研究背景：
隨著緊急醫療的精進與健保的普及，急診服務的需求也相對呈現逐年成長趨勢；非計劃性再返急診可能是急診照護的警訊，使得急性照護的醫療資源耗用與照護成本增加，影響到真正需要急診照護病患之權益，非計劃性返診的監測意謂著對於急診臨床現況進行檢視，以確保有效的急診醫療服務及品質。
研究目的：
為了解急診病患72小時內重返急診情況，探討影響病患非計劃性重返急診之危險因子，藉此了解急診流程、環境及人員在急診緊急情況下對醫療照護結果的影響，做為醫療機構有效管理及改善急診返診現況之依據。
研究方法：
本綜合性研究對象為某醫學中心的急診病患及醫師，研究一為前瞻性研究（Prospective study)之設計，醫師資料使用結構式問卷進行急診醫師之人格特質、職業疲勞及不適切照護情況的資料收集，檢視急診醫師人格特質是否會影響其提供醫療照護情形，以及職業疲勞對人格特質與照護行為影響，並採拔靴法重抽信賴區間檢視中介效果於兩變數關係中的角色；研究二病患資料採回溯性研究（Retrospective study）之設計，擷取某南部醫學中心2019年期間急診就醫之病患資料，並將三日內有急診就醫紀錄定義為72小時內有非預期再入急診者，擷取包含性別、年齡、身份別、檢傷級數、急診滯留時間、就診時間、急診壅塞程度、出院動向、是否72小時內再入急診等；經合併醫師資料後再針對涉及病患、疾病、醫師與醫院等現況因素進行72小時再返急診之相關因子探討，並以拔靴法、傾向分數配對法、卡方檢定、獨立樣本T檢定、複邏輯斯迴歸（Multivariate logistic regression）、多層次分析（Multi-level Analysis）等檢視變項間的關係與重返急診危險因子。
結果：
研究一探討急診醫師人格特質與不適切照護間的關係，五大人格特質會透過工作相關疲勞間接影響急診醫師提供的不適切照護情形；研究二探究急診病患72小時內重返的危險因子，該研究醫院2019年急診病患重返率4.47%，其中病患性別、檢傷級數、急診壅塞程度、急診就診時間、醫師的年齡與年資對於病患是否72小時內急診重返無顯著影響；病患年紀較大、病人身份別為重大傷病、急診滯留時間為6-48小時、病人自行離院或自動出院、醫師的人格特質為神經質以及有工作相關疲勞者皆達統計顯著影響；而探討醫師因素於二階層邏輯斯迴歸當中發現，醫師因素可以解釋病人72小時重返急診的變異百分比僅2.75%，且因隨機效果的變異數估計不收斂，二階層邏輯斯迴歸模型的結果會與邏輯斯迴歸模型相似，即醫師層級變數的影響對病患72小時內重返急診的影響性不大。
結論：
分析結果發現工作相關疲勞是主要影響急診醫師提供的不適切照護情形的重要因素，可藉由調整醫師班別的人力或提供緩解醫師工作疲勞措施，來改善醫師工作疲勞狀態，進而降低病患重返急診影響；針對顯著影響急診病患72小時內重返的相關風險因子，建議適時將年紀大、病人身份為重大傷病者、疑似可能自行離院或自動出院患者列為優先介入衛教族群，提供個別性溝通與加強出院衛教；考量醫師層級因素對於急診病患72小時重返的影響不大，可把重心放在病人教育與急診流程改善；另建議醫院針對急診醫療品質指標予以持續性的監測與定期性的檢討與介入。

Background:
With the advancement of emergency medical care and the generalization of national health insurance, the amount of emergency services is growing yearly. An unexpected return to the emergency department（ED）may indicate suboptimal or inappropriate care. The situation may increase the medical resources and costs, and affect those patients in need. Hospitals usually adopt varied strategies and reforms to improve the quality of care and reduce medical waste.
Objective:
This study investigated factors of an unexpected ED return within 72 hours. By identifying risk factors, the hospital may have the inspection and timely intervention on the outcome of emergency care related to the process, environmental, and personnel deficits.
Method:
The study combined and adopted subject data from patients and physicians in the ED of a south medical center. Study one is a prospective study collecting data from emergency physicians on personality traits, burnout, and suboptimal care with a structured questionnaire. The analysis applied the method of bootstrapping to represent the indirect effect of burnout among the causality. Study two is a retrospective study to gather patients’ data during the year 2019 through the emergency information system. Patients who had emergency medical treatment during this period were recruited and gathered information on patient gender, age, identity, length of stay, triage level, visiting shift, emergency crowding, and discharge mode. Emergency patients discharge and return to the ED within 72 hours are regarded as patients who have unexpectedly returned to the ED. The data from two studies were combined and matched by propensity score, so risk factors related to the patient, diseases, physician, and hospital were identified by applying the independent t-test, chi-square test, multivariate logistic regression, and multi-level analysis.
Results:
Work-related burnout of emergency physicians has an indirect effect on the relation of physicians’ personality and suboptimal care. The unexpected return rate of 4.47% was yielded with 4,086 patients returned out of the 91,582 included patients. The results found that patients’ age, the identity of severe illness, leaving without notice or discharge against advice, stay in the ED for 6-48 hours, physicians’ work-related burnout, and personality neuroticism were influential predictors of returning to the ED. No significant effect on physician-level was found in the multilevel logistic regression analysis regarded to evaluate ED revisiting within 72 hours.
Conclusion:
Patients with advanced age, the identity of severe illness, stay in the ED for 6-48 hours, and those likely to against advice or leave without notice should be implemented in discharge planning in priority. Reforms to adjust the workload or ease the burnout of physicians are essential for occupational health of professionals. Identifying risk factors of return to the ED within 72 hours could help hospitals to monitor and optimize the quality of emergency care concerning the clinical practice, emergency environment, and personnel management continuously.

論文審定書 i
致謝 ii
中文摘要 iii
英文摘要 v
目錄 vii
圖次 ix
表次 x
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 3
第二章 文獻探討及研究假設 4
第一節 急診醫學現況與流程 4
第二節 急診醫療品質指標 5
第三節 急診醫師的職業疲勞 6
第四節 72小時非預期性急診返診因素 10
第三章 研究設計與方法 22
第一節 研究步驟 22
第二節 研究一急診醫師因素 23
第三節 研究二72小時重返急診相關因素 26
第四章 研究結果 33
第一節 研究對象之描述性統計 33
第二節 量表之信度分析結果 36
第三節 職業疲勞對於醫師人格特質與不適切照護關係的影響 39
第四節 傾向分數配對後之資料分析 45
第五節 各變項對急診72小時重返急診之邏輯斯迴歸分析 50
第六節 二階層邏輯斯迴歸模型分析 52
第五章 研究討論與結論 56
第一節 研究假設驗證 56
第二節 研究討論 57
第三節 研究結論 61
第四節 研究限制 62
第五節 管理意涵與建議 63
參考文獻 65
附錄 73
附錄一 研究問卷 73
附錄二 IRB證明 78

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