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Highlights • Taiwan implemented on-board quarantine measures COVID-19on a cruise ship for the first time. • Throat swabs were collected based on specific recent symptoms or travel histories among passengers and crew. • Passengers and crew with negative tests disembarked and took 14-day self-health management measures., To early detect and prevent coronavirus disease 2019 from spreading via international cruise ships, Taiwan Central Epidemic Command Center implemented on-board quarantine measures on a cruise ship at Port of Keelung, Taiwan, on February 8, 2020. Quarantine officers, medical professionals and administrative staff of competent authorities conducted fever screening, investigated present illness and travel history of 1,738 passengers and 776 crew members on the ship. Throat swabs were collected from 128 (5.1%) passengers and crew members with fever or respiratory symptoms in the past 14 days or travel history to China, Hong Kong or Macao within 30 days. All swabs tested negative for severe acute respiratory syndrome coronavirus 2 by the national reference laboratory. The whole process, from on-board preparation to completion of testing, took 9 hours. All passengers and crew were permitted to disembark and were required to take mandatory 14-day self-health management measures. No cases were reported by the end of self-health management period.

BackgroundThis study examined whether corneas from bacteremic donors could be used for corneal transplant.MethodsCorneas donated to the National Eye Bank of Taiwan between 1 January 2014 and 30 June 2017 were included in this study. All the corneas had corneoscleral rim cultures during the retrieval process and were hypothermic preserved in the Optisol-GS storage medium. A microbial work-up flow chart was used for the sterility check of all grafts. Bacteremic donors were defined as those whose last blood culture before corneal donation was positive. The microbial contamination rates, the endothelial cell densities, the tissue utility rates and early complications after transplants were compared between the corneas from bacteremic versus non-bacteremic donors.Results697 corneas from 356 donors were analysed, 70 of which were from bacteremic donors. The microbial contamination rates of the corneas from bacteremic and non-bacteremic donors (7.1% vs 9.1%)(p=0.30) were close. None of the contaminated corneas grew the same bacterial strains as those from their blood cultures. The corneas from bacteremic donors and non-bacteremic donors have similar endothelial cell densities (2931±297 cells/mm2 vs 2903 ± 470 cells/mm2) (p=0.63). Corneas from bacteremic and non-bacteremic donors shared a similar utility rate (98.6% vs 99.4%)(p=0.41). None of the corneas caused infectious complications after transplants.ConclusionOur study showed that corneas from bacteremic and non-bacteremic donors have equally low contamination rates and are of the same quality in terms of endothelial cell density and safety.

Background: In most of the world, corneas from hepatitis B surface antigen (HBsAg)-positive donors have been considered unsuitable for transplantation because of assumed risk of disease transmission. Methods: In Taiwan, an HBV endemic area, corneas from HBsAg-positive donors can be allocated to recipients who are seropositive for HBsAg or antibody against HBsAg (anti-HBs). Between January, 2015 and December, 2019, we evaluated HBV DNA in serum and corneo-scleral rims retrieved from HBsAg-positive and HBsAg-negative donors. We assessed donor serum HBsAg, anti-HBs, hepatitis B core antibody (anti-HBc) and HBV DNA to predict the presence of their corneo-scleral HBV DNA. We conducted a look-back study of recipients transplanted with corneo-scleral HBV DNA-positive donor grafts. Their HBV serological profiles were examined to identify possible post-transplantation hepatitis B transmission. Findings: Forty-five and 125 corneal grafts from 28 HBsAg-positive and 85 HBsAg-negative donors, respectively, were included. The donor corneo-scleral rim HBV DNA-positive rate was significantly greater in HBsAg-positive donor grafts (80·0%) compared to that of the HBsAg-negative grafts (6·4%, [ P

Long work hours among physicians is a worldwide issue in the healthcare arena. Previous studies have largely focused on the work hours of resident physicians rather than those of attending physicians. The purpose of this study was to investigate total work hours and the composition of those work hours for attending physicians across different hospital settings and across different medical specialties through a nationwide survey. This included examining differences in physician workload and its composition with respect to different hospital characteristics, and grouping medical specialties according to the work similarities. A cross-sectional self-reported nationwide survey was conducted from June to September of 2018, and the two questionnaires were distributed to all accredited hospitals in Taiwan. The number of physician work hours in different types of duty shifts were answered by medical specialty in each surveyed hospital. Each medical specialty in a hospital filled only one response for its attending physicians. The findings reveal that the average total work hours per week of an attending physician is around 69.1 h, but the total work hours and their composition of different duty shifts varied among hospital accreditation levels, geographic locations, emergency care responsibilities, and medical specialties. Because of the variance in the number and composition of attending physicians’ work hours, adjusting physician work hours to a reasonable level will be a major challenge for health authority and hospital managers.

