Original Article 대한소아응급의학회지 2015 제 2 권제 1 호 Pediatric Emergency Medicine Journal Volume 2, Number 1, June, 2015 일반응급센터와의비교를통한소아응급전문센터방문환아분석 노현 김도균 1 이진희 1 곽영호 1 정진희 2 장혜영 3 이지숙 4 인제대학교의과대학응급의학교실, 서울대학교의과대학응급의학교실 1, 서울특별시보라매병원응급의학과 2, 순천향대학교의과대학응급의학교실 3, 아주대학교의과대학응급의학교실 4 Comparisons of Pediatric Patients who Visited to the Pediatric Emergency Department and the General Emergency Department Hyun Noh, M.D., Do Kyun Kim, M.D. 1, Jin Hee Lee, M.D. 1, Young Ho Kwak, M.D. 1, Jin Hee Jung, M.D. 2, Hye Young Jang, M.D. 3, Ji Sook Lee, M.D. 4 Department of Emergency Medicine, College of Medicine, Inje University, Seoul, Seoul National University, Seoul 1, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 2, Soonchunhyang University, Seoul 3, Ajou University, Suwon 4, Korea Purpose: In 2010 and 2011, the Korean Ministry of Health and Welfare designated 2 and 4 Pediatric Emergency Centers, respectively. This study was conducted to examine the characteristics of pediatric patients who visited the pediatric emergency department (PED) compared with the general emergency department (GED). Methods: We used the National Emergency Medical Department Information System (NEDIS) data on pediatric visits (<19 years old), from July 1 to December 31, 2011. We analyzed patients' general characteristics, number, severity, and length of stay (LOS). Results: A total of 709,050 children visited 132 GEDs and 6 PEDs during the study period. Male patients of PED was 57.6%, and the mean age of PED was younger than GED (4.7±5.0 yr vs. 5.7±5.5 yr). There were more numbers of patient visitations per center, number of critically ill or injured patients per center, number of admitted patients per center, and the number of operation per center in PED than GED. LOS of overall, discharged, and transferred patients was the same between PED and GED; however, LOS of admitted patients was longer in PED. Conclusion: We observed that PEDs did not function as a tertiary referral center. Further research is needed to find the reason for such phenomenon and provide possible solutions. Key Words: Emergency Medical Services; Child; Adolescent; Demography; Length of stay Corresponding Author Young Ho Kwak Department of Emergency Medicine, College of Medicine, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea Tel: +82-2-2072-1629 Fax: +82-2-3672-8871 E-mail: yhkwak@snuh.org 서론 응급센터에내원하는환자의수는꾸준히증가하고있으며이중약 3분의 1은소아환자이다 1). 그러나응급센터의양적, 질적지원에따른성장과는대조적으로소아응 29
