「重大外傷」是指外傷嚴重度分數（Injury Severity Score, ISS）大於或等於十六分以上之病患，行政院衛生署自民國98年起已將重大外傷病患照護品質列入醫院緊急醫療能力分級評定的必要項目。
本研究利用南部某重度級急救責任醫院的外傷登錄資料庫及醫院健保申報資料，自民國99年1月至100年12月期間所有急診外傷就診病人，經回溯性統計外傷嚴重度分數≧16分共452人，符合重大外傷標準。針對病人特性、外傷情況與外傷處置等相關因素，探討其住院天數、加護病房住院天數及醫療費用的差異。
研究發現，重大外傷住院病人以中壯年男性為主，平均47.0歲。外傷機轉多為鈍傷，四成五由外院轉入。受傷部位以頭頸部最多，四分之三以上的病人至少合併二個部位以上外傷。重大外傷住院病人中，極嚴重者（ISS≥分）占了三成五，有56人住院後死亡，死亡率為12.4%。大部分病人都有接受影像學檢查，約三分之二的病人有接受手術治療。平均住院日數是19.6日，平均加護病房住院日數8.7日，每次入院平均耗費269,259.4元，其中急診費用約23,795.7元。
影響住院日數的相關因素為到院方式、外傷嚴重度、住院死亡和手術；而影響加護病房住院日數的相關因素則只有外傷嚴重度和手術。費用方面，影響醫療費用的相關因素為外傷機轉、外傷嚴重度和手術；影響住院費用的相關因素為性別、外傷機轉、外傷嚴重度和手術；而影響急診費用的相關因素則較多，有年齡、外傷部位總數、外傷嚴重度、住院死亡、影像學檢查和手術。其中，外傷嚴重度分數、手術與腹部外傷對所有醫療資源使用都有顯著增加。
本研究建議衛生署應配合世界趨勢，盡快修定國內外傷嚴重度分數的最新參照版本與分數計算指引，以做為評估外傷病人嚴重度的依據 。在健康保險方面，將重大外傷病人再分類為嚴重（外傷嚴重度分數 ISS 16∼24分）與極嚴重（外傷嚴重度分數ISS ≥25分）二群，訂定分級的照護標準，給予不同的醫療給付。

Major trauma refers to an injury with an injury severity score (ISS) equivalent to or greater than 16. In 2009, the Department of Health, Executive Yuan, included quality of care for patients with major trauma as a required item for the grading and evaluation of hospitals’ emergency medical competency.
The trauma registry database and National Health Insurance (NHI) claim data from an emergency response hospital in Southern Taiwan was used in this study. According to retrospective analysis, among the patients admitted to the emergency unit because of trauma between January 2010 and December 2011, 452 matched the criterion of major trauma with an ISS≥16. Based on relevant factors such as patient characteristics, condition of trauma, and trauma first aid, this study examined the differences in patients’ general length of stay (LOS), intensive care LOS (ICULOS), and medical costs.
The research results indicate that these major trauma patients were primarily middle-aged men with an average age of 47. The most common mechanism of trauma was primarily blunt force trauma, and 45% were transferred from other hospitals. The traumatized sites in most cases were the head and neck, and three-fourths of the patients possessed at least two traumatized sites. Among the patients admitted for major trauma, 35% exhibited extremely severe trauma (ISS≥25), and 56 died following hospitalization (12.4% mortality rate). The majority of the patients received imaging examinations, and two-thirds received surgical therapy. The average LOS was 19.6 days, and the average ICULOS was 8.7 days. The average cost per admission was NT $269,259.40, in which emergency medical fees accounted for NT $23,795.7.
Relevant factors that influenced LOS includes the method of admission, severity of trauma, death during hospitalization, and surgery; whereas only the severity of trauma and surgery were relevant factors that affected ICULOS. Relevant factors that influence medical costs include mechanism of trauma, severity of trauma, and surgery. Factors that influence hospitalization costs include gender, mechanism of trauma, severity of trauma, and surgery. Numerous relevant factors affect emergency medical costs, including age, the total number of traumatized sites, severity of trauma, death during hospitalization, imaging examinations, and surgery. Among these factors, ISS score, surgery, and abdominal trauma all significantly increased all medical resource usage.
This study recommends that the Department of Health reference international trends and update the domestic ISS and scoring calculation guidelines to match the latest international standards. The revised ISS can be effectively used as a reference to evaluate patients’ severity of trauma. For NHI, patients who exhibit major trauma should be further divided into groups of severe (ISS between 16 and 24) and extremely severe (ISS≥25). Different medical payment plans should be provided to patients based on their level of care.

