手術排程效應和預防性抗生素對腹腔鏡全子宮切除手術醫療品質增進的研究

Quality-initiated Study of Schedule Effect and Prophylactic Antibiotic Use in Laparoscopic-Assisted Vaginal Hysterectomy

張維君(Wei-Chun Chang)

指導教授 ： 林隆堯

中山醫學大學/醫學院/醫學研究所/博士(2009年)

https://doi.org/10.6834/CSMU.2009.00030

摘要

研究目的：本研究旨在分析導出手術排程(schedule effect)對於接受腹腔鏡全子宮切除手術LAVH(laparoscopic-assisted vaginal hysterectomy)病人術中和術後醫療照護品質可能的影響。另對於以實證為基礎的預防性抗生素(prophylactic antibiotic)減量使用的品質改善(quality improvement)活動在腹腔鏡全子宮切除手術 LAVH(laparoscopic-assisted vaginal hysterectomy)的傷口和尿道感染預防，做成本效益分析研究。
研究方法及材料：本研究是依據某醫學中心病人病歷記載和醫院電子資料庫的回溯世代研究(retrospective cohort study)。一共有因婦科良性疾病接受LAVH的接續217位婦女，其中159位根據手術開始的3個不同時段而區分為3組，而有同一位主刀醫師的110位同樣地分為3組，關於他們術中及術後的醫療品質照護結果(operative and medical outcomes)做比較並以one-way ANOVA和卡方檢定(chi-squared test)做統計分析。另針對預防性抗生素共收集了310位接續於某醫學中心接受腹腔鏡全子宮切除手術的病人，依其使用壹劑或多劑預防性抗生素分為兩組，並觀察紀錄比較於住院中及出院後壹個月內發生骨盆腔炎或膿瘍、陰道頂部發炎、傷口感染和泌尿道感染的情形；計算兩組平均藥價和感染預防效果的ICER (incremental cost-effectiveness ratio)。
研究結果：不管是159位或110位兩組發現3個不同的手術排程(劃刀時間)對於平均住院日、血清血色素的改變量、血清血比容的改變量、術後排氣時間、術中失血量、輸血率、術後點滴使用超過2天和併發症發生率，都沒有統計上的差別；有趣的是劃刀時間在8：30到10：29之間的，其平均手術時間最長；而劃刀時間在下午15：30到17：29之間的，其平均手術時間最短。而在預防性抗生素方面，使用單一劑和多劑(2~4劑)預防性抗生素的兩組其感染預防效果沒有統計上的差異(94.6% vs. 93.9%，p＝0.986)，而且ICER在單一劑量組有意義地減少(153.3 vs. 460.4，p<0.001)。
結論與建議：在工作白天內不同的劃刀時間，對於接受腹腔鏡全子宮切除手術的婦女之術中、術後醫療照護的結果並沒有差別影響；不過實務上成功安全的腹腔鏡手術，臨床專家仍強調需要一個良好訓練又多元組合(multi-disciplinary)的紮實醫療團隊來執行。而單一劑量預防性抗生素在腹腔鏡全子宮切除手術是足夠且具成本效益 的(cost-effective)，在當今醫療資源受限的情況下，不僅維繫好的病人照 護品質且可節制適當的成本。

關鍵字

腹腔鏡全子宮切除手術

並列摘要

Background: Prolonged surgical workload and different starting times of
laparoscopic-assisted vaginal hysterectomy (LAVH) might be factors influencing
surgical and patient´s outcomes. Also an evidence-based initiation of quality improvement activity for reducing the usage of prophylactic antibiotic in laparoscopic-assisted vaginal hysterectomy (LAVH) was studied.
Aims: The aim of this study is to elucidate possible detrimental results of the
schedule effect on laparoscopic-assisted vaginal hysterectomy (LAVH) . The authors also investigated whether single or multiple doses cefazoline were more cost-effective in preventing postoperative infection associated with LAVH
Methods: Retrospective cohort study based on patient charts and hospital´s
electronic database in a tertiary teaching hospital . A total of 217 consecutive women
who underwent LAVH for gynecological diseases were enrolled . Among them , 159
LAVHs performed by four surgeons were divided into three groups according to three
different starting times of the operation . Among 159 LAVHs , 110 performed by the
same surgeon was divided into three groups in the same way . Variables related to
operative and medical outcomes were compared and analyzed by one way ANOVA
and chi-squared test . The prophylactic antibiotic study group comprised of 310 patients who had undergone LAVH continuously in the same center. Patients were divided into two groups on the basis of whether they received a single dose or multiple doses (range : two or four doses) of cefazoline during the perioperative period. Postoperative infections such as pelvic cellulitis or abscess, vaginal cuff abscess, wound infection and urinary tract infection that occurred either during hospitalization or within one month after discharge were observed and record. Incremental cost-effectiveness ratio (ICER) was calculated using the mean direct durg cost and the prophylactic effect of infection in both groups.
Results: Data on both all women(159 cases) and subgroup women (110 cases)
revealed that no statistical significant differences among the three groups including
length of hospital stay、shift of serum hemoglobin、shift of serum hematocrit、
flatulence-relief time、surgical blood loss、blood transfusion rate、rate of postoperative
fluid injection over two days after surgery or complication rate . Interestingly , the
first LAVH scheduled within the AM8:30 to 10:29 time slot had the longest mean
operation time . LAVHs starting within the PM15:30 to 17:29 time slot had the
shortest mean operation time . And the prophylactic effect of infection was similar in the single dose group and the multiple-dose group (94.6% vs 93.9% , P=0.986) . The ICER was significantly lower in the single-dose group (153.3 vs 460.4 , P<0.001) .
Conclusion: The time of day in which LAVH is performed does not have a
detrimental effect on outcome. Clinical experts suggest that successful LAVH is dependent on multidisciplinary team work to achieve good surgical and patient outcomes . And the result of prophylactic antibiotic study revealed that a single dose of cefazoline is more cost-effective than multiple doses in the prevention of infection associated with LAVH. It fulfils the goal of cost minimization and quality of care in today's environment of medical cost containment

並列關鍵字

Laparoscopic-Assisted Vaginal Hysterectomy

參考文獻

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