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1 대한응급의학회지제 18 권제 3 호 Volume 18, Number 3, June, 2007 원 저 119 구급대의병원전처치에대한전향적다기관평가 서울대학교의과대학의료관리학교실, 연세대학교원주의과대학응급의학교실 1, 이화여자대학교의과대학응급의학교실 2, 을지병원응급의학과 3 은상준 현 1 정구영 2 조광현 3 윤 Prospective Multicenter Evaluation of Prehospital Care by 119 Rescue Services Sang Jun Eun, M.D., Hyun Kim, M.D. 1, Koo Young Jung, M.D. 2, Kwang Hyun Cho, M.D. 3, Yoon Kim, M.D. Purpose: The purpose of this study was to evaluate the quality of prehospital care provided by 119 rescue services. Methods: An evaluation tool for prehospital care provided by 119 rescue services was developed from the consensus opinion of an expert panel consensus. Using the evaluation tool, a prospective survey was performed to 3,578 patients who were transported to three Regional Emergency Medical Centers and six Local Emergency Medical Centers by 119 rescue services between November 2004 and January A total 515 patients in six disease groups were included. Initial patient assessments (including vital signs and level of consciousness) and communication with medical director were evaluated. The frequency and appropriateness of prehospital care were analyzed for each of the types of emergency medical technicians (EMTs) and medical director. Results: The rates of assessment of vital signs were 26.6%~37.1%. Among the patients who had abnormal vital signs or level of consciousness at arrival, 7.7% were not assessed. Just 3.1% were communicated with medical director providing the prehospital care. The frequency and 책임저자 : 윤서울특별시종로구연건동 28번지서울대학교의과대학의료관리학교실 Tel: 02) , Fax: 02) yoonkim@snu.ac.kr 접수일 : 2007년 3월 12일, 1차교정일 : 2007년 3월 27일게재승인일 : 2007년 5월 3일 * 본연구는 2004년도보건복지부지원에의해수행된 응급의료기본계획수립및응급의료운영체계평가 의연구자료를토대로하였음. appropriateness of prehospital care were better when communication occurred between 119 rescue services personnels and medical director, but the differences were not statistically significant. Invasive procedures(e.g., intubation, intravenous line) and prehospital drug therapies(e.g., nitroglycerin) were performed to only 0.0%~10.6% of needed patients and other prehospital care(e.g., cervical fixation, oxygen supply) was provided for 42.3%~89.7%. The rates of appropriateness of prehospital care were 0.0%~37.1%. The performance of EMT-1 type was better than other types, but the differences were not statistically significant. Conclusion: The results of this study suggest the performance of 119 rescue services studied was not at high level and needs significant improvement. More communicating with medical direction and increased provision of EMT-1 could be the considerations in improving the quality of prehospital care. Key Words: Prehospital care, Quality of health care, Emergency treatment Department of Health Policy and Management, Seoul National University College of Medicine, Department of Emergency Medicine, Yonsei University Wonju College of Medicine 1, Department of Emergency Medicine, Ewha Womans Univesity College of Medicine 2, Department of Emergency Medicine, Sangkye Eulji Hospital 3 서 병원전단계에서응급환자에게시행되는응급처치의질적관리는중요하다 1). 응급환자의진료결과를향상시키기위해서는현장에서환자상태를정확히평가하고필요한응급처치를적시에적절하게시행하는것이필요하기때문이다 2-5). 응급구조사제도시행이후, 응급처치시행률및적절률, 의사지도시행률등병원전응급처치의질을평가한연구 론 177