論文審定書 ......................................................i
誌謝 ................................................................ii
中文摘要 ....................................................... iii
英文摘要 ........................................................iv
目錄 ...............................................................vi
表 次 ........................................................... viii
圖 次 ............................................................ ix
第一章 緒論 .................................................. 1
第一節 研究背景及動機 .................................1
第二節 研究目的 ........................................... 3
第二章 文獻查證 ........................................... 4
第一節 外傷概況 ........................................... 4
第二節 重大外傷 ........................................... 8
第三節 外傷醫療資源使用 ..........................11
第三章 研究方法 ..........................................19
第一節 研究假設與架構 ...............................19
第二節 資料來源與收集程序.........................22
第三節 研究變項的操作型定 ........................24
第四節 資料處理與分析方法 ........................27
第四章 研究分析與結果 ...............................28
第一節 描述性統計分析 ...............................28
第二節 病人特性與醫療資源使用之分析.......32
第三節 外傷情況與醫療資源使用之分析.......37
第四節 外傷處置與醫療資源使用之分析.......47
第五節 研究結果摘要 ...................................50
第五章 討論與建議 .......................................51
第一節 研究討論 ...........................................51
第二節 研究限制 ...........................................55
第三節 建議 ..................................................56
第四節 研究貢獻 ...........................................57
參考文獻 ........................................................58
一、中文文獻 .................................................58
二、英文文獻 ................................................60

一、中文文獻：
期刊雜誌
王雅玲、黃崇謙、楊啟賢（2006）。頭部外傷原因與醫療資源耗用。北市醫學雜誌， 3(11)，53-64。
李卓倫、陳瑞杰、陳文意、梁亞文、陳慈純（2010）。中台灣嚴重外傷病患死亡率相關因素探討：對外傷登錄與外傷體系之意涵。醫護科技期刊，12(2)，96-108。
李卓倫、陳瑞杰、陳文意、梁亞文、陳慈純（2010）。嚴重外傷存活病患的失能影響因素。臺灣公共衛生雜誌，29(6)，518-527。
紀煥庭、邱文達、楊大羽、蔡行瀚（2009）。台北市輕度頭部外傷之流行病學及醫療資源使用情形。中華民國急救加護醫學會雜誌，18(2)，61-70。
黃睦舜、繆珣、李建賢（2000）。創傷登錄的實施及其重要性。榮總護理，17(2)，119-124。
蔡卓城、陳瑞杰、蔡維謀、蔡宛真、謝屈平、劉永弘、邱文達（2003）。使用外傷登錄探討台灣都會地區之傷害型態：以六所醫院為例。中華民國急救加護醫學會雜誌，14(2)，47-56。
簡立建（2010）。如何成立一個有效率的外傷中心。臺灣醫界，53(8)，428-432。
羅崇杰（2008）。提升臺灣之外傷照顧-由建立外傷中心與外傷照顧體系談起。臺灣醫界，51(4)，44-49。

碩士論文
王雅玲（2006）。探討頭部外傷的傷害機轉與醫療資源耗用（碩士論文）。取自台灣碩博士論文知識加值系統。（系統編號 094TMC00528016）
洪美香（2008）。頭部外傷住院病患醫療資源耗用及其相關因素之探討（碩士論文）。取自台灣碩博士論文知識加值系統。（系統編號 096KMC05528018）
陳瑞杰（2003）。探討台灣外傷系統之設計-資料探勘分析法於健康資料庫之應用（碩士論文）。取自台灣碩博士論文知識加值系統。（系統編號 091TMC00674017）
簡立建（2005）。肝脾損傷住院病患特性與醫療資源耗用之實證研究（碩士論文）。取自台灣碩博士論文知識加值系統。（系統編號093ISU05121117）

