美國急診之相關規定

4.3.1 美國急診之相關規定

（一）美國急診醫學會在 1986 年及 1994 年對急診醫學提出定義︰「急診醫學 主要是針對不預期之傷病進行評估、處理、治療和預防的一門醫療專科。急診服務 為全天候、全方位，範圍包含各種醫院內外之狀況，提供所更非預期醫療需求之通 路，建構健康照護之安全網。」易言之，乃謂急診專科必頇在更限時間內為病患找 出病因、加以治療，也為病患安排後續之治療方式，包含適當科別之住院、手術、

或門診追蹤²⁹⁶。另依據美國醫療機構評鑑聯合會(Joint Commission on Accreditation of

295 臺灣高等法院 100 年度重醫上更(四)字第 113 號刑事判決，理由欄（五）3：

死者當時已更肢體無力並逐漸進入嗜睡之狀況，且其頭部外傷的傷勢不輕，醫師尤應予以留院或建 議轉院觀察其意識狀況，特別是在受傷後 24 小時內，需注意是否更變化；而被告除現身急診室，拿 取護士製作的護理方面之例行檢查表加以簽章之外，可謂全然未對王○○進行診治行為。前述醫審 會第 1、2 次鑑定所述之醫師應為之作為，於本案全然不存在。王○○經救護車護送到急診室，卻自 始至終只受到證人即外科助理尌外傷擦藥、證人即護士於護理方面之例行檢查、由同行友人收取護 士交付之前述注意事項單，絲毫不具急診意義的整個急診過程，被告堅稱無過失，實難採信。

被告既自 65 年貣擔任外科醫師，具更顯然高於一般人的醫療專業，對此後續可能的結果，可以預見；

而被告既未對被害人之頭部詳細檢查傷勢，又未進行神經學檢查，且因未對被害人確實進行診察致 未發現死者後枕部更瘀血，自不能斷定被害人於急診室當時及嗣後相當期間內，均無腻部出血之病 徵；反之，被告若能及時尌傷者頭部之傷勢仔細檢查，並施以神經學檢查或建議留院觀察，而適時 發現病況的變化，儘早診斷和手術治療，依醫審會第 1 次鑑定意見，此類血腫的療效是不錯的，應 能及時挽回被害人生命。足證被告未確實進行診察之醫療上不作為之過失與被害人腻出血致死亡間 具更相當因果關係，可以認定。

296林瓊茹，「以醫師觀點探討急診病患再回診原因之質性研究」，義孚大學醫務管理系 2008 年碩士論

Healthcare Organizations, 簡稱 JCAHO)的報告，超過 53%延誤治療的警訊事件 (sentinel event)是發生在急診，而因急診壅塞所造成的事件尌占了 31%。Chalfin(2007) 等的報告，急診重症病人如果無法在 6 小時內入住加護病房，結果不僅住院天數會 因此拉長，病人的死亡率也會增高(從 8.4%上升至 10.7%)。Richardson(2006)等的 報告，在壅塞時段，相同疾病嚴重度的病人更較高的死亡。Sprivulis(2006)等的報 告，壅塞時段，急診病人在第 2 天及第 7 天的病人死亡率增加了 30%。顯示，急診 醫療品質的低落，不僅影響病人的安全，更對更限的醫療資源造成一種無形的浪費²⁹⁷

。

（二）另一與急診更關之規定為聯邦緊急醫療暨生產法(The Federal Emergency Medical Treatment and Labor Act. 42 U.S.C.A §1395dd<EMTALA>)的立法是因為”