2 178 / 대한응급의학회지 : 제 18 권제 3 호 2007 들이보고되고있다 3-11). 그러나, 기존의국내연구들은다음과같은한계점을가지고있었다. 첫째, 대부분의연구가구급활동일지와응급실의무기록자료를활용한후향적조사방법으로수행되었다 3-10). 구급활동일지와응급실의무기록자료는자료의질적수준이낮기때문에 6,12) 보다신뢰성이높은자료를활용할필요성이있다. 또한, 후향적조사방법은응급처치가시행된이후에조사가수행되기때문에평가에필요한정보를충분히획득하지못할가능성이있다 12). 둘째, 1개응급의료기관을대상으로조사된연구가대부분이었다 3-8,10). 셋째, 응급환자의병원전의식상태및생체징후측정에대한평가에한계가있었다. 기존의연구에서는구급활동일지와응급실의무기록에기재된의식상태의일치율을산출하여평가하였다. 이러한방식은현장에서병원전의식상태를측정한후병원까지도착하는데소요되는시간을고려하지못한제한점이있었다 5). 넷째, 구급인력의유형에따른응급처치적절성이평가된바없다. 119 구급대의구급인력은 1급및 2급응급구조사, 간호사, 기타인력으로구분된다 13). 이러한구급인력유형에따라병원전응급처치수행능력 (performance) 에차이가있다면, 수행능력이더좋은구급인력의양성및배치를지원할정책적근거가될수있을것이다. 다섯째, 병원전응급처치시행시의료지도를받았는지여부가측정된바있지만 3,4,9,11), 어떠한지도의사로부터의료지도를받았는지를보고한연구는없었다. 따라서, 이연구는 119 구급대의병원전응급처치의시행률및적절률을측정하기위해 3개지역의 9개응급의료센터를대상으로전향적조사방법을사용하고자하였다. 그리고, 구급인력유형에따른응급처치시행률및적절률차이를확인하고, 병원전응급처치에필수적인의료지도시행정도와 6,14,15) 지도의사유형별의료지도시행률을파악하고자하였다. 대상과방법 1. 평가도구개발평가대상질환및응급처치선정을위해문헌검토및전문가합의방법 (consensus method) 이사용되었다. 미국캘리포니아주의 1998년 응급의료체계의지속적질향상을위한표준및지침 (Standards and Guidelines for Statewide EMS System Continuous Quality Improvement) 시범사업에서사용된평가지표를검토하였다. 시범사업의평가지표는이송시간평가, 특정질환자에대한응급처치시행률및성공률, 적절이송비율에대한것으로구성되어있다. 이가운데응급처치평가지표는기관내삽관및정맥로확보성공률과심인성흉통 (coronary ischemic chest pain), 천명을동반한호흡곤란 (respiratory distress with wheezes) 을대상으로환자평가및약물투여시행률을평가한다 16). 이와함께응급의료에관한법률시행규칙제33 조응급구조사의업무를검토하여기도유지, 호흡처치, 순환처치, 약물투여, 외상처치로구성되는평가대상응급처치의범위를파악하였다 17). 이러한검토결과를고려하여, 임상경력 5년이상의권역및지역응급의료센터소속응급의학과전문의 9명으로구성된전문가패널회의를통해병원전응급처치시행정도와적절성을평가할질환및포함기준과평가대상응급처치를합의하여선정하였다. 선정된평가질환및응급처치는심정지 ( 심정지확인, 기관내삽관, 정맥로확보, 자동제세동기사용, 심폐소생술 ), 심인성흉통의심 ( 산소투여, 니트로글리세린투여 ), 저혈당의심 ( 저혈당확인, 포도당투여 ), 저혈량성쇽의심 ( 정맥로확보, 수액투여 ), 천식발작의심 ( 기관지확장제흡입, 산소투여 ), 다발성외상 ( 경추고정 ) 이었다 (Table 1). 이에따라선정된평가대상질환및응급처치를평가하기위한구조화된조사지와조사지침서를개발하였다. 조사지는전문가패널회의에서예비조사지와예비조사지침서를작성하여 1개권역응급의료센터와 2개지역응급의료센터로 119 구급대를통해내원한 8명의평가질환환자를대상으로 1차예비조사를수행하였다. 그리고, 1개권역응급의료센터와 3개지역응급의료센터의 12 명의환자를대상으로 2차예비조사를수행하였다. 예비조사에서나타난조사지와조사지침서의문제점을수정하여전문가패널회의의합의를통해조사지와조사지침서를최종확정하였다. 조사지의주요문항은구급활동일지및병원도착시의생체징후, 구급담당자유형, 의료지도시행여부및지도의사종류, 평가질환별응급처치시행여부및적절성평가였다. 구급활동일지의생체징후는 119구급대의초기환자평가시행정도를측정하기위해포함되었고, 구급활동일지의수축기혈압, 이완기혈압, 분당호흡수, 의식상태 (AVPU법: Alert/Verbal/Pain/Unresponsive) 가기재된다. 병원도착시의생체징후도동일사항이기재된다. 구급담당자유형은 119 구급차운전자를포함한구급담당자를 1급응급구조사, 2급응급구조사, 구급교육, 간호사, 간호조무사로구분하였다. 의료지도시행여부는예, 아니오, 실패 ( 의료지도를받으려고했으나받지못한경우 ) 로, 지도의사종류는후송병원의사, 1339의사, 소방서의사, 기타로구분하였다. 응급처치시행여부는예, 아니오, 실패 ( 응급처치를시행하려고했으나성공하지못한경우 ) 로, 적절성평가는적절과부적절로구분하였다. 2. 조사대상및방법 3개지역별로권역응급의료센터 1개소, 지역응급의료센
