影響長期呼吸器依賴病患留置因素與整合式照護之成效分析－以南部某醫學中心為例

Factors Related to Long-term Ventilator-Dependent Patients and the Effectiveness of the Integrated delivery Managed Care –One Medical Center as example

沈連喜(Lien-Shi Shen)

指導教授 ： 張永源

高雄醫學大學/健康科學院/醫務管理學研究所碩士在職專班/碩士(2010年)

摘要

目的
隨著現代醫療進步，加護病房提供對重症病患較好的照護，這些患者一年耗費約佔健保支出的3%。呼吸照護中心主要是提供延長使用呼吸器病患之加強照護。
本研究的目的在於希望藉由回溯性的資料整理與統計後，以瞭解影響呼吸器依賴病患呼吸器脫離、呼吸器脫離後再使用、下轉呼吸照護醫院之相關因子，探討此類病患醫療資源使用情形及其相關影響因素；每位病患至少有一年追蹤期，追蹤該次住院於出院後一年的照護情形。
方法
本研究為回溯性之研究，主要是針對南部某醫學中心，於2008年1月至2008年12月住進呼吸照護中心之病患為主要研究對象，共計283位。以多項式對數迴歸分析、二項式對數迴歸分析與複迴歸分析，探討研究期間病患的人口學特質、使用呼吸器的主要原因、疾病嚴重度及臨床報告，包括過去研究認為可作為預測呼吸器脫離的預測變項，對呼吸器依賴病患RCC照護結果、照護品質和當次住院之醫療費用與住院天數的影響。
結果
研究結果顯示，研究期間病患平均年齡為72±13歲，男性病患164位（58%）多於女性，以內科加護病房所轉入的病患居多（66.1%）；使用呼吸器的主要原因重大病患最多（57.2%），病患疾病嚴重度（APACHE II）平均為16.9±6.4；有24.7% 的病患有作氣切，再次使用呼吸器平均天數18.5±6.4，當次住院出院後一年內的死亡率為59%。
進一步以多項式對數迴歸分析發現，RCC照護結果呼吸器依賴預測因子，在重置組呼吸衰竭（相對危險比：0.16）是其他組的6.13倍、Cr肌酐不正常（相對危險比：0.20）是正常的4.9倍、K鉀不正常（相對危險比：7.12）是正常的7.12倍；成功組呼吸衰竭（相對危險比：0.26）是其他組的3.87倍、Cr肌酐不正常（相對危險比：0.27）是正常的3.77倍、K鉀不正常（相對危險比：3.25）是正常的3.25倍。 另探討病患該次住院及出院後的一年內照護品質有關之主要影響因子，結果顯示氣切、呼吸器脫離中、電解質、氧療用具與介面皆是影響照護品質之重要因子。 而影響醫療資源相關因素中，結果顯示病患是否有氣切、電解質、APACHE II、超期留置因素與RCC照護結果之相互關係，皆是影響病患住院天數和資源耗用之重要因子。此研究結果將可作為呼吸照護中心未來醫療照護品質參考。
結論與建議
本研究證實病患其是否作氣切、是否再次使用呼吸器、APACHE II、超期留置因素、電解質平衡、氧療介面是減少住院天數及醫療資源耗用，最具影響力之變項；因此建議要為呼吸器依賴病患做呼吸器脫離之準備時，能給於足夠的相關訓練，且在疾病病程穩定控制後再進行，同時在拔管後可使用氧氣面罩或非侵入性呼吸器，可降低重插管率，提高病患脫離呼吸器的成功率，進而減少病患住院天數，降低其醫療資源之耗用。
也建議理想的呼吸照護病房之設立，對急性加護病房病床的利用與呼吸器病患的照護會有很大幫助，可提高醫療資源的運用。而醫學中心之RCC病患轉至地區之RCW，能夠縮短醫學中心的天數，使醫學中心之急性和RCC能有效率的運用床位，解決醫學中心長期呼吸器患者滯留現象和減少醫療成本之浪費。