대한소아응급의학회지제 2 권제 1 호 2015 급분야에대한관심은미미하였다 2,3). 이에 2010년말보건복지부에서는 ' 차세대응급실모델구축시범사업 ' 의일환으로소아전용응급센터를 2개소지정하였다. 이를시작으로 2011년 4개소, 2012년 4개소가추가지정되어 2015년현재총 10개소의소아전용응급센터가운영중이다. 초기소아전용응급센터의지정목표는소아응급진료의질적향상을꾀하고, 과밀화된응급의료체계에서소아를분리하여운영하는것이었다. 이를위해전문인력, 시설및장비를배치하고, 소아의독립적인진료시설을마련하게하였다. 그러나 3개년동안소아전용응급센터 10 개소를지정, 운영한이후에소아응급환자의소아전용응급센터이용에대한연구는없는실정이다. 이에본연구를통하여소아전용응급센터지정이후소아환자방문실태및과밀화정도에대해확인하고자한다. 대상과방법 2011년까지소아전용응급센터로지정된 6개소와그외의응급센터 ( 이하일반응급센터 ) 132개소에내원한 19세미만의소아환자를대상으로하였다. 총 6개의소아전용응급센터가지정된후인 2011년 7월부터 12월까지 6개월의기간동안국가응급환자진료정보망 (National Emergency Department Information System, NEDIS) 자료를수집하여소아전용응급센터와일반응급센터에방문한환자의일반적특징및과밀화지표에대한분석을시행하여소아전용응급센터와일반응급센터사이의결과를비교하였다. 일반적특징으로는성별, 나이, 내원사유, 내원경로및응급진료결과를비교하였으며과밀화지표로는내원환자수, 중증도지수, 체류시간을비교하였다. 과밀화지표각각에대한정의는다음과같다 (Table 1, 2). 산출되는결과가범주형변수인경우에는빈도및분율로, 연속형변수인경우에는평균과표준편차를사용해표기하였으며, 시간변수에대해서는제1사분위수 (p25), 중위수 (p50) 및제3사분위수 (p75) 를표기하였다. 모든분석은 Stata 11.0 (Stata Corp LP, College Station, TX, USA) 을이용하였고, 군간의차이를확인하기위하여카이제곱검정 (Chi-square test) 및 t-검정 (t-test) 을시행하여 P<0.05인경우를통계적으로유의한것으로해석하였다. 결과 1. 내원환아의일반적인특성 소아전용응급센터와일반응급센터에내원하는 19 세 Table 1. Definitions of overcrowding indices. Overcrowding index Definitions Mean number of visits per day Mean number of patients (<19 yr old) who visited at one ED* during one day Severity Indices Rate of critically ill patients (No. of critically ill patients/no. of overall patients) 100 (%) Rate of admission (No. of admitted patients/ No. of overall patients) 100 (%) Rate of ICU admission (No. of ICU admitted patients/no. of overall patients) 100 (%) Rate of emergency operation (No. of emergency operated patients/no. of overall patients) 100 (%) Length of Stay (LOS) Interval between the arrival time at the ED and the departure time from the ED in minutes LOS of overall patients The mean LOS of overall patients who visited ED LOS of discharged patients The mean LOS of patients who discharged after ED management LOS of admitted patients The mean LOS of patients who admitted to that hospital LOS of transferred patients The mean LOS of patients who transferred to other hospital * ED: emergency department, ICU: intensive care unit Table 2. Definitions of critically ill patients. 1. Child who was dead in ED* 2. Child who received CPR in ED (including DOA patients) 3. Child whose final ED diagnosis was Cardiac arrest or Respiratory arrest 4. Child who was directly admitted to ICU 5. Child who was admitted to ICU via operating room * ED: emergency department, CPR: cardiopulmonary resuscitation, DOA: death on arrival, ICU: intensive care unit 30 Pediatric Emergency Medicine Journal
일반응급센터와의비교를통한소아응급전문센터방문환아분석 미만의소아환자중남자환아가차지하는비율은각각 57.6% 와 58.7% 로차이를보였으며, 이들의평균나이는각각 4.7±5.0세와 5.7±5.5세로소아전용응급센터에방문한소아환자의평균나이가더어린것이관찰되었다. 내원사유는소아전용응급센터에내원한환아의질병비율이 74.3% 로일반응급센터의 70.3% 에비하여높았다. 내원경로는소아전용응급센터로는직접내원한환아의비율이 93.4% 로일반응급센터의 91.1% 에비하여높았으며, 이에반해일반응급센터에서는외부에서전원되어온비율이 7.5% 로소아전용응급센터의 5.1% 보다높았다. 응급진료결과는소아전용응급센터의경우귀가한환아의비율이일반응급센터보다높았고 (88.4% vs. 86.3%), 입원환아비율 (11.1% vs. 12.8%) 및타병원으로의전원환아비율 (0.5% vs. 0.6%) 이낮은결과를보였다 (Table 3). 2. 내원환자수대상기간에해당하는 6개월동안 132개일반응급센터에약 63만명, 6개소아전용응급센터에약 8만여명의환아가방문하였다. 