연령은 4.8±4.8세로재방문환자군이더나이가어렸으며이는통계적으로유의한차이를보였다 (p=0.005). 또한상태악화로인해재내원한환자군에서도평균연령 4.9±4.8세로재방문하지않은환자군보다더낮았으며이차이도는통계적으로유의하였다 (p=0.001)(table 2). 응급실과밀화의백분위수에따라각환자의방문시점의과밀화정도를 4개구간으로나누어비교하였을때, 재방문환자군이나상태가악화되어내원한재방문환자군모두재방문하지않은환자군과비교하였을때그비율에차이를보이지않았다 (Table 3). 해당기간응급실을내원한전체환자중 EMR에진단명이명확히기입되지않은 864명 (6.3%) 의환자를제외한 Table 1. Changes of ESI level in revisit patients. n (%) Revisit First visit (0.2) 05 (0.9) 030 (05.6) 00 (00.0) 0 (0.0) 036 (06.7) 2 0 (0.0) 09 (1.7) 026 (04.9) 04 (00.8) 1 (0.2) 040 (07.5) 3 0 (0.0) 24 (4.5) 336 (62.9) 55 (10.3) 4 (0.8) 419 (78.5) 4 0 (0.0) 00 (0.0) 027 (05.1) 07 (01.3) 2 (0.4) 036 (06.7) 5 0 (0.0) 00 (0.0) 002 (00.4) 00 (00.0) 1 (0.2) 003 (00.6) total 1 (0.2) 38 (7.1) 421 (78.8) 66 (12.4) 8 (1.5) ESI: emergency severity index First visit vs. Revisit, p<0.001 total

4 532 / 대한응급의학회지 : 제 25 권제 5 호 2014 나머지환자들에대하여진단분류를하였다 (Table 4). 그중소화기계질환 ( 재방문환자군 23.0% vs 비재방문환자군 17.4%, p<0.001), 혈액질환 ( 재방문환자군 2.6% vs 비재방문환자군 1.5%, p<0.001), 신생물질환 ( 재방문환자군 12.4% vs 비재방문환자군 6.4%, p<0.001), 호흡기계질환 ( 재방문환자군 14.4% vs 비재방문환자군 8.9%, p<0.001) 의경우유의한확률로재방문환자의비율이높았으며, 이비인후과 / 치아및구강질환 ( 재방문환자군 16.7% vs 비재방문환자군 20.5%, p=0.037), 외상환자 ( 재방문환자군 5.6% vs 비재방문환자군 17.7%, p<0.001) 의경우유의한확률로재방문환자의비율이낮았다. 상태악화로인한재방문환자군의경우소화기계질환, 혈액질환, 호흡기계질환에서는재방문환자의경우와마찬가지로재방문하지않은환자군에비해그비율이높고외상환자의경우재방문환자의비율이낮았으나, 신생물질환 (8.3% vs 6.4%, p=0.188), 이비인후과 / 치아및구강질환 (20.3% vs 20.5%, p=0.993) 의경우상태악화 및재발로인한재방문환자군과재방문하지않은군사이에통계적으로유의한차이는보이지않았다. 고찰본연구에서는일개권역응급의료센터소아응급실을 48 시간이내에재방문한환자의특성및재방문과관련된인자에대한분석을시행하였다. 환자의특성중성별, 보험종류, 내원당시환자의중증도, 내원당시응급실내과밀화정도에있어서는재방문환자와재방문하지않은환자를비교하였을때유의한차이를보이지않았다. 다만연령의경우재방문환자가더어렸으며진단별로는소화기계질환, 신생물질환, 호흡기계질환의경우에유의한확률로재방문비율이높음을확인할수있었다. 기존소아응급실의재방문과관련된국내외연구결과들을보면, 전체내원환자와비교하였을때재방문환자의 Table 2. Baseline characteristics of the study population. n (%) Characteristics Revisit ED Revisit ED due to worsened Did not revisit (n=534) symptoms (n=374) (n=13,146) Boys 314 (58.9) 217 (58.0) 7,580 (57.7) 0-2Y 259 (48.5) 194 (51.9) 5,510 (41.9) 3-5Y 135 (25.3) 086 (23.0) 3,599 (27.4) Age* 06-11Y 076 (14.2) 052 (13.9) 2,519 (19.2) 12Y- 064 (12.0) 042 (11.2) 1,518 (11.5) National medical insurance 522 (97.8) 369 (98.7) 12,675 (96.4)0 Insurance No insurance 000 (00.0) 000 (00.0) 087 (0.7) Medical Aid 010 (01.9) 005 (01.3) 294 (2.2) Others 002 (00.4) 000 (00.0) 090 (0.7) (00.0) 000 (00.0) 004 (0.0) (07.1) 026 (07.0) 665 (5.1) ESI level (77.9) 292 (78.1) 10,511 (80.0) (13.5) 050 (13.4) 01,718 (13.1) (01.5) 006 (01.6) 248 (1.9) ED: emergency department, ESI: emergency severity index * p=0.005, Revisit ED vs. Did not revisit ED p=0.001, Revist ED due to worsened symptom vs. Did not revisit ED Table 3. Number of