3 은상준외 : 119 구급대의병원전처치에대한전향적다기관평가 / 179 터 2개소의총 9개응급의료센터를조사대상기관으로선정하였다. 조사는전문가패널이개발한구조화된조사지를이용하여조사대상기관의응급의학과전공의에의해전향적으로수행되었다. 조사에앞서응급의학과전공의는개발된조사지침서의내용을전문가패널로부터교육받았다. 조사대상은 2004년 11 월 8일부터 2005년 1월 2일까지 119구급대를통해조사대상기관으로내원한총 3,578명의환자중에서평가질환에해당되는 515명 (14.4%) 이었다. 단, 한환자가 2개이상의평가질환을동반하고있는경우에는중복기재하도록하였기때문에, 평가질환자는 534 명이었다. 3. 응급처치적절성평가방법평가질환별조사대상응급처치가운데적절성을평가한응급처치는심정지의심정지확인, 기관내삽관, 정맥로 확보, 자동제세동기사용, 심폐소생술, 심인성흉통의심의니트로글리세린투여, 저혈당의심의포도당투여, 저혈량성쇽의심의정맥로확보, 수액투여, 천식발작의심의기관지확장제흡입, 다발성외상의경추고정이었다. 병원전응급처치적절성평가는응급의학과전공의가조사를수행하면서평가질환자를직접평가하였고, 전문가패널이이를재검토하였다. 평가질환별평가대상응급처치가모두적절하게시행된경우 적절 로, 하나라도시행되지않았거나부적절하게시행된경우는 부적절 로평가하였다. 4. 분석방법 119 구급대에의한초기환자평가시행정도를평가하기위해응급환자의생체징후및의식상태측정률을산출하였다. 초기환자평가측정률은조사대상전체건수중수축기 Table 1. Disease groups, inclusion criteria of disease group and procedures for evaluation of prehospital 119 rescue services Disease groups Inclusion criteria Procedures Patients with cardiac arrest except for persons with Assessment of cardiac arrest** postmortem lividity, terminally ill patients due to Intubation** Cardiac arrest cancer etc., patients with cardiac arrest due to trauma Peripheral IV line** AED application** CPR ** Patients with ischemic chest pain that is pain or Oxygen supply R/O* ischemic chest pain discomfort on the substernum or left sided chest or Nitroglycerin sublingual spreads to the shoulders, arms, jaw etc. administration** R/O* hypoglycemia Patients whose level of consciousness is V, P or U or have past history of diabetes mellitus and who have one of the following symptoms and signs: tachypnea (>20/minute), pale and clammy skin, sweating, vertigo, headache, tachycardia, syncope, seizure, hunger, behavioral change Assessment of hypoglycemia Glucose administration** Patients with systolic blood pressure <90 mmhg and Peripheral IV line** R/O* hypovolemic shock symptoms or signs of shock (tachycardia, change in Fluid administration** consciousness, clammy skin, sweating or thirsty) R/O* asthma attack Patients with wheezes Bronchodilator administration** Oxygen supply Patients with road traffic injuries (that include all the Multiple trauma vehicle-related injuries and pedestrian injuries) and Cervical fixation** fall down injuries (that do not include slip down injuries) * R/O: rule out V: verbal P: pain U: unresponsive AED: automated external defibrillator CPR: cardiopulmonary resuscitation ** They are prehospital cares that should be performed in each disease group and are evaluated for appropriateness of prehospital care
4 180 / 대한응급의학회지 : 제 18 권제 3 호 2007 혈압, 이완기혈압, 분당호흡수또는의식상태측정건수의비율로구하였다. 그리고, 초기환자평가의적절성을평가하기위해병원도착시생체징후및의식상태이상을나타낸환자중에서 119 구급대가생체징후및의식상태를측정하지않은비율을산출하였다. 수축기혈압 90 mmhg 미만또는분당호흡수 10 회미만이거나 30 회이상인경우를생체징후이상으로, 그리고 AVPU법에의한의식상태가 V, P, U인경우를의식상태이상으로간주하였다. 현장및이송단계에서 119 구급대가의료지도를받는정도를평가하기위해의료지도시행여부가기재된건수중의료지도를받은건수의비율을산출하였다. 의료지도를시행받은경우지도의사종류별비율을산출하였다. 또한, 평가질환별평가대상응급처치를모두시행하지않은경우를미시행으로, 하나라도시행한경우를시행으로분류하여, 의료지도시행여부에따른응급처치시행률과적절률을분석하였다. 119 구급대의응급처치시행률은해당응급처치시행여부가기재된건수중응급처치시행건수의비율로산출하였다. 응급처치적절률은평가대상응급처치시행여부가모두기재된건수중 적절 로평가된건수의비율로구하였다. 그리고, 응급처치시행률및적절률을구급인력유형별로산출하였다. 이를위해구급차에탑승한구급담당자유형에따라구급인력유형을구분하였다. 구급차에 1급응급구조사가탑승한경우구급인력유형을 1급응급구조사로, 2급응급구조사가탑승하고 1급응급구조사는탑승하지않은경우 2급응급구조사로, 간호사또는간호조무사가탑승하고 1급및 2급응급구조사가탑승하지않은경우기타로분류하였다. 응급처치시행률및적절률차이는카이제곱검정 (χ 2 test) 과피셔의정확검정 (Fisher s exact test) 을이용하여비교하였다. 통계처리는 SPSS 12.0K와 SAS 9.1을이용하였다. 결과 1. 