이를센터당일평균내원환자수로환산하면 1개의소아전용응급센터에방문한일평균내원환아수는약 72명으로, 일반응급센터의일평균내원환아수인26명의약세배에해당하였다 (Table 4). 3. 내원환자의중증도지수소아전용응급센터의중증환아비율은 0.25% 로일반응급센터에비해낮았으나기간중 1개센터에내원한중증환아의수는각각 33.3명과 15.9명으로두배이상이었다. 또한입원환아비율역시소아전용응급센터가 Table 3. General characteristics of patients who visited the GEDs* and the PEDs. Total GED PED (N=709,050) (N=629,658) (N=79,392) n % n % n % P value Sex (Male) 415,348 58.6 369,640 58.7 45,708 57.6 <0.001 Age (years) 5.6±5.5 5.7±5.5 4.7±5.0 <0.001 Types of Visits Disease 498,769 70.3 439,789 69.8 58,980 74.3 <0.001 Injury 209,693 29.6 189,316 30.1 20,377 25.7 Others and Unknown 000,588 00.1 000,553 00.1 00,035 0.04 Route of Arrival Direct 647,886 91.4 573,716 91.1 74,170 93.4 <0.001 Transfer from other hospital 051,059 07.2 046,993 07.5 04,066 05.1 Transfer from OPD 009,559 01.3 008,434 01.3 01,125 01.4 Others and Unknown 000,546 00.1 000,515 00.1 00,031 0.04 Outcome of ED visits Discharge 613,810 86.6 543,656 86.3 70,154 88.4 <0.001 Death 000,325 0.05 000,298 0.05 00,027 0.03 Admission 089,074 12.6 080,282 12.8 08,792 11.1 Transfer 004,026 00.6 003,655 00.6 00,371 00.5 Others and Unknown 001,815 00.3 001,767 00.3 00,048 00.1 * GEDs: general emergency departments, PEDs: pediatric emergency departments, OPD: out patients department, ED: emergency department Table 4. Number of patients who visited the GEDs* and the PEDs. Total (n) GEDs (n) PEDs (n) Total number of patients 709,050 629,658 79,392 Mean number of patients who visited one ED during one day 27.9 25.9 71.9 * GEDs: general emergency departments, PEDs: pediatric emergency departments Pediatric Emergency Medicine Journal 31
대한소아응급의학회지제 2 권제 1 호 2015 11.1% 로일반응급센터의 12.8% 보다낮아경증으로귀가하는환아의비율이더높음을보여주고있으나, 1개센터당소아환자의일평균입원수는소아전용응급센터가 8 명으로일반응급센터의 3.3명보다두배이상많았다. 중환자실입원비율은소아전용응급센터와일반응급센터에서각각 0.42% 와 0.49% 였으나, 6개월간 1개소평균중환자실입원환아수로환산할경우각각 55.8명과 23.4명으로소아전용응급센터에서두배이상많았다. 응급수술환아비율은소아전용응급센터에서 0.28%, 일반응급센터에서 0.5% 로일반응급센터에서높았으나, 6 개월간 1개소평균건수로환산할경우소아전용응급센터의응급수술건수가 37.2건으로일반응급센터의 23.7건에비하여많았다 (Table 5). 4. 내원한환아의체류시간소아전용응급센터와일반응급센터에내원한전체환아의체류시간, 귀가환아의체류시간및타병원으로전원된환아의체류시간은양군간에차이가없었다. 그러나입원환아의경우소아전용응급센터의체류시간이 389분으로일반응급센터의체류시간인 322분에비하여약 60 분가량긴것으로나타났다 (Table 6). 고찰 소아전용응급센터에내원한소아환아의평균나이는 4.7±5.0세로일반응급센터에내원한 5.7±5.5세와차 Table 5. Severity Indices of patients who visited the GEDs* and the PEDs. Total GEDs PEDs (N=709,050) (N=629,658) (N=79,392) P value n (%) P1ED n (%) P1ED n (%) P1ED Critically Ill Pts 02,302 0.32 16.7 02,102 0.33 15.9 0,200 0.25 33.3 <0.001 GW Admitted Pts 89,074 12.6 3.5* 80,282 12.8 3.3* 8,792 11.1 8.0* <0.001 ICU Admitted Pts 03,429 0.48 24.8 03,094 0.49 23.4 0,335 0.42 55.8 <0.008 Emergency op**. Pts 03,347 0.47 24.3 03,124 00.5 23.7 0,223 0.28 37.2 <0.001 * GEDs: general emergency departments, PEDs: pediatric emergency