revisit patients for each crowding measures. n (%) Crowding measure Revisit ED Revisit ED due to worsened symptoms Did not revisit ED 00~25 percentile 099 (18.5) 072 (19.3) 2,354 (17.9) 25~50 percentile 183 (34.3) 138 (36.9) 4,320 (32.9) 50~75 percentile 120 (22.5) 077 (20.6) 2,973 (22.6) 75~100 percentile 132 (24.7) 087 (23.3) 3,499 (26.6) ED: emergency department Revisit ED vs. Did not revisit ED, p=0.771 Revisit ED due to worsened symptoms vs. Did not revisit ED, p=0.224

5 장동현외 : 계획되지않은소아응급실재방문 : 환자의임상적특성과응급실과밀화와의관련성 / 533 경우나이가더어리고, 중증도가높은결과를보여주었다 8,10,12,16,17). 본연구에서도나이가어린경우재방문의비율이높아이전의연구와유사한결과를보였으나, ESI level 을기반으로한중증도에있어서는재방문환자와재방문하지않은환자군사이에유의한차이가없는것으로나타났다. McCarthy 등 5) 은응급실의과밀화정도가응급실내환자의적절한처치를늦어지게하고응급실재원시간을늘리는등문제를유발할수있다고보고한바있다. 이에본연구자들은응급실방문당시의응급실과밀화정도가환자의재방문율에미치는영향을분석하기위해환자내원당시의응급실과밀화정도를 4단계로나누어분석하였으나과밀화정도에따른재방문율의유의한차이를확인할수없었다. 본연구에서사용한과밀화지표는응급실내의료인력및시설규모를대변할수있는응급실병상규모에대한비율을활용하여산출한것으로, 단순히재원환자수로응급실과밀화의정도를평가하는것보다정확할것이라평가되어이와같은분석방법을사용하였다. 본연구는응급실과밀화정도에따른재방문율차이를분석한첫번째연구라는점에서그의의가있겠으며, 향후후향적분석이아닌전향적기법으로과밀화지표와의관계를살피는 연구가더필요할것으로생각된다. 성인과소아모두를대상으로응급실재방문환자의진단별차이를분석했던 Kim 등 3) 의연구에서는소화기계질환, 인후염, 호흡기계질환, 요로결석환자의경우재방문의비율이높다고보고하였다. 짧은시간동안환자를파악하고진단을추정해야하는응급진료의특성상응급실퇴실진단명의경우정형화되지않은증상별진단이많아그분류에어려움이있다. 이에저자들은최근진단별통합분류를제안한미국 PECARN의연구결과를국내에맞게수정한, 한국형 DGS에따라진단명을구분하였으며, 그결과소화기계질환, 혈액질환, 신생물질환, 호흡기계질환에서유의한확률로재방문환자의비율이높음을확인하였다 14,15). 하지만신생물질환에서는증상의재발이나악화에의하여재방문한환자에국한하여다시분석한결과에서는유의한차이를보이지않았다. 소화기계질환및호흡기계질환을가진환자들이특히증상의재발이나악화에의하여재방문하는비율이높다는사실은, 응급실방문이비교적용이하여질병의초기단계부터응급실방문이많은국내응급의료의특성을고려할때질병초기상태에응급실을방문후귀가하였다가병의진행에따라환자상태가악화되어재방문한경우가많았을것으로생각할수있다. Table 4. Number of revisit patients for each diagnostic criteria. n (%) Diagnostic criteria Revisit ED Revisit ED due to worsened symptoms Did not revisit ED Allergic, immunologic & rheumatologic diseases 09 (01.7)* 08 (02.1)* 336 (02.7) Circulatory & cardiovascular diseases 01 (00.2)* 00 (00.0)* 066 (00.5) Diseases of the eye 03 (00.6)* 01 (00.3)* 153 (01.2) ENT, dental & mouth diseases 89 (16.7)* 76 (20.3)* 2515 (20.5)0 Endocrine, metabolic & nutritional diseases 04 (00.8)* 02 (00.5)* 064 (00.5) Fluid & electrolyte disorders 02 (00.4)* 02 (00.5)* 013 (00.1) Gastrointestinal diseases 123 (23.0) 89 (23.8) 2135 (17.4)0 Genital & reproductive diseases 03 (00.6)* 02 (00.5)* 104 (00.8) Hematologic diseases 14 (02.6) 08 (02.1) 186 (01.5) Musculoskeletal & connective tissue diseases 04 (00.8)* 01 (00.3)* 185 (01.5) Neurologic diseases 29 (05.4)* 22 (05.9)* 688 (05.6) Noeplastic diseases (cancer, not benign) 66 (12.4) 31 (08.3)* 792 (06.4) Psychiatric and behavioral diseases & symptoms 03 (00.6)* 01 (00.3)* 116 (00.9) Respiratory diseases 77 (14.4) 61 (16.3) 