조사대상의특성 1) 조사대상환자의일반적특성조사대상은총 515 명으로 65 세미만이 359 명 (69.7%), 남자가 333 명 (64.7%), A지역이 183 명 (35.5%) 이었다. 평가질환은총 534 건으로다발성외상이 267 건 (50.0%), 저혈당의심이 80건 (15.0%), 심정지가 79건 (14.8%), 심인성흉통의심이 49 건 (9.2%), 저혈량성쇽의심이 31 건 (5.8%), 천식의심이 28건 (5.2%) 이었다 (Table 2). 2) 조사대상환자의임상적특성 119 구급대가측정한생체징후및의식상태는다음과같다. 수축기혈압, 이완기혈압, 분당호흡수는각각평균 84.4 mmhg, 49.4 mmhg, 8.6회였고, 초기의식상태는 A 56.0%, V 14.3%, P 9.5%, U 20.2% 였다. 수축기혈압이상은 43.5%, 분당호흡수이상은 89.1%, 의식상태이상은 44.0% 였다. 병원도착시측정한수축기혈압, 이완기혈압, 분당호흡수는각각평균 mmhg, 67.9 mmhg, 17.5회였다. 병원도착시의식상태는 A 64.3%, V 9.2%, P 8.2%, U 18.3% 였다. 병원도착시수축기혈압이상은 21.0%, 분당호흡수이상은 20.2%, 의식상태이상은 35.7% 였다 (Table 3). Table 2. General characteristics of surveyed population Variables Categories Frequency Percentage (%) Age group <65 years years Gender Male Female Province A B C Total Disease group Cardiac arrest R/O ischemic chest pain R/O hypoglycemia R/O hypovolemic shock R/O asthma attack Multiple trauma Total
5 은상준외 : 119 구급대의병원전처치에대한전향적다기관평가 / 초기환자평가시행률및적절률 3. 의료지도시행률 생체징후측정률은수축기혈압 37.1%, 이완기혈압 32.6%, 분당호흡수 26.6% 였다. 의식상태측정률은 88.3% 였다. 병원도착시수축기혈압이상인환자중에서 119 구급대가수축기혈압을측정하지않은환자의비율은 18.7% 였다. 병원도착시분당호흡수이상인환자중에서 119 구급대가분당호흡수를측정하지않은환자의비율은 21.0% 였다. 그리고, 병원도착시의식상태이상인환자중에서 119 구급대가의식상태를측정하지않은환자의비율은 7.7% 였다 (Table 4). 의료지도시행여부에대해조사된 452 건가운데 119 구급대가현장및이송단계에서의료지도를받은경우는 14 건 (3.1%) 뿐이었다. 의료지도를제공한지도의사의종류가조사된 11 건중후송병원의사가 8명 (72.7%) 으로이송받을병원의의사에의한의료지도가대부분이었다 (Table 5). 그리고, 의료지도를받은경우의응급처치시행률은 64.3% 로의료지도를받지않은경우의 53.2% 보다더높았다. 응급처치를시행한경우에서응급처치의적절률은의료지도를받았을때 (3건, 37.5%) 의료지도를받지않은경우 (44.1%) 보다낮았다. 그러나다발성외상환자에대한 Table 3. Clinical characteristics of surveyed population Variables Prehospital vital signs Hospital vital signs Continuous Mean±SD* Mean±SD* Systolic blood pressure (mmhg) 84.4± ±54.1 Diastolic blood pressure (mmhg) 49.4± ±33.0 Respiratory rate (bpm ) 8.6± ± 8.6 Categorical Frequency Percentage (%) Frequency Percentage (%) Level of consciousness Alert Verbal Pain Unresponsive Abnormal systolic blood pressure (<90 mmhg) Abnormal respiratory rate (<10 or >29 bpm) Abnormal level of consciousness (V, P, U ) * SD: standard deviation bpm: breaths per minute V: verbal P: pain U: unresponsive Table 4. Initial patient assessment (vital sign and level of consciousness) of 119 rescue services Assessment items The number (%) of measured populations The number of abnormal vital sign or level of consciousness at arrival The number (%) of unmeasured populations Systolic blood pressure 191 (37.1) (18.7) Diastolic blood pressure 168 (32.6) NA* NA* Respiratory rate 137 (26.6) (21.0) Level of consciousness 455 (88.3) ( 7.7) * NA: not applicable Measured populations: patients who were measured the vital sign or level of consciousness prior to hospital arrival by 119 rescue services Unmeasured populations: patients who were not measured the vital sign or level of consciousness prior to hospital arrival by 119 rescue services among those who had abnormal vital sign or level of consciousness at hospital arrival