關鍵字

呼吸器依賴 ； 呼吸照護中心 ； 呼吸器脫離 ； 呼吸照護病房 ； 醫療資源

並列摘要

Objectives
The intensive care units provide a good care quality for the critical ill patients in modern medicine. In Taiwan, they cost about 3% of the total medical insurance expense. Respiratory care center (RCC) provide effective care for patients.
The purposes of this study were to understand the factors related to ventilator weaning in patients with ventilator-dependence, the patients re-use the mechanical ventilation after weaning. And the patients are referred between the hospitals. This study is to investigate the utilization of medical resources and its relevant influencing factors for these patients, and track to the best results of these patients within a year after hospital discharge by collecting retrospective data and statistics.
Method
This study is a retrospective study and the research subjects were mainly the patients hospitalized in the respiratory care center in certain medical center in southern Taiwan from January, 2008 to December, 2008. A total of 283 patients were enrolled in this study. Statistical methods such as multinomial logistic regression, binary logistic regression, Multiple linear regression were used to investigate the influences of demographic profiles of patients, main reasons for using ventilators, APACHE II score, and clinical data, including variables identified previously as predictive of weaning success among highly selected populations, outcome analysis, quality of care, medical expenditure, and the inpatient days of ventilator-dependent patients.
Results
The research results indicated that the average age of patients was 72±13 years and the number of male patients was 164 (58%), which was more than female ones; most of the patients (66.1%) were transferred from the internal intensive care unit; the main reason for using ventilators was mostly (57.2%) severity illness included congestive heart failure (CHF); the average disease severity of patients (APACHE II) was 16.9±6.4; 24.7% patients had received tracheostomy; the average re-use the mechanical ventilation days after weaning 18.5±15.4, the mortality of patients after hospital discharge within a year was 59%.
In a multinomial logistic regression analysis, significant predictors of ventilator-dependent, the re-use of mechanical ventilation group included respiratory failure（0dds ratio〔OR〕0.16）、Cr un-normal lever（OR, 0.2）,K un-normal lever（OR,, 7.12）,at RCC admission. the patients successfully weaned group respiratory failure（OR 0.26）,Cr un-normal lever（OR, 0.27）,K un-normal lever（OR, 3.25）. Variables that were found to be significantly related to investigate the main influencing factors relevant to the survival, ventilator dependent or dead of patients after hospital discharge within a year. The results indicated that tracheostomy, long-term use of ventilators reasons, electrolyte, route on transfer were all important factors that influenced the medical care quality of patients. The relevant factors of inpatient days indicated that receiving tracheostomy, electrolyte, APACHE II, respiratory failure, multiple organ failure were all important factors which influenced the inpatient days and the utilization of medical resources of patients. The results could be helpful in the accreditation of medical care quality and may provide for future.
Conclusions and Suggestions
The study showed that the receiving tracheostomy, re-use ventilators, APACHE II, long-term use of ventilators reason , keeping electrolyte balance, route on transfer, significant predictors factors relevant to the decrease inpatient days, and reduce the cost of medical resources. It is suggested that when preparing for weaning ventilator-dependent patients from ventilators, it is necessary to provide patients with enough relevant training and the weaning shall be conducted after patients’ condition is steadily controlled. The O2 face tent or Mask–BiPAP was applied after extubation, could be reduced the re-intubations rate.
The optimal function of respiratory care center could be maintained. The outcome of patients with long-term ventilator dependence in local hospital is as good as those in medical center. In addition, the total hospital days in medical center could be reduced, the bed utilization rate of medical ICU and RCC could be elevated, the ventilators and acute ward could save more acute-illness patients. Therefore, the limited health resources could be best utilized.

並列關鍵字

ventilator-dependent ； Respiratory Care Center, ventilator weaning ； Respiratory Care ward ； medical resources

參考文獻

中文部份

1. 于煥中、吳清平、葉秀逸、王如華 (2000) 以護理觀點談呼吸照護中心成立的初步經驗•Taiwan Critical Care Medicine, 2, 91-99。

2. 中央健康保險局『我國全民健康保險與各國健康照護服務系統現況比較』。

3. 中央健康保險局（2009）即時統計資訊，全民健康保險重大傷病證明實際有效領證統計表 (98年11月)。

http://www.nhi.gov.tw/webdata/webdata.asp?menu=1&menu_id=4&webdata_id=805&WD_ID=4