The paper aims to introduce the current status of shared decision making (SDM) in Taiwan under its mixed health care system and single-payer health insurance system. With experiences in promoting both evidence based medicine and patient safety, the Joint Commission of Taiwan has implemented a nationwide SDM program under the aegis of the Ministry of Health and Welfare since 2016, incorporating multiple approaches such as developing patient decision aids (PDAs), executing the Medical Decision Aids Campaign, establishing a SDM platform, and integrating SDM in clinical practice. In this article, we share the positive and negative responses to the SDM program from hospitals, health care providers, and patients.

Background/Purpose Epidemiology data of medical adverse events (MAEs) are crucial for patient safety policymaking. However, no epidemiological data on MAE exist in Taiwan. In this study, we aimed to investigate the incidence of MAEs at a major medical center in northern Taiwan. Methods The Harvard Medical Practice Study methodology was modified using a criterion-based screening algorithm and critical medical record review process to investigate the risks and incidences of MAEs. A Criterion-Based Screening for Medical Adverse Events (CBSMAE) checklist was developed, and a three-tier strategy was applied to screen and review 2007 inpatient hospitalizations from a single institution. Results A total of 2934 charts was sampled (Tier 1) and 950 possible MAEs were identified (Tier 2). One hundred and sixty-one probable MAE cases were subsequently critically reviewed (Tier 3). Nineteen (0.7%) MAE cases were confirmed. The MAEs involved 10 women and nine men (mean age, 70 years). Most MAEs were from the surgery department [11 (57.9%) patients]. The major admission diagnoses were cardiac diseases [7 (36.8%) patients] with a cardiac problem [13 (31.7%) patients] as the major comorbidity. Major MAE attributes were a staff technique problem [12 (46.2%) patients] and patients' underlying conditions (likelihood rating, 2.2). Eight (42.1%) patients required additional medical management, four (21.1%) patients had a disability, and five (26.3%) patients had in-hospital mortality. Night MAEs (47.4%) were considered preventable. Conclusion Surgical patients with cardiac conditions were at risk of MAE, particularly patients who received invasive procedures. The epidemiology information from this study can serve as baseline data to monitor a patient safety improvement campaign.

Objective: Strong earthquakes often cause massive structural and nonstructural damage, timely assessment of the catastrophe related massive casualty incidents (MCIs) for deploying rescue resource a...

Background To examine the association between health literacy, level of disease knowledge, and adherence behavior among patients with type 2 diabetes. Methods A cross-sectional survey study of 1059 Mandarin- and Taiwanese-speaking patients aged 20 years or older with type 2 diabetes was conducted. The demographic profiles of the sample strata were determined by analyzing the Taiwanese National Health Insurance Database. Participants were enrolled and completed questionnaires between April and November of 2015. The patients were assessed using a self-developed questionnaire with high internal consistency (KR-20 = .84). Results Construct validity was supported by Confirmatory Factor Analysis. Respondents scored lowest in diet-related knowledge. Health literacy and diabetes knowledge were significantly greater when patients cared for themselves with additional caretaker assistance. Patient age, gender, and educational attainment were associated with adherence behavior. Conclusion This study conducted a nation-wide survey of patients with diabetes and the results showed that respondents possessed fairly strong diabetes-specific health literacy and knowledge. However, health literacy shouldn’t be assessed as an isolated concept. Instead, it should be assessed in conjunction with adherence behavior.