6 182 / 대한응급의학회지 : 제 18 권제 3 호 2007 경추고정처치와이외의환자에대한처치를구분하여분석하였을때는이와반대의결과가나타났다. 경추고정의적절률은의료지도를받았을때 (2건, 100.0%) 의료지도를받지않은경우 (97.1%) 보다높았다. 경추고정이외처치의적절률도의료지도를받았을때 (1건, 16.7%) 의료지도를받지않은경우 (3건, 2.3%) 보다높았다. 이러한차이가통계적으로유의하지는않았다 (Table 6). 4. 응급처치시행률및적절률심정지환자에서심정지확인과심폐소생술은각각 70 명 (89.7%) 과 52 명 (67.5%) 에대해시행되었다. 자동제세동기사용은 4명 (5.3%), 정맥로확보는 1명 (1.3%) 에대해서만시행되었고, 기관내삽관은시행되지않았다. 심정지환자에게필수적으로제공되어야할응급처치를모두시행한경우가한건도없었으므로응급처치적절률은 0% 였다. 심인성흉통의심환자가운데 26 명 (55.3%) 에대해산소투여를시행하였고, 니트로글리세린은 5명 (10.6%) 에게투여되었다. 니트로글리세린을적절히투여받은경우는 3명으로응급처치적절률은 6.4% 였다. 저혈당의심환자의경 우 26 명 (32.9%) 에대해저혈당을확인하였고, 포도당을투여한경우는없었다. 저혈당의심환자에대한응급처치적절률은 0% 였다. 저혈량성쇽의심환자중에서정맥로확보와수액투여는 1명에대해서만시행되었다. 응급처치를적절히시행받은경우는 1명으로응급처치적절률은 3.2% 였다. 천식의심환자중 22 명 (84.6%) 에대해산소가투여되었고, 기관지확장제를투여한경우는없었다. 천식의심환자에대한응급처치적절률은 0% 였다. 다발성외상환자를대상으로경추고정은 113 명 (42.3%) 에대해시행되었다. 적절히경추고정을한경우는 99 건으로응급처치적절률은 37.1% 였다 (Table 7). 1급응급구조사유형, 2급응급구조사유형, 기타유형은심정지환자에대해심정지확인을각각 94.1%, 90.7%, 83.3%, 자동제세동기사용을 11.8%, 4.8%, 0.0%, 정맥로확보를 5.9%, 0.0%, 0.0% 의환례에서시행하였다. 심폐소생술은 70.6%, 61.9%, 91.7% 에대해시행되었다. 심인성흉통의심환자의경우산소투여는 66.7%, 41.2%, 0.0%, 니트로글리세린투여는 18.5%, 0.0%, 0.0% 의환례에서시행되었고, 응급처치적절률은 1급응급구조사유형이 10.7%, 나머지유형은 0.0% 였다. 저혈 Table 5. Communication with medical direction of 119 rescue services Communication with medical direction Frequency Percentage (%) Total Not tried Tried Medical direction provided By doctor of hospital to transport By doctor of Emergency Medical Information Center (1339) By doctor of Fire Station By others Failure Table 6. Frequency and appropriateness prehospital care provided by 119 rescue services according to medical direction Procedure p-value Undone Done (Number (%)) (Number (%)) 0.414* Medical Appropriateness of prehospital care direction Appropriate (Number (%)) Not appropriate (Number (%)) Cervical Except Cervical Except fixation cervical fixation cervical fixation fixation Yes 5 (35.7) 9 (64.3) 3 (37.5) 2 (100.0) 1 (16.7) 5 (62.5) 0 ( 0.0) 5 (83.3) No 203 (46.8) 231 (53.2) 101 (44.1) 100 (97.1) 3 ( 2.3) 128 (55.9) 3 ( 2.9) 128 (97.7) * p-value by χ 2 test p-value by Fisher s exact test
7 은상준외 : 119 구급대의병원전처치에대한전향적다기관평가 / 183 Table 7. Frequency and appropriateness of prehospital care provided by 119 rescue services according to the types of emergency medical technicians Disease groups Procedures Frequency EMT*-1 EMT*-2 Others p-value Number (%) n2 Number (%) n3 Number (%) n3 Number (%) n3 Assessment of cardiac arrest 70 (89.7) ( 94.1) (90.7) (83.3) ** Intubation 0 ( 0.0) 77 0 ( 0.0) 17 0 ( 0.0) 42 0 ( 0.0) 12 - Cardiac arrest Peripheral IV line 1 ( 1.3) 77 1 ( 5.9) 17 0 ( 0.0) 42 0 ( 0.0) ** (n1 =79) AED application 4 ( 5.3) 76 2 ( 11.8) 17 2 ( 4.8) 42 0 ( 0.0) ** CPR 52 (67.5) ( 70.6) (61.9) (91.7) ** Appropriate 0 ( 0.0) 75 0 ( 0.0) 17 0 ( 0.0) 42 0 ( 0.0) 12 - R/O ischemic Oxygen supply 26 (55.3) ( 66.7) 27 7 (41.2) 17 0 ( 0.0) chest pain Nitroglycerin sublingual administration 5 (10.6) 47 5 ( 18.5) 27 0 ( 0.0) 17 0 ( 0.0) ** (n1 =49) Appropriate 3 ( 6.4) 47 3 ( 10.7) 28 0 ( 0.0) 17 0 ( 0.0) ** R/O Assessment of hypoglycemia 26 (32.9) ( 51.2) 41 3 (12.0) 25 1 (14.3) ** hypoglycemia Glucose administration 0 ( 0.0) 