透過您的圖書館登入
IP:3.85.167.119
  • 學位論文

急診嚴重敗血症「及早目標導引治療」療效與醫療資源耗用之探討

The medical outcomes and resources utilization of Early Goal-Directed Therapy for severe sepsis in Emergency Department

指導教授 : 李易蓁
若您是本文的作者,可授權文章由華藝線上圖書館中協助推廣。

摘要


研究目的 敗血症發生率逐年增加且接近六成病患第一次就診就是在急診;其中嚴重敗血症患者死亡率由35%到67%不等。過去10年國內外對於治療嚴重敗血症強調在急診介入及早目標導引治療。本研究探討介入及早目標導引治療前後治療療效及醫療資源耗用情形。 研究方法 以台灣南部某醫學中心病例資料庫,採用病例回溯分析,並通過人體試驗委員會(IRB)審核。分析2012年1月1日至2013年12月31日在急診就醫之成年符合嚴重敗血症患者資料。以2012年病患為介入前之常規治療組,2013年病患為介入及早目標導引治療之EGDT組。藉由病例回溯審查獲得本研究所需的變項資料進行統計,迴歸分析EGDT和臨床療效與醫療資源耗用之相關性。 研究結果 2012年到2013年共納入1439人次病患,分為介入前常規治療組715人次,以及介入後EGDT組724人次。兩組病患之病患特性和疾病特質(年齡、性別、到院方式、既有疾病、檢傷分類、生命徵象、實驗數據、感染部位、呼吸衰竭、休克以及APACHE II分數)並無顯著差異。EGDT組死亡率顯著下降(常規治療組50.2%,EGDT組30.7%);平均給予抗生素時間縮短超過100分鐘;乳酸濃度廓清率大於10%比例顯著提高(85.6% vs 54.1%)。EGDT組病患住院天數(20 vs 17.7天)和加護病房停留天數(12.3 vs 10.2天)均比常規治療組顯著縮短。經由迴歸分析,介入EGDT皆為降低死亡率,縮短抗生素時間、達成乳酸濃度廓清率大於10%比例及住院天數的獨立相關因子。EGDT組在急診抗生素及急診費用比標準組高,但整體住院費用、抗生素費用及加護病房費用上兩組並無顯著差異。 結論與建議 本研究指出,於急診介入及早目標導引治療,雖急診成本提高,但整體醫療費用並無差異;更重要的是能顯著降低病患死亡率,縮短給予抗生素時間,提高乳酸濃度廓清率大於10%比例及縮短住院天數。急診介入及早目標導引治療可以有效改善嚴重敗血症病患治療療效且減少醫療資源耗用。

並列摘要


Objective The incidence of sepsis increases annually and more than 60% patients initially present to the emergency department (ED) with this syndrome. The mortality of severe sepsis is very high, around 35% to 67% worldwide. In the past ten years, the management to severe sepsis is improving continuously and focuses on the early goal-directed thearpy (EGDT) in the ED. The aim of this study is to determine the effectiveness of treatment and medical resources consumption of severe sepsis before and after the interventon of EGDT. Methods Analysis of 2012-2013 ED data with chart review from a medical center in southern Taiwan and the study had approved by The Institutional Review Board / Ethics Committee (IRB/EC). Patients with consensus criteria for severe sepsis were asigned to usual care group during time period of 2012/01/01 to 2012/12/31; others were asigned to EGDT group after 2013/01/01. Results We enrolled 1439 patients, with 715 assigned to usual care group and 724 to EGDT group; there were no significant differences between the groups with respect to base-line characteristics. In-hospital mortality was 30.7% in the EGDT group, as compared with 50.2% in the usual care. The door-to-antibiotics time in EGDT group improved more than 100 minutes. The percentage of achieving lactate clearance more than 10 percent is significant higher in EGDT group (85.6 % vs 54.1%). EGDT group shortened both the length of stay (LOS) of hospital and ICU as compared with usual group. The intervention of EGDT was the independent factor of reducing mortality, shortening door-to-antibiotics time, achieving lactate clearance more than 10 percent and LOS in regression model. The ED antibiotics and medical costs were higher in EGDT groun than usual care group; however, there were no significal differences in overall hospital costs. Conclusions and Recommendations EGDT in ED provides significant benefits with reducing mortality, shortening door-to-antibiotics time, achieving lactate clearance more than 10 percent and LOS in patients with severe sepsis. Although the initial ED costs are increased, the overall costs are not significant difference.

參考文獻


中文文獻
張宏泰(民99)。醫學中心急診壅塞問題的分析及改善措施之研究-以某醫學中心改善方案為例。國立中山大學高階經營碩士班論文。
網站參考資料
衛生福利部統計處,歷年醫院醫療服務量統計(民國89年-103年)。http://www.mohw.gov.tw/cht/DOS/DisplayStatisticFile.aspx?d=50648
衛生福利部統計處,102年度衛生統計動向,肆、全民健康保險。http://www.mohw.gov.tw/cht/DOS/DisplayStatisticFile.aspx?d=48151

延伸閱讀