Background/purpose The purpose of this study was to understand the overall conditions of dental teaching and training by dental departments in Taiwan's hospitals. Materials and methods In 2007–2008, a questionnaire survey (evaluation form) about dental teaching and training criteria was mailed to 165 hospital dental departments in Taiwan. After the questionnaires were mailed back, a field survey of dental departments of these hospitals was carried out. Each hospital was visited to check the answers to the questionnaire. The survey return rate was 62%. This research examined 28 criteria concerned with dental teaching and training, and the results were analyzed. Scores of the criteria in the questionnaire (evaluation form) were on a five-point scale, from high to low: A = totally achieved; B = above the average standard; C = the average standard; D = below the average standard; and E = not suitable. If an item was not applicable, then the respondent could choose NA. The percentages of A–E and NA were analyzed according to the location of the dental department (i.e., in a medical center, regional hospital, or district hospital), then for every respective criterion, and finally for the entire dataset. Results For overall dental teaching and training, 65% of medical centers received an A, 24% of regional hospitals received a C level, and 67% of district hospitals received NA. Dental departments that received above C were 98% of medical centers, 56% of regional hospitals, and 26% of district hospitals. Conclusion For overall dental teaching and training, our study showed medical centers were superior to regional hospitals, which were superior to district hospitals. Medical centers (98% above average standard) provided satisfactory teaching and training in their dental departments.

Objective The aim of this study is to create a national database to record incidents that endanger patient safety. We try to identify systemic problems in hospitals in order to avoid safety incidents in the future and improve the quality of healthcare. Method The Taiwan Patient Safety Reporting System employs a voluntary notification model. We define 13 types of patient safety incidents, and the reports of different types of incidents are recorded using common terminology. Statistical analysis is used to identify the incident type, time of occurrence, location, person who reported the incident, and possible reasons for frequently occurring incidents. Results There were 340 hospitals that joined this program from 2005 to 2010. Over 128,271 incident events were reported and analyzed. The three most common incidents were drug-related incidents, falls, and endo tube related incidents. By analyzing the time of occurrence of incidents, we found that drug-related incidents usually occurred between 8 and 10am. Falls and endo tube incidents usually occurred between 4 and 6am. The most common location was wards (57.6%), followed by intensive care areas (13.5%), and pharmacies (9.1%). Among hospital staff, nurses reported the highest number of incidents (68.9%), followed by pharmacists (14.5%) and administrative staff (5.5%). The number of incidents reported by doctors was much lower (1.2%). Most staff members who reported incidents had been working for less than five years (58.1%). Conclusion The unified reporting system was found to improve the recording and analysis of patient safety incidents. To encourage hospital staff to report incidents, hospitals need to be assisted in establishing an internal report and management system for safety incidents. Hospitals also need a protection mechanism to allow staff members to report incidents without the fear of punishment. By identifying the root causes of safety incidents and sharing the lessons learned across hospitals is the only way such incidents can be stopped from happening again.

In June 2015, nearly 500 concert attendees suffered injuries from smoke inhalation and severe burns following a color-dust explosion at a waterpark in Taiwan. We report on the progressions of the incident and government responses, share cross-departmental mobilization and case management lessons, and reflect on clinical and complex policy issues emerged. The timely and coordinated emergency responses, a high-quality universal health care system, and dedicated clinicians voluntarily working overtime resulted in an unprecedented 2.4% mortality rate (international statistics predicted 26.8%).

Objective. In 2004, the Taiwan Department of Health set the national patient safety goals. To date, however, there has been no evaluation of these goals. This study aimed to develop a method to evaluate the status of the national patient safety goals in Taiwan. Design. A cross-sectional questionnaire surveys to measure achievements on Taiwan’s national patient safety goals. This survey was also followed up with an onsite audit to ensure accuracy. Setting. All hospitals in Taiwan. Participants. A total of 361 hospitals in Taiwan respond to questionnaire survey and 80 randomly selected hospitals for onsite audit. Intervention(s). None. Main Outcome Measure(s). Average scores on achievements of the national patient safety goals. Results. Among the 516 hospitals to which the questionnaire was sent, 361 (70%) responded. A total of 80 hospitals were randomly selected according to geographic location and size for onsite audit. The results show that the longer the period of implementation, the higher the average scores on achievements of the goals. After stratified analysis by hospital size, the large hospitals were found to have a higher average score in every goal, especially in the new goals. Furthermore, in terms of the difference between self-report results and the onsite audit, the score in the self-report was higher than the score given by experts upon onsite audit; however, they were similar. Most items were approximately the same in the self-report score and the onsite judgment, and those that differed were merely either one rank higher or lower. Conclusion. The self-report questionnaire combined with an onsite audit appears to be a promising approach for measuring scores on achievements of the national patient safety goals. The Department of Health could conduct this program annually to evaluate the progress and propose coping strategies.

