背景
財團法人醫院評鑑暨醫療品質策進會一直以來都致力於解決急診壅塞，包括降低急診病人滯留大於48小時的比例。我們因此執行品質改善專案以降低滯留大於48小時比例，並且將其執行結果在此報告。
研究方法
我們採取三個行動方案。第一，改變病人針對轉至他院繼續接受治療的選擇架構，從選擇參加改成選擇不參加。第二，增加病房床位的周轉率以及每天由急診轉病房住院的人數。第三，病人滯留急診大於32小時者，由醫師優先審視。
研究結果
轉院比例在行動方案執行之後些微上升。每天由急診轉病房住院的人數並沒有顯著增加。內科病房午後出院的比例，以及病人滯留急診大於48小時的比例均顯著下降。
討論
病人選擇架構的改變，是否有影響轉院比例，仍需要更長的時間觀察。更全面的床位管理計畫，並且加速病床的周轉率，是必須的。在此品質改善專案執行之後，急診病人滯留大於48小時比例顯著下降。

Background
The Taiwan Joint Commission on Hospital Accreditation has stressed the importance of solving emergency department (ED) overcrowding, such as reducing the proportion of patients with a length of stay (LOS) of over 48 hours. We initiated a Quality Improvement Project (QIP) and report the results.
Methods
We initiated three action plans. The first was to change the choice architecture of patients’ willingness to transfer from opt-in to opt-out. The second was to increase the turnover rate of medical beds and the admitted number from ED to medical ward. The third entailed that patients with over 32 hours LOS be re-evaluated with priority.
Results
The transfer rate increased minimally after implementation. There was no significant increase in the number of free medical beds for the ED. Both the rates of discharge after 12 pm and the proportion of over 48 hours LOS decreased significantly (p<0.001).
Conclusions
Changing the choice architecture require a longer duration of observation. A more comprehensive bed management plan and to speed up the turnover rate of inpatient beds are necessary. After QIP, the proportion of over 48 hours LOS dropped significantly.

論文審定書 i
論文公開授權書 ii
摘要 iii
Abstract iv
目錄 v
圖次 vi
表次 vii
Chapter 1　Introduction 1
Chapter 2　Methods 3
Section1　Study Design and Setting 3
Section2　Statistical Ana lysis 10
Chapter 3　Results 11
Chapter 4　Discussion 16
Acknowledgements 19
References 20

1. Di Somma S, Paladino L, Vaughan L, Lalle I, Magrini L and Magnanti M. Overcrowding in emergency department: an international issue. Intern Emerg Med. 2015;10:171-175.
2. Hoot NR and Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52:126-136.
3. Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, McCarthy M, John McConnell K, Pines JM, Rathlev N, Schafermeyer R, Zwemer F, Schull M, Asplin BR and Society for Academic Emergency Medicine EDCTF. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16:1-10.
4. McCarthy ML, Zeger SL, Ding R, Levin SR, Desmond JS, Lee J and Aronsky D. Crowding delays treatment and lengthens emergency department length of stay, even among high-acuity patients. Ann Emerg Med. 2009;54:492-503 e4.
5. Schull MJ, Vermeulen M, Slaughter G, Morrison L and Daly P. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med. 2004;44:577-585.
6. Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS and Datner EM. The effect of emergency department crowding on patient satisfaction for admitted patients. Acad Emerg Med. 2008;15:825-831.
7. Pines JM and Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008;51:1-5.
8. Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR and Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006;184:208-212.
9. Guttmann A, Schull MJ, Vermeulen MJ and Stukel TA. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ. 2011;342:d2983.
10. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006;184:213-216.
11. Plunkett PK, Byrne DG, Breslin T, Bennett K and Silke B. Increasing wait times predict increasing mortality for emergency medical admissions. Eur J Emerg Med. 2011;18:192-196.
12. Liu SW, Thomas SH, Gordon JA, Hamedani AG and Weissman JS. A Pilot Study Examining Undesirable Events Among Emergency Department–Boarded Patients Awaiting Inpatient Beds. Ann Emerg Med. 2009;54:381-385.
13. Stang AS, Crotts J, Johnson DW, Hartling L and Guttmann A. Crowding measures associated with the quality of emergency department care: a systematic review. Acad Emerg Med. 2015;22:643-656.
14. Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N and Camargo CA, Jr. A conceptual model of emergency department crowding. Ann Emerg Med. 2003;42:173-180.
15. Powell ES, Khare RK, Venkatesh AK, Van Roo BD, Adams JG and Reinhardt G. The relationship between inpatient discharge timing and emergency department boarding. J Emerg Med. 2012;42:186-196.