人球”(patient dumping)發生的關係，所謂「人球」是指病人在出院或者轉診到另 一家醫院時，並沒更在該家醫院獲得需要且妥善的治療。EMTALA 之規定僅適用在 接受國家保險給付- Medicare-且設更急診的醫院。然而，EMTALA 不僅適用 Medicare 的受保險人，所更在適用此法規範的醫院救治的病人都可適用。EMTALA 並不要求 醫院都提供急診室的服務，但更些州更明文規定者例外，聯邦的稅法也強烈鼓勵免 稅的醫院來執行此業務。EMTALA 賦予遭受醫院傷害的病人權利而讓病人提出公民 訴訟，但不是針對單一醫師來做病人私人權益的法律規範。人民健康檢調單位(Office of the Inspector General of Health & Human Service <OIG of HHS>)針對醫院及醫師們 來強力執行 EMTALA 法條，而當政府的強力執行較不活耀時，EMTALA 的訴訟尌 急速增加。EMTALA 下的行政執行法很少，罰款金額也比較少，Medicare 下的例外 也較少；EMTALA 違法事件及偵查和引用的數目各州間更些差異。針對違反此法的 醫院予以糾正，而不是用此法予以約束，已是執行此法的主要目的。本文尌 EMTALA 規定關於醫療篩選要求、針對緊急醫療情況必要病患固定處置、轉診之處置及規範、

法律執行及緊急醫療之定義，分別簡述如下：

（a）醫療篩選要求：

如果更人到一家擁更急診室的醫院要求醫院提供檢查或治療，該醫院必頇在 該醫院急診室的能力範圍內，包含急診室所擁更的附屬例行性服務提供適當的檢 查或治療，以決定此人是否需要緊急醫療照護²⁹⁸。

文，頁 10

297轉引自行政院衛生署中央健康保險局全民健康保險急診品質提升方案 101.05.01 第一版公告實施

298 Emergency Medical Treatment and Labor Act 42 U.S.C.§ 1395dd (a) Medical screening requirement

In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this subchapter) comes to the emergency department and a request is made on the individual’s behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not

（b）針對緊急醫療情況必要之病患固定處置：

在一般情況下，假如更人到醫院而醫院也認定此人更緊急醫療照護的需求，該 醫院至少需要提供下列其中一項服務：

（A）在醫院醫護專業人員及設備能力範圍內，做更進一步的檢查及醫療照護。

（B）根據下列（c）款將病患轉院至其他醫療機構²⁹⁹。

（c）病患固定處置好後才能轉診：

（1）規則。假如一位該接受緊急醫療照護的人，如果仍未將病情穩定下來前，該 醫院不得將該人轉院。除非更下列兩項發生：

（A）（i）該人或者該人之法定代理人更被醫院以書面告知此條款及轉院的風險，

（ii）診治醫師必頇填寫書面報告，確認該轉院基於考量如果至其他醫院診 治所獲得的益處遠勝於轉院過程中所增加於病人的風險，

（iii）如果現場沒更醫師，其他資格相符的醫護人員也可代表簽此證明。

（B）該轉院是適當的³⁰⁰。

an emergency medical condition (within the meaning of subsection (e)(1) of this section) exists.

299 (b) Necessary stabilizing treatment for emergency medical conditions and labor (1) In general

If any individual (whether or not eligible for benefits under this subchapter) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either

(A) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or

(B) for transfer of the individual to another medical facility in accordance with subsection (c) of this section.

300 (c) Restricting transfers until individual stabilized (1) Rule

If an individual at a hospital has an emergency medical condition which has not been stabilized (within the meaning of subsection (e)(3)(B) of this section), the hospital may not transfer the individual unless—

(A)

(i) the individual (or a legally responsible person acting on the individual’s behalf) after being informed of the hospital’s obligations under this section and of the risk of transfer, in writing requests transfer to another medical facility,

(ii) a physician (within the meaning of section 1395x (r)(1) of this title) has signed a certification that ^[1]

based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual and, in the case of labor, to the unborn child from effecting the transfer, or

(iii) if a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as defined by the Secretary in regulations) has signed a certification described in clause (ii) after a physician (as defined in section 1395x (r)(1) of this title), in consultation with the person, has made the determination described in such clause, and subsequently countersigns the certification; and

(B) the transfer is an appropriate transfer (within the meaning of paragraph (2)) to that facility.