departments, P1ED: mean number of patients who visited at one ED during one day, Pts: patients, GW: general ward, ICU: intensive care unit, **op: operated Table 6. LOS of patients who visited the GEDs* and the PEDs. N Mean SD p25 p50 p75 P value LOS of overall patients Total 589,975 279.2 1,720.5 155 196 278 GED 522,944 278.7 1,639.5 155 196 277 0.49 PED 067,031 283.5 2,254.4 155 195 286 LOS of discharged patients Total 505,319 239.5 1,842.8 151 186 251 0.92 GED 446,716 239.6 1,757.0 151 186 251 PED 058,603 238.8 2,398.2 151 183 254 LOS of admitted patients Total 079,327 528.3 548.1 228 329 558 <0.001 GED 071,297 519.8 544.8 224 322 547 PED 008,030 604.2 570.9 274 389 660 LOS of transferred patients Total 003,523 396.4 420.7 199 285 421 0.69 GED 003,192 395.5 427.9 195 281 421 PED 000.331 405.2 345.1 245 316 421 * GEDs: general emergency departments, PEDs: pediatric emergency departments, SD: standard deviation, p25: first quartile, p50: median, p75: third quartile 32 Pediatric Emergency Medicine Journal
일반응급센터와의비교를통한소아응급전문센터방문환아분석 이가관찰되었다. 2008년부터 2년간국가응급환아진료정보망 (NEDIS) 을분석하여발표한연구에서의평균나이인 5.4±5.4세와도차이가있어 1), 소아전용응급센터의의료인력, 시설, 장비의도움이더욱필요한어린나이의환자들이더많이내원함을시사하고있다. 또한소아전용응급센터에내원한환아의질병비율은약 74% 로일반응급센터의약 70% 에비하면높은비율을차지한다. 이는소아응급환자의발생비율이손상보다는질병에서높다는점을감안하면당연한귀결일수있다. 그러나응급센터에내원하는중증환아중에서는손상환아의비율이매우높다는점을고려할때소아와성인응급센터로의적절한인력배치가어렵다는점을시사하는부분이기도하다. 연구에포함된기간에운영된소아전용응급센터중손상을주소로내원한환아는주로성인응급실공간에서진료되는경우가많았다는점은이를뒷받침해준다. 소아전용응급센터로는직접내원한환아의비율이약 93% 로일반응급센터의약 91% 보다높았고, 일반응급센터에서는외부에서전원된비율이 7.5% 로소아전용응급센터의 5.1% 에비해높았다. 이는소아전용응급센터가지역내에서상급병원전원의뢰센터로기능하기보다는근처에거주하는소아환자의진료를담당하고있음을나타내는것이다. 또한소아전용응급센터의응급진료결과귀가한환아의비율이약 88% 로일반응급센터의 86% 에비하여높았으나입원및전원환아의비율은더낮은결과를보였다. 이는경증으로소아전용응급센터에내원하는환아의비율이높음을방증하는결과이다. 센터당일평균내원환아수가소아전용응급센터는약 72명이지만일반응급센터는약 28명인것에서도확인되는것처럼소아전용응급센터로경증환아가몰리면서당초의센터지정목적인과밀화해소에기여하지못하고있다는점을유추할수있다. 소아전용응급센터의중증환아비율은 0.25% 로매우낮았다. 그러나본연구에서정의한소아중증환아의범위는매우제한적이어서실제임상적의미의중증환아와는차이가있다. 또한장중첩증이나기관내이물과같이사망률등을고려한임상적의미의중증도는높지않더라도소아에서특이적인질환군에대한추가의자원이필요한질환의경우역시포함되지않았다. 그러나같은기간센터당내원한중증환아의수는소아전용응급센터가 33.3명으로 15.9명인일반응급센터와비교하여약두배많았다. 중증소아응급환자의처치에필요한자원은특별한준비와수련이필요하므로, 같은수준을유지하기위하여필요한노력과비용이성인에비하여크고비싸다고알려져있다 4). 따라서당초소아전용응급센터의지정취지 에부합하는환아군의내원비율이일반응급센터와비교하여높은지, 증가추세인지등에대한추가분석뿐아니라특정질환으로내원하는환아의비율및진료결과등에대한추가분석이필요하다. 이를통해현재높은비율을차지하고있는경증환이의진료는 1차의료기관에서담당하고, 중증소아환아의진료는소아전용응급센터에서담당하는방식으로소아응급의료체계개선을도모할수있을것으로사료된다. 소아전용응급센터의입원율은약 11% 로일반응급센터에비해낮아경증으로귀가하는환아의비율이더높음을보여주고있으나 1개센터당소아환자의일평균입원수는 8명으로일반응급센터의 3.3명보다두배이상높은것이확인되었다. 이는소아전용응급센터의내원환자수가약세배많고입원결정의문턱이낮아진데기인한것으로추정된다. 마찬가지로중환자실의센터당입원환자수, 응급수술건수도소아전용응급센터가일반응급센터에비하여많았다. 2010년과 2011년당시소아전용응급센터의지정조건에는소아중환자실혹은소아중환자침상에대한기준이없음에도불구하고이와같은결과를나타냄을감안한다면추후소아전용응급센터관련기준에는소아중환자와관련된항목이포함되어야함을시사하고있다. 또한수술과같이인적, 물적자원이집중되어수행되어야할기능이소아전용응급센터에요구되고있음을보여준다고할수있다. 미국의경우소아응급의료체계에필요한시설과장비에대한기준이유관학회에서제정되어권고되고있으며정기적으로충족률을점검하고있다 5-9). 