76 0 ( 0.0) 40 0 ( 0.0) 23 0 ( 0.0) 7 - (n1 =80) Appropriate 0 ( 0.0) 76 0 ( 0.0) 42 0 ( 0.0) 25 0 ( 0.0) 7 - R/O hypovolemic Peripheral IV line 1 ( 3.2) 31 1 ( 7.1) 14 0 ( 0.0) 12 0 ( 0.0) ** shock Fluid administration 1 ( 3.2) 31 1 ( 7.1) 14 0 ( 0.0) 12 0 ( 0.0) ** (n1 =31) Appropriate 1 ( 3.2) 31 1 ( 7.1) 14 0 ( 0.0) 12 0 ( 0.0) ** R/O asthma Bronchodilator administration 0 ( 0.0) 25 0 ( 0.0) 7 0 ( 0.0) 17 0 ( 0.0) ** attack Oxygen supply 22 (84.6) 26 7 (100.0) 7 14 (77.8) 18 0 ( 0.0) ** (n1 =28) Appropriate 0 ( 0.0) 25 0 ( 0.0) 7 0 ( 0.0) 18 0 ( 0.0) 0 - Multiple trauma Cervical fixation 113 (42.3) ( 48.5) (38.8) (33.3) (n1 =267) Appropriate 99 (37.1) ( 43.3) (34.1) (25.0) * EMT: emergency medical technicians Others: nurses, nursing aides, EMT-trained rescue personnels n1: the number of patients in each disease group n2: the number of cases which have valid data n3: the number of 119 rescue personnel which have valid data They are prehospital cares that should be performed in the case of each disease and are evaluated for appropriateness of prehospital care ** p-value by Fisher s exact test p-value by χ 2 test
8 184 / 대한응급의학회지 : 제 18 권제 3 호 2007 당의심환자에대해저혈당확인은 51.2%, 12.0%, 14.3% 의환례에서시행되었다. 저혈량성쇽의심환자의경우정맥로확보와수액투여는 1급응급구조사유형이각각 1건만시행하였으며, 적절률은 7.1% 였다. 천식발작의심환자에게산소투여는 100.0%, 77.8%, 0.0% 에서시행되었다. 다발성외상환자의경우 48.5%, 38.8%, 33.3% 의환례에대하여경추고정을시행하였고, 적절률은 43.3%, 34.1%, 25.0% 였다. 이러한구급인력유형에따른차이는자동제세동기사용과저혈당확인을제외하고는통계적으로유의하지않았다 (Table 7). 고찰 1. 연구결과에대한고찰 119 구급대의생체징후측정률은수축기혈압 37.1%, 이완기혈압 32.6%, 분당호흡수 26.6% 였다. 기존연구에서생체징후측정률은약 10%~50% 수준으로보고된바있지만 4,9), 연구마다산출방법이달라서이연구결과와의차이를비교하기에는무리가있을것으로보인다. 그렇지만, 본연구에서도생체징후측정률은 30% 내외에불과하여여전히낮은수준이었다. 의식상태측정률은 88.3% 로 90% 이상으로보고한기존연구결과와유사하였다 4,5,7,9). 초기환자평가의부적절률은수축기혈압 18.7%, 분당호흡수 21.0%, 의식상태 7.7% 였다. 이는병원도착시생체징후나의식상태가비정상이었음에도불구하고현장및이송단계에서생체징후나의식상태를평가조차하지않은경우가 10%~20% 나된다는것을의미한다. 또한심정지환자에서심폐소생술시행률이 67.5% 였던것을고려하면, 기본적인환자평가없이심폐소생술이시행되었을가능성도있다 14). 이와같은결과는응급환자상태평가의가장기본이되는초기환자평가에문제가있으며 4), 119 구급대의초기환자평가능력개선을위한방안마련이필요하다는것을시사한다. 병원전처치시 119 구급대가의료지도를받은경우는 3.1% 뿐이었다. 이러한결과는의료지도시행률을 0.0%~12.9% 로보고한기존연구결과와유사하였다 3,4,9,11). 병원전처치에대한의료지도는응급구조사업무범위외의처치수행에필수적이며 6,14,17), 효과적으로병원전처치를제공하는데있어핵심적인역할을하기때문에 18,19), 응급의료체계의구성요소로서중요성이강조되고있다 20). 통계적으로유의하지는않았지만, 의료지도를받은경우응급처치시행률과적절률이더높았던이연구의결과도이러한중요성을뒷받침하고있다. 그럼에도불구하고, 119 구급대는의료지도를거의받고있지않는것으로나타났다. 그리고의료지도를받은경우주로후송병원의의사에 의해이루어졌다. 김등 21) 의연구에서 119 구급대원이의료지도를받기위해응급의료정보센터를이용하는경우는 4.9% 에불과하였고, 이송중의료지도를받아본적이없다고응답한 119 구급대원이 61.2% 나되었다. 소방방재청의료지도이용에관한기존연구는찾을수없었지만, 이연구에서의료지도의주요담당자로간주한응급의료정보센터와소방방재청의료지도실의이용도가낮다는것을연구결과에서확인할수있었다. 이상의결과는 119 구급대원의응급처치시행률이낮아의료지도를받을필요 (need) 가적 고 21) 전문적인지도의사가부족한점등에기인하는것으로 지적되고있다 22). 따라서, 이러한문제점을개선할정책적지원이필요할것으로판단된다. 119 구급대의병원전응급처치시행률은심정지확인, 심폐소생술, 산소투여, 경추고정등의경우 40%~90% 로상대적으로높았지만, 기관내삽관, 정맥로확보, 자동제세동기사용, 니트로글리세린, 포도당, 수액또는기관지확장제투여는 0%~10% 로낮았다. 심정지, 저혈당의심, 천식발작환자에게응급처치가적절하게시행된경우는한건도없었다. 심인성흉통의심, 저혈량성쇽의심환자에대한응급처치적절률도 5% 내외로미미한수준이었고, 다발성외상환자의경우는 37.1% 의상대적으로높은응급처치적절률을나타내었다. 기존연구에서 119 구급대의응급처치시행률은약 40%~80% 였고 6,8), 시행된응급처치의적절률은약 40%~90% 였는데 5,6,8,11) 이연구의결과와차이를보였다. 