網頁資料
中央健康保險局（2011）。全民健康保險重大傷病範圍。取自http://www.nhi.gov.tw/Resource/webdata/18137_2_10000406%E9%87%8D%E5%A4%A7%E5%82%B7%E7%97%85%E7%AF%84%E5%9C%8D%E8%A1%A8-%E7%BD%AE%E7%B6%B2%E7%AB%99.pdf
行政院衛生署（2012）。100年度主要死因分析。取自行政院衛生署統計公佈欄<衛生統計系列(一)死因統計<上卷。取自http://www.doh.gov.tw/CHT2006/DM/DM2_2.aspx?now_fod_list_no=12336&class_no=440&level_no=4
行政院衛生署（2012）。101年醫院緊急醫療能力分級評定基準及評分說明。取自http://www.doh.gov.tw/CHT2006/DM/DM2_p01.aspx?class_no=24&level_no=1&doc_no=85597
行政院衛生署（2012）。100年全民健康保險醫療統計年報。取自http://www.doh.gov.tw/CHT2006/DM/DM2_2_p02.aspx?class_no=440&now_fod_list_no=12488&level_no=3&doc_no=86437
林口長庚外傷急重症中心（2010）。林口長庚紀念醫院外傷年報。取自http://www1.cgmh.org.tw/intr/intr2/c3290/traumareport98.pdf
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二、 英文文獻：
期刊文章
Aday, L.A. & Andersen, R. M. (1995). “Revisiting the behavior model and access to medical care: Dose it matter?”. Journal of Health and Social Behavior, 36,pp1-10.
Baker, S. P., O’Neill, B., Haddon, W., & Long W.B. (1974). The injury severity socre: a method for describing patients with multiple injuries and evaluating emergency care. Journal of Trauma, 14(3), 187-196.
Bennett, K.M., Scarborough, J.E., & Vaslef, S. (2010). Outcomes and health care resource utilization in super-elderly trauma patients. Journal of Surgical Research, 163(1), 127-131.
Boyd, D. R., Rappaport, D. M., Marbarger, J. P., Baker, R. J., & Nyhus, L. M. (1971). Computerized trauma registry: a new method for categorizing physical injury. Aerospace medicine, 42(6), 607-615.
Celso, B., Tepas, J., Langland-Orban, B., Pracht, E., Papa, L., Lottenberg, L., & Flint, L. (2006). A Systematic Review and Meta-Analysis Comparing Outcome of Severely Injured Patients Treated in Trauma Centers Following the Establishment of Trauma Systems. The Journal of Trauma and Acute Care Surgery, 60(2), 371-378.
Cochran, A., Mann, N. C., Dean, J. M., Cook, L. J., & Barton, R. G. (2004). Resource utilization and its management in splenic trauma. The American Journal of Surgery, 187, 713-719.
Moore, L., & Clark, D. E. (2008). The value of trauma registries. Injury, 39(6), 686-695.
Nwomeh, B. C., Lowell, W., Kable, R., Haley, K., & Ameh, E. A. (2006). History and development of trauma registry: lessons from developed to developing countries. World journal of emergency surgery : WJES, 1, 32-32.
O'Keefe, G. E., Jurkovich, G. J., Copass, M., & Maier, R. V. (1999). Ten-year trend in survival and resource utilization at a level I trauma center. Annal of Surgery, 229(3), 409-415.
O’Reilly, G. M., Cameron, P. A., & Joshipura, M. (2012). Global trauma registry mapping: A scoping review. Injury, 43, 1148-1153.

書籍
Committee on Trauma. (2007). Resources for Optimal Care of the Injured Patient 2006. Chicago, IL: American College of Surgeons.
Michael, L. N. (2011). National Trauma Data Bank Annual Report 2011. Chicago, IL: American College of Surgeons. 5-6.
Thomas A. G. (Ed.). (2008). The AIS&#169; 2005 Update 2008. Barrington, IL: Association for the Advancement of Automotive Medicine. 1-11.
Mock, C., Lormand, J. D., Goosen, J., Joshipura, M., & Peden, M. (Ed.). (2004). Guidelines for essential trauma care. Geneva, Switzerland: World Health Organization.
Mock, C., Juilard, C., Brundage, S., Goosen, J., & Joshipura, M. (Ed.). (2009). Guidelines for trauma quality improvement programmes. Geneva, Switzerland: World Health Organization.

網路資料
Brohi, K. (2007). Abbreviated Injury Scale (AIS) Score - Overview of the anatomical scoring tool. Retrieved from http://www.trauma.org/index.php/main/article/510/
Brohi, K. (2007). Injury Severity Score - Overview and Desktop Calculator. Retrieved from http://www.trauma.org/index.php/main/article/383/
Victorian State Trauma System (2010). Definition of major trauma. Retrieved from http://www.health.vic.gov.au/trauma/definition.htm