소아응급의료체계가안정적으로유지되기위해가장중요한의료인력에대한고려와더불어장비, 시설에대한지속적인지원및사후관리가필요하다고할수있다. 소아전용응급센터와일반응급센터사이에전체환아체류시간및퇴원환아체류시간의중위값에는차이가없었다. 그러나일부환아의체류시간이지나치게길어짐에따라응급실의과밀화가초래된다는점을짐작할수있다. 전원환아의체류시간역시양군사이에차이가없었으나소아환자의경우성인에비해상대적으로전원이어렵다는점을감안한다면이역시응급실과밀화에기여할것으로생각된다. 입원의경우소아전용응급센터의환아는체류시간이약 389분으로일반응급센터에서입원하는환아에비해약 1시간가량응급실에더체류하는것을확인할수있었다. 소아전용응급센터에내원하는환아및입원환아수가일반응급센터에비해높은데반해병실로의입원이원활하지않으므로이역시응급실의과밀화에기여할것으로사료된다. 성인응급실의문제점중하나인응급실과밀화가소아전용응급센터에서재현되고있다는 Pediatric Emergency Medicine Journal 33
대한소아응급의학회지제 2 권제 1 호 2015 점을고려하여이를해결하기위한시스템정비가필요하다고할수있다. 본연구는후향적연구로, 이미정해져조사된변수만으로분석을하였기때문에갖는한계점이있다. 소아환자의경우자료결측률이높은활력징후를제외할수밖에없었으므로중증환아에대한정의가협소하였고추가자원이필요한질환에대한분석이제외되었다. 또한 2012 년추가로지정된 4개소아전용응급센터에대한분석이제외되었으며자료의한계로인하여진료결과의질측정이이루어질수없었다. 이는각소아전용응급센터가갖는특성과함께추후의연구에서보완되어야할것이다. 결론 소아전용응급센터 6개소와일반응급센터 132개소를비교한결과질병의사유로내원하는경증환아가소아전용응급센터의주요환자군으로파악된다. 또한소아전용응급센터는일반응급센터에비하여일평균내원환아수, 중환자실입원환아수, 수술건수및입원건수가현저히많은데반해환아체류시간에는큰차이가없거나입원환아의경우오히려체류시간이더길게나타나므로소아전용응급센터의과밀화를악화시키는것으로보인다. 따라서이를개선하기위한중환자실소아침상지정, 소아환자의입원절차개선등이고려되어야한다. REFERENCES 01. Kwak YH, Kim do K, Jang HY. Utilization of emergency department by children in Korea. J Korean Med Sci 2012; 27:1222-8. 02. Kim do K, Kwak YH, Lee SJ, Jung JY, Song BK, Lee JH et al. A national survey of current practice patterns and preparedness of pediatric emergency care in Korea. J Korean Soc Emeg Med 2012;23:126-31. 03. Kwak YH, Kim DK, Lee JH, Noh H, Jang HY, Jung JY. Development of strategy of advanced pediatric emergency care system. The Ministry of Health and Welfare of Korea. 2011:121-51. 04. Council of the Society of Critical Care Medicine. Consensus report for regionalization of services for critically ill or injured children. Crit Care Med 2000;28: 236-9. 05. American Academy of Pediatrics Committee on Pediatric Emergency Medicine. Guidelines for pediatric emergency care facilities. Pediatrics 1995;96:526-37. 06. American Academy of Pediatrics Committee on Pediatric Emergency Medicine; American College of Emergency Physicians Pediatric Committee; Emergency Nurses Association Pediatric Committee. Joint policy statementguidelines for care of children in the emergency department. Ann Emerg Med 2009;54:543-52. 07. Committee on Ambulance Equipment and Supplies, National EMSC Resource Alliance. Guidelines for pediatric equipment and supplies for basic and advanced life support ambulances. Pediatr Emerg Care 1998;14:62-4. 08. Moody-Williams JD, Dawson D, Miller DR, Schafermeyer RW, Wright J, Athey J. Quality and accountability: Children s emergency services in a managed care environment. Ann Emerg Med 1999;34:753-60. 09. Moody-Williams JD, Krug S, O Connor R, Shook JE, Athey JL, Holleran RS. Practice guidelines and performance measures in emergency medical services for children. Ann Emerg Med 2002;39:404-12. 34 Pediatric Emergency Medicine Journal