1099 (08.9)0 Skin, dermatologic & soft tissue diseases 10 (01.9)* 07 (01.9)* 288 (02.3) Systemic states 51 (09.6)* 37 (09.9)* 1028 (08.4)0 Trauma 30 (05.6) 16 (04.3) 2178 (17.7)0 Urinary tract diseases 05 (00.9)* 03 (00.8)* 136 (01.1) Other 11 (02.1)* 07 (01.9)* 200 (01.6) ED: emergency department, ENT: ear neck throat * p<0.05, Revisit ED vs. Did not revisit ED p<0.01, Revisit ED vs. Did not revisit ED p<0.01, Revisit ED due to worsened symptom vs. Did not revisit ED p<0.001, Revisit ED vs. Did not revisit ED p<0.001, Revisit ED due to worsened symptom vs. Did not revisit ED

6 534 / 대한응급의학회지 : 제 25 권제 5 호 2014 본연구자들의문헌검색에의하면지금까지소아응급실재방문환자에서첫방문과재방문당시중증도의변화를 ESI level을이용하여분석하였던연구는없었다. Canadian Triage Assessment Scale (CTAS) 을이용하여분석하였던 Goldman 등 17) 의연구에따르면응급실재방문이후다시퇴원하였던환자의경우재방문시의 CTAS 점수가감소하였고, 응급실재방문이후입원하였던환자의경우재방문시의 CTAS 점수가증가하였다. 본연구에서는 ESI level을이용하여재방문환자의첫방문과재방문당시의중증도변화를비교하였는데, 재방문때의 ESI level이첫방문의경우에비하여유의하게악화되는것을확인할수있었다. 재방문당시입원혹은퇴원여부에따라 ESI level 악화여부를확인하였을때에도입퇴원여부에관계없이 ESI level이악화되는경향을보여이전 Goldman 등의연구와는차이를보였다. 이와같이환자의입퇴원여부에관계없이유사한 ESI level 변화추세를보이는결과는, 이연구가 3차종합병원에서시행되어상당한정도의상태악화가아닌경우에는입원이쉽지않다는점, 그리고만성적인질환을가지고있는채추적관찰중인환자가일시적악화로내원하였다가응급실에서단기간치료후퇴원한환자가많다는점에서기인하였을것으로추정해볼수있다. 본연구는몇가지제한점을가지고있다. 첫째, 중증도판정을간호사의초진도구인 ESI를사용했다는점이다. 본연구에서는나이가어릴수록재방문율이높다는점은이전의연구결과와유사하나, 중증도에따른재내원율이전연구결과와달리차이가없는것으로나타났다. 기존외국의연구의경우주로특정질환군을대상으로하여, 천식의경우급성악화나호흡수, 장염의경우설사나복통의강도나횟수등증상의강도나악화의횟수등을수치화하여중증도를평가하였다. 본연구에서는응급실전체환자를대상으로하였기때문에서로다른질환의환자군들에대하여이와같은일관된지표를사용할수없어 ESI level 을활용하여그중증도를결정하였다. 응급실첫방문당시의 ESI level의수준이재방문빈도에유의할만한영향을주지않는다는사실을확인하였다는점에서본연구분석에의의가있겠으나, ESI level이활력징후및환자의주관적증상이나초기의심진단에따른분류라는점을감안할때실제중증도를정확히반영하지못했을것이라는점은이연구의한계점중하나라할수있다. 두번째, 진단군분류과정에서약 6.5% 정도의환자가 EMR 상뚜렷한진단을확인할수없거나활용한진단별집단분류에서진단군을결정하기어려운이유로탈락되었다는점이다. 세번째, 본연구가 3차종합병원에서시행된연구라는특성에서신생물질환환자의비율이비교적높았다는점이다. 그러나신생물질환환자를제외하고는소화기계질환및호흡기계질환환자의재방문비율이유의하게높았다는 점에서는이전의국내외연구결과와유사한결과를보여신생물질환환자군을제외하고는일반적인응급실의특성을반영했다고평가할수있겠다. 네번째, 본연구가 EMR 기록을바탕으로한후향적연구였고재내원사유분석을의무기록만으로수행하였다는점이다. 향후정확한재내원사유분석과분석결과의일반화를위해서는전향적인추가연구를통한재평가가필요하리라생각된다. 결 일개권역응급의료센터소아응급실에서 1년간응급실을단기재방문하는환자의비율은 3.9% 였고나이가어린환자및소화기계, 신생물질환계, 그리고호흡기계증상을호소하는환자의경우퇴원후재방문의비율이높았으며내원당시과밀화정도는재방문비율을높이지않았다. 재방문비율이높은특성을가진환자들의경우재방문을줄이기위한적절한교육및향후질병경과에대한자세한설명등이필요할것으로생각된다. 론 참고문헌 01. Kim SJ, Song KJ, Jang SJ, Lee HS. Revisit patients in emergency department. J Korean Emerg Med. 1991;2: Jang SJ, Choi YH, Ko JW, Im TH, Chung SP, Hwang TS, et al. Short-term revisit to the emergency department. J Korean Emerg Med. 2000;11: Kim IB, Koo MS, Moon DS, Park SH, Kim KW. Shortterm revisits to emergency medical center. J Korean Emerg Med. 2003;4: Liaw SJ, Bullard MJ, Hu PM, Chen JC, Liao HC. Rates and causes of emergency department revisits within 72 hours. J Formos Med Assoc. 