그이유는평가대상질환및응급처치와적절성평가방법이다르기때문인것으로생각된다. 이연구에서는주요질환군을대상으로응급처치시행여부와적절성을평가한반면, 기존연구는대부분전체질환군을대상으로평가하였다. 그리고, 평가대상응급처치가기존연구에서는구급활동일지의기재사항에해당되는 11개응급처치에대해시행률과적절률을산출한반면, 이연구는평가질환환자에대해반드시시행되어야할응급처치를선정하여이에대한시행률및적절률을산출하였다. 응급처치적절성평가방법도이연구는응급처치가필요한환자중평가대상응급처치를모두적절하게시행한경우만 적절 로분류하여미시행된건도 부적절 에포함한반면, 기존연구는응급처치가시행된환자중에서만응급처치의적절성을판정하였다 5,6,8). 따라서, 이연구의결과는주요응급질환군환자의병원전단계의학적필요 (need) 가충족된정도를평가하였다는점에서 119구급대의응급처치성과 (performance) 를보다타당성있게반영하는것으로생각된다. 1급응급구조사구급인력유형은 2급응급구조사및기타유형보다심정지환자에대한심폐소생술을제외하고는응급처치시행률이더높았다. 심정지확인, 자동제세동기사용, 산소투여, 저혈당확인, 경추고정과같이 2급응급구조사업무범위에속하는처치에서도 1급응급구조사유형
9 은상준외 : 119 구급대의병원전처치에대한전향적다기관평가 / 185 의시행률이다른유형보다높았다. 또한, 심정지, 저혈당의심, 천식발작의심환자에대한응급처치적절률은모든구급인력유형에서 0% 였지만, 심인성흉통의심, 저혈량성쇽의심, 다발성외상환자에대해서는 1급응급구조사유형의응급처치가다른유형보다적절하였다. 이러한결과는 1급및 2급응급구조사의업무범위차이를반영하는것이지만, 2급응급구조사및기타유형의 119 구급대가 1급응급구조사유형보다평가대상응급환자의의학적필요를덜충족시켰다는것을의미한다. 이는구급차에 1급응급구조사가탑승한경우가그렇지않았을때보다응급환자에대해보다적절한응급처치를제공할가능성이있다는점을시사한다. 그러나, 응급구조사수가매년증가해왔지만, 119 구급대원중 1급응급구조사의비율은 33.3% 로여전히부족한상황이다 23). 이연구에서도구급인력유형의비율은 1급응급구조사유형 40.9%, 2급응급구조사유형 49.7%, 기타 9.4% 로, 1급응급구조사가구급차에탑승한경우가적었다. 따라서, 1급응급구조사의 119 구급대배치를증가시킬필요가있을것으로생각된다. 그러나, 연구결과에서 1 급응급구조사업무에대한 1급응급구조사유형의응급처치시행률은 0.0%~18.5% 로낮은수준이었다. 이는 1급응급구조사업무가의료지도하에수행되어야하지만 17), 전술한바와같이의료지도를받는경우가거의없기때문에시행률이낮았던것으로보인다. 또한 1급응급구조사유형의응급처치적절률도대부분의평가질환에서 10% 수준에미치지못하였고다발성외상의경우도과반수이상의환자에게응급처치가부적절하게제공되었다. 이러한결과는 1 급응급구조사의질향상이필요하다는것을보여주는것으로, 1급응급구조사의양적확대와함께질적수준을제고할방안도마련되어야할것으로판단된다. 구급인력유형에따른응급처치시행률과적절률차이는심정지환자에서자동제세동기사용, 저혈당의심환자에서저혈당확인을제외하고는통계학적유의성이없었다. 이점은본연구의한계이며, 추후에충분한크기의표본을대상으로한조사를통해차이의유의성을확인해야할것으로판단된다. 2. 연구방법에대한고찰이연구에서사용된평가도구는 9명의응급의학과전문의로구성된전문가패널의합의를통해개발한구조화된조사지였다. 전문가합의에의한평가도구개발은전문가선택시비뚤림 (selection bias) 이발생하여전체전문가의의견을대표하지못할수있고, 동의수준을계량화하기어려운한계가있다 24,25). 따라서, 2회의예비조사와 5회의전문가패널회의를거쳐서평가도구에대한패널의합의를도출하고내용타당도 (content validity) 를검증함으로써이러한한계를최소화하고자하였다. 또한, 기존연구가구급활동일지와응급실의무기록을토대로후향적으로응급처치 적절성을평가한반면 5,6,8), 이연구는구조화된조사지를통해전향적으로평가함으로써, 보다충분한정보를가지고응급처치자체의적절성을평가할수있었다. 따라서, 기존연구에비해평가의타당도는상대적으로더높을것으로판단된다. 그렇지만, 평가도구의신뢰도는검증되지못하였다. 이는조사자간일치도산출에필요한자료를수집하기위해 2인이상의조사자가동일환자를평가해야했지만, 시간과인력이부족하여자료수집이어려웠기때문이었다. 하지만, 조사자들은예비조사수행과정과조사전교육을통해조사지침을숙지하였고, 조사가진행되는동안에도전문가패널이조사자간불일치가발생할수있는문제점을보고받아조사자들에게지침을환류하였다. 이러한과정을통해신뢰도가검증되지못한제한점을최소화하고자하였다. 그리고, 연구의조사기간은 55 일이었고조사대상기관으로 119 구급대를통해내원한환자의 14.4% 가조사되었다. 조사기간이짧고, 119 구급대가이송한환자의일부만평가된것은이연구의한계이다. 그러나, 이연구는 3개지역의 9개권역및지역응급의료센터를대상으로수행된다기관연구 (multicenter study) 로 1개응급의료기관이나 1개지역에국한되어수행되었던 3-10) 기존연구보다대표성을확보하여연구결과의타당성을높였다는점에서의의가있다. 또한, 오등 5) 과박 10) 의연구는구급활동일지와응급실의무기록의일치율로초기환자평가의적절성을평가하였다. 이경우, 119 구급대의초기환자평가결과가응급실에서의평가와불일치하더라도이송과정에서환자상태가악화또는호전되었을수있기때문에적절성을판단하기어려운문제가있었다. 이러한점을고려하여이연구에서는 119 구급대의초기환자평가적절성을병원도착시의식상태및생체징후이상환자중 119 구급대가의식상태및생체징후를측정하지않은환자의비율로평가하였다. 이는병원도착시의식상태나생제징후의이상이있는환자에대해현장및이송중의식상태나생체징후가측정되지않은것은부적절한초기환자평가라고간주할수있기때문이다. 이를통해기존연구에서나타난초기환자평가적절성판단의모호성을감소시킬수있을것으로생각된다. 그러나, 119 구급대에의한초기환자평가결과의정확성은평가하지못하는점이여전히한계로남는다. 119 구급대의응급처치적절성을전향적으로조사한국내연구로는배등 8) 과권 11) 의연구가있었다. 그러나, 병원전응급처치의적절성은후향적으로평가되었거나, 조사자가응급구조학과학생이어서평가가부적절하였을가능성이있는문제가있었다. 이연구는응급의학과전공의가조사대상환자를직접확인하여병원전응급처치의적절성을전향적으로평가하였다. 따라서, 기존의국내연구보다더신뢰성있는평가가이루어졌을것으로판단된다.