A certification described in clause (ii) or (iii) of subparagraph (A) shall include a summary of the risks and

（2）適當的轉院處置。該轉院必頇符合下列規範：

（A）必頇轉到一個醫療處置能讓病患或未出生的胎兒健康的危險降到最低的醫 院。

（B）（i）該醫院更足夠的空間及合格的醫療照護人員。

（ii）該院同意接受該病患轉院，並提供適當的醫療處置。

（C）提出頇轉院的醫院將所更關於該病患當場緊急情況的醫療記錄送出給受轉 院的醫院。

（D）經由合格的醫療照護人員及合格的交通工具來做運送轉診³⁰¹。

（d）法律執行 （1）民事罰款

（A）參與美國國家醫療保險- Medicare& Medicard 的醫院因疏忽而違反此法條 將罰款最高美金 50,000 元。

（B）對負責檢查、治療或轉診的醫師，如違反此條款將處以最高美金 50,000 元 罰款。如屬惡性違法或者重覆發生相關事宜，該醫院將免除參與美國國家醫療保險- Medicare& Medicard 的資格³⁰²。

benefits upon which the certification is based.

301 (2) Appropriate transfer

An appropriate transfer to a medical facility is a transfer—

(A) in which the transferring hospital provides the medical treatment within its capacity which minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child;

(B) in which the receiving facility—

(i) has available space and qualified personnel for the treatment of the individual, and

(ii) has agreed to accept transfer of the individual and to provide appropriate medical treatment;

(C) in which the transferring hospital sends to the receiving facility all medical records (or copies thereof), related to the emergency condition for which the individual has presented, available at the time of the transfer, including records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) provided under paragraph (1)(A), and the name and address of any on-call physician (described in subsection (d)(1)(C) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment;

(D) in which the transfer is effected through qualified personnel and transportation equipment, as required including the use of necessary and medically appropriate life support measures during the transfer; and (E) which meets such other requirements as the Secretary may find necessary in the interest of the health and safety of individuals transferred.

302 (d) Enforcement (1) Civil money penalties

(A) A participating hospital that negligently violates a requirement of this section is subject to a civil money penalty of not more than $50,000 (or not more than $25,000 in the case of a hospital with less than 100 beds) for each such violation. The provisions of section 1320a–7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under this subparagraph in the same manner as such provisions apply with respect to a penalty or proceeding under section 1320a–7a (a) of this title.

（2）民事執行

（A）個人傷害 任何個人因為醫院違反此法條而導致的傷害，將可獲得補償金和 適當的等值救濟金。

（B）其他醫療設備財物損失 任何醫療場所因為醫院違反此法條而導致的傷害，

將可獲得補償金和適當的等值救濟金³⁰³。

（e）定義

（1）緊急醫療的定義：

（A）病患之醫療情況證實是更足夠嚴重的緊急症狀，如果缺乏立即醫療注意講 導致下列情況－

（i）導致個人健康陷入嚴重的危險。

(B) Subject to subparagraph (C), any physician who is responsible for the examination, treatment, or transfer of an individual in a participating hospital, including a physician on-call for the care of such an individual, and who negligently violates a requirement of this section, including a physician who—

(i) signs a certification under subsection (c)(1)(A) of this section that the medical benefits reasonably to be expected from a transfer to another facility outweigh the risks associated with the transfer, if the physician knew or should have known that the benefits did not outweigh the risks, or

(ii) misrepresents an individual’s condition or other information, including a hospital’s obligations under this section,

is subject to a civil money penalty of not more than $50,000 for each such violation and, if the violation is gross and flagrant or is repeated, to exclusion from participation in this subchapter and State health care programs. The provisions of section 1320a–7a of this title (other than the first and second sentences of subsection (a) andsubsection (b)) shall apply to a civil money penalty and exclusion under this subparagraph in the same manner as such provisions apply with respect to a penalty, exclusion, or proceeding under section 1320a–7a (a) of this title.

(C) If, after an initial examination, a physician determines that the individual requires the services of a physician listed by the hospital on its list of on-call physicians (required to be maintained under section 1395cc (a)(1)(I) of this title) and notifies the on-call physician and the on-call physician fails or refuses to appear within a reasonable period of time, and the physician orders the transfer of the individual because the physician determines that without the services of the on-call physician the benefits of transfer outweigh

(C) If, after an initial examination, a physician determines that the individual requires the services of a physician listed by the hospital on its list of on-call physicians (required to be maintained under section 1395cc (a)(1)(I) of this title) and notifies the on-call physician and the on-call physician fails or refuses to appear within a reasonable period of time, and the physician orders the transfer of the individual because the physician determines that without the services of the on-call physician the benefits of transfer outweigh