Objective The aim of this study was to evaluate the factors related to outcome regarding in–intensive care unit (ICU) cardiac arrest (IICA) in a university hospital. Patients and Methods Adult nontraumatic ICU patients who sustained IICA were prospectively enrolled. Several patient and event-related variables, as well as outcomes, were recorded and summarized based on the revised Utstein-style template. Results A total of 202 episodes of IICA happened during the study period. Return of spontaneous circulation (ROSC) was achieved in 127 patients (62.9%), whereas the overall survival-to-discharge rate was 15.3% (31 patients). In univariate analysis, a shorter duration of resuscitation and pulseless ventricular tachycardia/ventricular fibrillation (VT/VF) as initial arrest rhythm represented better outcomes. Independent predictors of survival to hospital discharge were VT/VF as the initial rhythm (odds ratio [OR], 3.81; 95% confidence interval [CI], 1.50-9.67; P = .005), lower Acute Physiology and Chronic Health Evaluation II score (OR 0.92, 95% CI 0.87-0.98, P = .008), and shorter resuscitation durations (OR 0.91, 95% CI 0.87-0.96, P Conclusion Shorter resuscitation duration and initial VT/VF are predictors for both ROSC and hospital survival, whereas lower Acute Physiology and Chronic Health Evaluation II scores predict the latter.

To evaluate the effects of change of ambient temperature on emergency department (ED) patient visits.This prospective observational study was conducted in the ED of National Taiwan University Hospital from January 2002 to January 2007. The daily ED patient numbers of different triage levels in different service specialties were collected and correlated with the daily average temperature (T) and change in temperature (deltaT) compared with the previous day. A univariate analysis was performed with the Pearson correlation and a multivariate analysis with multiple linear regression analysis.A total of 505,224 patient visits were included in this study. On univariate analysis, there was no significant correlation between T and the ED volume (r = 0.012, p = 0.608), but there was a significant correlation between deltaT and ED volume (r = 0.109, p0.001). On multivariate analysis, deltaT and holidays were identified as independent predictors of ED volume. We established the following formula in predicting the ED patient number: y = 265.42 + (0.06 x T) + (2.57 x deltaT) + (59.77 x holiday). There was a positive association between T and the trauma patient number, while there was a negative association between T and medical and paediatric patient numbers. On the triage level, a low T was associated with increased patient triage level, while no significant association was noted between deltaT and the proportion in any triage level.Our study demonstrated that ambient temperature had differential effects on ED patient visits of different specialties and severities.

Regarding to the article written by Dr. Ching-Yi Liu, on behalf of the Department of Health, I would like to make the following comments. First of all, the amended Biobank Act on Article 29 and Article 30 has been passed by the Legislative Yuan and came into effect on January 26, 2011. Amended Article 29 has already specified that Articles 6, 15, 16, and 20 shall apply, where appropriate, to those biomedical researches not using the biologic specimens, derivatives, relevant data, and information from the biobank. In addition, for those genetic analyses that could not be carried out in Taiwan or due to other special reasons could be exported under the approval of the Competent Authority if the biological specimens are not from the biobank. Furthermore, the corrective process has also been postponed until February 2012 in the amended Article 30 as well. As for the research area a biobank could serve, a biobank can serve genetic and nongenetic research that has been approved by the institutional review board and