10 186 / 대한응급의학회지 : 제 18 권제 3 호 2007 결 이연구에서 119 구급대의의식상태측정률은비교적높았지만, 생체징후는 30% 내외에서만측정되고있었다. 또한의식상태나생체징후가불안정한응급환자에대해초기환자평가가이루어지지않는경우도 10%~20% 나되었다. 그리고, 응급처치시행을위해의사지도를받는경우는 3.1% 에불과하였다. 1급응급구조사업무범위에해당되는응급처치는거의시행되지않고있었으며, 119 구급대의응급처치적절률은다발성외상을제외한평가질환에서 10% 도되지않았다. 1급응급구조사유형의구급대는응급처치시행률과적절률이상대적으로높았지만, 여전히낮은수준이었다. 이러한연구결과는 119 구급대의초기환자평가및응급처치수행능력을향상시킬필요성을보여주고있다. 또한, 의료지도를활성화시키고, 1급응급구조사의양적 질적수준제고할필요가있다는점을시사하고있다. 이연구는평가도구신뢰도검증부재, 표본수의제한등의한계가있다. 그러나, 이러한한계에도불구하고, 119 구급대의응급처치시행정도와적절성을평가하기위해전향적조사방법으로 3개지역의 9개응급의료센터에서수행된국내의첫다기관연구라는점에이연구의의의를찾을수있다. 론 참고문헌 11. Swor RA, Rottman SJ, Pirrallo RG, Davis E. Quality management in prehospital care. 1st ed. St. Louis: Mosby Lifeline; p MacFarlane C, Benn CA. Evaluation of emergency medical services systems: a classification to assist in determination of indicators. Emerg Med J 2003;20: Park JO, Lee KH, No SG, Choi CS. An analysis of prehospital care on the patients transported via 119 system. J Kor Soc Emergency Med Technology 2003;7: Kim YK, Ryoo JH, Moon WS, Chun BJ, Heo T, Min YI. An analysis on the patient transported via 119 system. J Korean Soc Emerg Med 2000;11: O SH, You KC, Park SH, Kang MS, Kim JH, Kang GH et al. An analysis of prehospital care by 119 rescue services. J Korean Soc Emerg Med 2006;17: Jung KY, Kim CW. Medical control for prehospital emergency care - retrospective run record review -. J Korean Soc Emerg Med 1999;10: Ryu SY, Kim WY, Kim KH, Lee SL, Lee KH, Kim HY et al. Needs for appraisal of the quality of prehospital patient s care and for reeducation. J Korean Soc Emerg Med 2000;11: Bae HA, Ryu JY, Eo EK, Jung KY. Study of the appropriateness of 119 rescue usage. J Korean Soc Emerg Med 2004;15: Lee JH, Kim EC, Lee HS, Kim SH, Park IC, Yoon YS et al. Prehospital ambulance run report: how much collected and contents are completed?. J Korean Soc Emerg Med 2005;16: Park SH. Evaluation for pre-hospital care by 119 rescuer. Graduate School of Public Health. Hallym University Kwon SS. Analysis on the propriety of pre-hospital care in the emergency medical services (EMS) system through the activity of 119 rescuer. Graduate School of Public Health. Chungnam National University Jeong H, Yu TY, Jin Y, Jeong TO, Lee JB. Methodological assessment of medical records reviews in articles in the Journal of the Korean Society of Emergency Medicine. J Korean Soc Emerg Med 2006;16: National Emergency Management Agency National Emergency Management administrative and statistic data. Seoul: p Lee SH, Choi OK, Jung KY. Quantity & quality of prehospital emergency care. J Korean Soc Emerg Med 1996; 7: Walz BJ. Introduction to EMS systems. 1st ed. New York: Delmar; p Sobo EJ, Andriese S, Stroup C, Morgan D, Kurtin P. Developing indicators for emergency medical services (EMS) system evaluation and quality improvement: a statewide demonstration and planning project. Jt Comm J Qual Improv 2001;27: Korea Ministry of Government Legislation. The law about emergency medical care enforcement regulation No The Ministry of Health and Welfare. a partial revision Wuerz RC, Swope GE, Holliman CJ, Vazquez-de MG. On-line medical direction: a prospective study. Prehospital Disaster Med 1995;10: Väisänen O, Mäkijärvi M, Pietiläe K, Silfvast T. Influence of medical direction on the management of prehospital myocardial infarction. Resuscitation In Press, Corrected Proof, Available online 27 June Delbridge TR, Bailey B, Chew JL, Conn AK, Krakeel JJ, Manz D et al. EMS agenda for the future: where we are.where we want to be. Ann Emerg Med 1998;31: Kim SK, Cho SJ, Shin PH. Survey for application of emergency medical information center at firehouse rescue services. J Korean Soc Emerg Med 2006;17: Ministry of Health and Welfare. 05~ 10yr Emergency
11 은상준외 : 119 구급대의병원전처치에대한전향적다기관평가 / 187 Health Care Plan. 1st ed. Seoul: Ministry of Health and Welfare; p National Emergency Medical Center Annual Statistical Report of Emergency Medical Services. 1st ed. Seoul: National Emergency Medical Center; p Lee JY. Development and application of medical health needs assessment tools for the disabled. College of Medicine. Seoul National University Bowling A. Research methods in health: investigating health and health services. 2nd ed. Philadelphia: Open University Press; p
12 188 / 대한응급의학회지 : 제 18 권제 3 호 2007 < 부록 > 병원전응급처치시행률및적절률평가조사지
13 < 부록 > 병원전응급처치시행률및적절률평가조사지 은상준외 : 119 구급대의병원전처치에대한전향적다기관평가 / 189
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