1999;6: McCarthy ML, Zeger SL, Ding R, Levin SR, Desmond JS, Lee J, et al. Crowding delays treatment and lengthens emergency department length of stay, even among highacuity patients. Ann Emerg Med. 2009;4: Miró O, Antonio MT, Jiménez S, De Dios A, Sánchez M, Borrás A, et al. Decreased health care quality associated with emergency department overcrowding. Eur J Emerg Med. 1999;2: Sills MR, Fairclough D, Ranade D, Kahn MG. Emergency department crowding is associated with decreased quality of care for children. Pediatr Emerg Care. 2011;9: Zimmerman DR, McCarten-Gibbs KA, DeNoble DH, Borger C, Fleming J, Hsieh M, et al. Repeat Pediatric Visits to a General Emergency Department. Ann Emerg

7 장동현외 : 계획되지않은소아응급실재방문 : 환자의임상적특성과응급실과밀화와의관련성 / 535 Med. 1996;28: Ali AB, Place R, Howell J, Malubay SM. Early pediatric emergency department return visits: a prospective patientcentric assessment. Clin Pediatr (Phila). 2012;7: Alessandrini EA, Lavelle JM, Grenfell SM, Jacobstein CR, Shaw KN. Return visits to a pediatric emergency department. Pediatr Emerg Care. 2004;3: Wuerz RC, Milne LW, Eitel DR, Travers D, Gilboy N. Reliability and validity of a new five-level triage instrument. Acad Emerg Med. 2000;3: Goldman RD, Ong M, Macpherson A. Unscheduled return visits to the pediatric emergency department-one-year experience. Pediatr Emerg Care. 2006;8: Ding R, McCarthy ML, Desmond JS, Lee JS, Aronsky D, Zeger SL. Characterizing waiting room time, treatment time, and boarding time in the emergency department using quantile regression. Acad Emerg Med. 2010;8: Alessandrini EA, Alpern ER, Chamberlain JM, Shea JA, Gorelick MH. A new diagnosis grouping system for child emergency department visits. Acad Emerg Med. 2010;2: Lee JH, Hong KJ, Kim do K, Kwak YH, Jang HY, Kim HB, et al. Validation of the new diagnosis grouping system for pediatric emergency department visits using the International Classification of Diseases, 10th Revision. Pediatr Emerg Care. 2013;12: Freedman SB, Thull-Freedman JD, Rumantir M, Atenafu EG, Stephens D. Emergency department revisits in children with gastroenteritis. J Pediatr Gastroenterol Nutr. 2013;5: Goldman RD, Kapoor A, Mehta S. Children admitted to the hospital after returning to the emergency department within 72 hours. Pediatr Emerg Care. 2011;9:

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386-390.hwp 386 HANYANG MEDICAL REVIEWS Vol. 29 No. 4, 2009 우리나라 미숙아의 통계와 의료비용 Statistics and Medical Cost of Preterm in Korea 윤혜선 을지대학교 노원을지병원 소아청소년과학교실 Hye Sun Yoon, M.D., Ph.D., Department of Pediatrics, Nowon