Summary Purpose of the study The Web-Based Registry System on In-hospital Resuscitation (WRSIR) is the first prospective, web-based, multi-site, and Utstein-based reporting system in Taiwan. This study was conducted to evaluate the feasibility of the system in one of the participating hospitals and identify prognostic factors associated with survival. Material and methods The WRSIR is an on-line registry system coded with the active server page (ASP) programming method. Information was gathered and entered on-line by trained staff using spreadsheets that could be automatically created according to the updated Utstein in-hospital template. Through the implementation of the system, in a tertiary teaching hospital we evaluated all adults with in-hospital cardiac arrest receiving cardiopulmonary resuscitation between 1 October 2004 and 30 September 2005. The main outcome measures were return of spontaneous circulation (ROSC), survival to hospital discharge, and cerebral performance category score at the time of discharge. Logistic regression analysis was performed to determine independent predictors of survival. Results A total of 330 cases experienced in-hospital resuscitation. ROSC occurred in 233 cases (71%) and 61 patients (18%) survived to hospital discharge. Thirty-five patients (58%) had a good neurological outcome with the cerebral performance category (CPC) score of 1 or 2 among survivors. The major predictor of ROSC was initial rhythm of VT/VF (adjusted OR 0.36, 95% CI 0.16–0.78). Conclusion This study examined the feasibility of a web-based registry system on in-hospital resuscitation using the Utstein style in an oriental country. It provides a comprehensive and standardised method for on-line registry of data collection, allowing individual hospitals to track each case for quality improvement. A further nationwide registry will enforce the possibility of data analysis and future perspective research of in-hospital resuscitation.

Life is priceless, so pre-hospital evaluation and management is important in emergency medical service. To enhance the quality of emergency medical service, the mobile hospital emergency medical system (MHMES) is designed to provide for e-prepared services. This system could improve the communication among the ambulance, the dispatch and mission control center and the emergency department of the hospital via a wireless network, and provide comprehensive service during pre-hospital resuscitation and transportation of the patients. The MHMES consists of three sub-systems located in three sites respectively, dispatch and mission control center, emergency department of hospital and ambulance. It includes electrical map to track the ambulances and transfer patients situation and histories with the hospital to follow the symptom. Therefore, this system would be able to reduce the mortality during transportation and enhance the safety and quality of emergency medical service. It structures an emergency informatics system of National Taiwan University Hospital to provide a application of wireless network in a medical emergency service network.

Study objectives: In the emergency medical services (EMS) system, appropriate prehospital care can substantially decrease casualty mortality and morbidity. This study designed a simulation model, evaluated the existing EMS system, and suggested improvements. Methods: The study focused on 23 networked EMS hospitals affiliated with 36 emergency response units (subgroups) to perform two-tier rescues (advanced life support [ALS] in addition to basic life support [BLS] services) in Taipei, Taiwan. Using the existing EMS model as a base, this research constructed a computer simulation model and explored several model alternatives to achieve the study's objectives. The virtual models varied with staffing level, number of assigned emergency network hospitals, and various two-tier rescue probabilities. Results: Increasing the staffing to two teams for Hospital 22 lessened the call waiting probability (delay between rescue call and ambulance dispatch) by 50%, even if the dispatch rate of the two-tier rescue increased from the empirical 2% to a simulated 10 and 20%. Changing the two-tier rescue pattern so each EMS subgroup cooperated with two specific, preassigned network hospitals lowered the probability of patients having to wait for rescue dispatch to under 1%. Conclusion: The following alternatives provided the greatest combination of effectiveness, quality patient care, and cost-efficiency: (1) because of its unique location, increase Hospital 22's staffing level to two ALS teams. (2) Establish a specific rescue protocol for the two-tier system that preassigns two network hospitals to each of the 36 EMS subgroups along with a prearranged calling sequence. If implemented, this will improve EMS performance, streamline the system, reduce randomness, and enhance efficiency.

