住院手術病人非計畫性重返手術室醫療品質 及醫療資源耗用之探討~以南部某醫學中心為例

Study of the quality of medical care & medical resources utilization for inpatients of unplanned returns to operating room--- An example of one southern medical center

劉麗珒(Li-Ching Liu)

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(2006年)

摘要

目 的:
本研究目的係探討住院手術病人非計畫性及計畫性重返手術室之基本屬性、手術後醫療品質及醫療資源耗用指標構面之比較，並探討有關危險因子，以找出可顯著預測醫療品質指標與醫療資源耗用指標構面之因子。
方 法:
採準實驗研究，資料來源為南部某醫學中心於93年9月1日至94年8月31日住院手術病人，研究對象共516位。資料經由整理比對除誤後，以Microsoft® Excel 2003與SPSS for Windows10.0版套裝軟體進行描述性及推論性分析比較。
結 果:
結果發現：（一）基本屬性方面：非計畫性及計畫性重返手術室病人在傷口分類、麻醉方式、手術次數及手術時間達顯著相關或差異；在手術科別定及麻醉危險程度未達顯著相關性。（二）醫療品質指標構面：總住院天數及住加護病房天數，非計畫性重返手術室病人顯著高於計畫性重返手術室病人兩組達顯著差異；手術後存活比率並不會因非計畫性重返與計畫性重返手術室而有明顯相關。（三）醫療資源耗用指標構面：總住院費用及手術費用非計畫性重返手術室顯著高於計畫性重返手術室病人達顯著差異。（四）影響非計畫性重返手術室有關危險因子：（1）總住院天數危險因子為手術科別、麻醉方式、手術次數及麻醉危險程度；（2）加護病房天數危險因子為手術科別、麻醉方式、手術次數及麻醉危險程度；（3）手術後存活危險因子為麻醉危險程度；（4）住院醫療費用危險因子為手術科別、麻醉方式、手術次數、麻醉危險程度及手術時間；及（5）手術費用危險因子為手術科別、麻醉方式、手術次數及手術時間。（五）醫療品質指標與醫療資源耗用指標構面之顯著預測因子，以複迴歸及複對數迴歸分析預測因子為結果：（1）總住院天數子為組別及手術次數；（2）加護病房天數為組別及手術科別；（3）死亡狀態（死亡vs.存活）為手術科別、麻醉危險程度及手術時間；（4）總住院醫療費用為手術科別、傷口分類、手術次數及手術時間；而（5）手術費用為組別、麻醉方式、手術次數及手術時間。
結論與建議:
由結果得知，非計畫性重返手術室病人於醫療品質指標構面及醫療資源耗用指標面的確比計畫性重返病人於品質面及資源耗用面來的高。故仍須持續落實醫療品質監測，除了可節省醫療資源耗用外亦可對手術醫療品質有保障，因此，在手術全期醫療照護過程仍需加以審慎評估及照護，以促進醫療品質提升。另未來可再對該兩組病人進行手術困難度及手術危險度分數評估之比較，並建議院方未來可對該指標成效進行個別性科別輔導。
關鍵詞：非計畫性重返手術室、醫療品質、醫療資源耗用

關鍵字

非計畫性重返手術室 ； 醫療品質 ； 醫療資源耗用

並列摘要

Abstract
Objective:
The unplanned return to the operating room is inevitable; however, it is still adopted as one of quality indicators for surgical medical treatment. Therefore, this study is to explore the basic attributes and the comparison of indicator components between medical treatment quality after surgery and medical resource utilization in terms of in-patients of both unplanned and planned returns to the operating room. Meanwhile, probing the relevant risk factors is able to locate the indicator-component factors which can significantly predict the medical treatment quality and medical resource utilization.
Methods:
Among in-patients in one southern medical center from Sep 1, 2004 to Aug. 31, 2005, 516 patients were screened (256 for unplanned & 256 for planned) with the quasi-experimental design. Patients’ data, after being processed, debugged and matched, are proceeded by descriptive and theoretical comparison and analysis by means of software of Microsoft® Excel 2003 & SPSS for Windows 10.0.
Results:
1. Basic attributes aspect：In-patients of unplanned and planned return to OR show significance or variation in terms of surgical wound classification, mode of anesthesia, number of operation and operation time. But there’s no significant difference on surgical specialty and anesthesia risk class.
2. Indicator component of medical treatment quality: As to the total length of stay (LOS) and ICU LOS, the group of unplanned return to the OR is higher than the planned-return group. In addition, these two groups also show significant difference on LOS & ICU LOS. Neither unplanned nor planned return to the OR group shows significance on survival rate after surgery.
3. Indicator component of medical resource utilization：For total hospitalization fees and operation expenses, patients of unplanned return to the OR are higher than those of planned return to the OR with significance.
4. The relevant risk factors which affect unplanned return to the OR: (1) The risk factors for total LOS are surgical specialty, mode of anesthesia, number of operation and anesthesia risk class (2)ICU LOS：surgical specialty, mode of anesthesia, number of operation and anesthesia risk class. (3)Survival risk factor after surgery：anesthesia risk class. (4) Hospitalization fees：surgical specialty, mode of anesthesia, number of operation, operation time and anesthesia risk class. (5) Operation expense：surgical specialty, mode of anesthesia, number of operation and operation time.5. Significant predicting factors for medical quality indicator and medical resource utilization are analyzed by multiple regression and the results are：(1) The predictive factors for total LOS are group and number of operation; (2) ICU LOS：group and surgical specialty; (3) Mortality (death vs. survival)：With multiple logistic regression, the predicting factors are surgical specialty, anesthesia risk class and operation time; (4) Total hospitalization fees：surgical specialty, surgical wound classification, number of operation and operation time; (5) Operation expense：group, mode of operation, number of operation and operation time.
Conclusion & Suggestion:
For indicator components of medical treatment quality and medical resource utilization, patients of unplanned return to the OR are indeed higher than those of planned return. Therefore, the quality surveillance for medical treatment is consistently carried out. Thus this can not only save the medical resource utilization, but also the quality of surgical medical treatment is guaranteed. Consequently, the duration of perioperative medical care is required for deliberate evaluation and monitoring to advance the medical treatment quality. Furthermore, for these two groups, the evaluation comparison of operation difficulty and operation risk scale is suggested in the near future. Meanwhile, that the individual counseling for each surgical specialty is implemented based on the indicator outcome might be proposed to this hospital center.

Key words：unplanned return to the operating room、quality of medical treatment、utilization of medical resource

並列關鍵字

unplanned return to the operating room ； quality of medical treatment ； utilization of medical resource

參考文獻

參考文獻

中文部分

田芳南(1993)•大型醫院手術室空間配置及業務量之分析•未發表的碩士論文•台北：國立台大公衛學院。

陶阿倫、薛亞聖(2003)•非計畫性重返病人特質及其資源耗用研究-以加護病房為例•於財團法人醫院評鑑暨醫療品質策進會，醫療品質指標理論與運用（209-223頁）•台北：合記。

廖熏香(2003)•品質指標實務應用研究•於財團法人醫院評鑑暨醫療 策進會，醫療品質指標理論與方法(31-51頁)•台北：合記。