Objectives: To determine the impact and outcome of out-of-hospital cardiac arrests (OHCA) while using automated external defibrillators (AED) with biphasic waveforms and its effectiveness when using the Utstein Style community-wide in Taipei. Material and methods: A one-year study was conducted to collect OHCA patients with AED utilization prospectively in Taipei City. All events and variables were recorded in the Utstein Style. Electrocardiography and voice records recovered from AED data cards were analysed. The endpoints were survival outcomes. Results: Of 653 OHCA patients with AED utilization, only 80 (12.6%) patients with 635 true arrests presented with ventricular fibrillation or tachycardia (VF/VT) as the initial rhythm. The interval between call-to-shock was 5 min longer than call-to-EMS arrival (9.3 min versus 4.0 min). Fourteen (25%) of the 55 witnessed VF/VT arrests survived to home discharge. Ninety-seven percent of shockable rhythms were successfully terminated with less than three shocks. For all OHCA patients, initial rhythm of VF/VT (OR 3.4; 95% CI = 1.2–9.4), witnessed status (OR 4.7; 95% CI = 1.3–16.6), and presence of organised rhythm irrespective of pulse during prehospital resuscitation (OR 9.2; 95% CI = 3.2–26.8) demonstrated an independent association with survival to home discharge. For VF/VT arrests, witnessed status, shorter call-to-shock time, high successful rate of the first shock, fewer averaged number of shocks delivered for each patient, and presence of an organised rhythm during prehospital resuscitation showed a likelihood to predict to predict discharged survival in univariate analysis. Conclusions: Low frequency of VF arrests is unique to certain eastern populations but without a reduction of AED shock efficacy with biphasic waveform. Besides initial VF and witnessed status, a prehospital post-shock organized rhythm irrespective of pulse appears to be correlated to survival. Certain circumstances in a congested metropolitan city consume time to deliver shocks even after EMS arrival, and might require bystander or public access defibrillation.

Introduction: Improving outpatient resource utilization significantly enhances the efficiency of healthcare organizations. Substantial number of walk-in patients (average of 72% in our study) to outpatient services is a universal characteristic of Taiwan's healthcare organizations. Consequently, scheduling becomes extremely complicated and important. Selecting the right scheduling alternative, a healthcare organization can markedly improve operating efficiency of outpatient resources. Objective: This research applied simulation methodology to analyze several scheduling solutions and found that setting the appropriate arrival time interval for preregistered patients significantly impacts queuing problems in outpatient services. Method: Using established simulation models, the effects of various scheduling policies on patients' throughput time and waiting times were revealed. Under alternative model A, the first 20 numbers are reserved for scheduled patients; after that, only even numbers are offered for scheduled ones. Odd numbers after 20 are left for walk-ins. Under alternative model B, front numbers were assigned to scheduled patients successively. The later numbers were left for walk-ins. Alternative model C assigned scheduled patients with even numbers and walk-ins with odd numbers in sequence. Finally, alternative model D was designed to examine the optimal scheduled time interval by conducting the model with different scheduled time intervals such as 3, 5, 7, 9, and 11 min. Result: The alternative sequence (alternative model C—assigning even numbers for scheduled patients and odd numbers for walk-in patients, or vice versa) significantly has the least throughput time (average: 34.9 min vs 55.2, 56.2, and 46.2 min) and waiting times (average: 14.7 min vs 34.9, 35.8, and 25.8 min) for walk-in patients compared with other registration strategies. Scheduling the appointments with flexible time interval (alternative model D) has the least throughput time (average: 24.2 min vs 28.4, 28.2, and 37.2 min) and waiting times (average: 8.0 min vs 12.5, 12.3, and 20.5 min) for scheduled patients compared with other registration strategies. Conclusion: The findings of this research could be applied possibly to any outpatient clinic with mixed-registration-type (walk-in and scheduled), particularly which accounts for high percentage of walk-in patients.

Emergency medical service (EMS) policy makers must seek to achieve maximum effectiveness with finite resources. This research establishes an EMS computer simulation model using eM-Plant software. The simulation model is based on Taipei city's EMS system with input data from prehospital care records from December 2000; it manipulates resource allocation levels and rates of idle errands. Presently, EMS ambulance utilization is about 8.78%. On average, 20.89 minutes are required to transport a patient to the hospital. Computer simulations showed that reducing the number of ambulances to one at each of the 36 response units increases the utilization rate to 15.47% but does not compromise the current service quality level. Thus, ambulance utilization improves, times of patients waiting for pre-hospital care and arrival at hospitals are only slightly affected, and considerable cost savings result. This study provides a research methodology and suggests specific policy directions for resource allocation in EMS. Limiting the number of ambulances to one per response unit reduces costs, increases efficiency, and yet maintains the same operational pattern of medical service.