探討呼吸器相關肺炎之醫療資源耗用與醫療療效-長期縱貫性研究

Medical Resource Utilization and Outcomes in Ventilator-Associated Pneumonia: A Longitudinal Study

李明璋(Ming-Jang Lee)

指導教授 ： 李金德

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士在職專班/碩士(2013年)

摘要

摘 要
研究目的
呼吸器相關肺炎(Ventilator-associated pneumonia,VAP)造成住院日數延長及死亡率增加,欲藉由服務醫院收集相關病例找出重要影響因子，改善臨床工作，增進臨床品質。本研究目的在於探討呼吸器相關肺炎之趨勢，及影響醫療資源耗用和醫療療效之重要因子。
研究方法
本研究針對南部某區域教學醫院之成人加護病房住院患者，其罹患呼吸器相關肺炎為對象，以收集西元2005年1月至2012年12月期間病歷資料登錄表，作回溯性資料研究分析。共收錄276位病例。以醫院感控室的蒐集相關病例，由專人依研究變項一一抄錄相關數據資料進行研究。業已通過高雄醫學大學附設中和紀念醫院人體試驗審查委員會，同意進行臨床試驗，IRB編號：KMUH-IRB-20120429。P值小於0.05定義為統計學上顯著意義。
研究結果
呼吸器相關肺炎病人中使用呼吸器原因為外傷者(OR 3.80)及神經科病人(OR 2.30)比率，隨時間傾向有增加之趨勢；感染菌種ORSA(OR 0.17)及使用呼吸器日數超過22天者(OR 0.43)，隨時間傾向有減少之趨勢；住院日數≦30天(OR 1.76)有增加之趨勢，住院日數>30天(OR 0.44)有減少之趨勢。接受手術(P=0.041)、白血球異常(P=0.006)、使用呼吸器日數(P<0.001)、從住院至感染日(P<0.001)及從使用呼吸器至感染日(P<0.001)皆顯著影響住院日數。罹患心臟病者(P=0.012)、接受手術(P<0.001)、抗生素使用(P=0.045)、使用呼吸器日數(P<0.001)、從住院至感染日(P<0.001)，從使用呼吸器至感染日(P<0.001)及外科患者(P=0.044)皆顯著影響住院總費用。罹患腎臟病(P=0.004)、上消化道出血(P=0.003)及人工氣道選擇插管再加氣切(P=0.001)皆顯著影響住院期間死亡。罹患腎臟病(P=0.011)、接受輸血(P<0.001)、人工氣道選擇插管再加氣切(P<0.001)及使用呼吸器至感染日(P<0.001)皆顯著影響呼吸器依賴。人工氣道選擇插管再加氣切(P=0.025)及外科病人(P=0.047)皆顯著影響轉至呼吸照護病房(RCW)之比率。
結論與建議
本研究蒐集台灣南部某區域教學醫院之加護病房住院患者，罹患呼吸器相關肺炎住院資料進行統計分析，找出八年期間之趨勢以及影醫療資源耗用及醫療療效的重要因子，期望能提供醫療單位制訂更精準的政策及專業人員訓練方向，以增進醫療品質。

關鍵字

呼吸器相關肺炎 ； 醫療資源耗用 ； 醫療療效 ； 長期縱貫性研究 ； 加護病房 ； 區域醫院

並列摘要

Abstract
Objectives
Ventilator-associated pneumonia (VAP) causes prolonged lengths of stay (LOS) and increases mortality. In this study, cases were collected by providing services at a regional hospital in order to identify the important factors that contribute to the development of VAP . The aims of this study were to analyze the trend of VAP and to explore the key factors affecting medical resource utilization and medical efficiency.
Methods
Adult ICU patients admitted to a regional teaching hospital in southern Taiwan. The 276 subjects' medical records between January 2005 and December 2012 were retrospective collected. Relevant cases obtained from the Office of Infection Control were copied in detail according to the variables specified in this study.It was approved by the IRB of Kaohsiung Medical University Chung-Ho Memorial Hospital. A p-value <0.05 was defined as statistically significant.
Results
The ratios of patients with VAP due to trauma(OR 3.80) and who were from the Department of Neurology(OR 2.30) increased .The ratios decreased with bacterial infections of ORSA(OR 0.17) and who used mechanical ventilator for more than 22 days(OR 0.43).The LOS have reduced as well≦30days(OR 1.76) >30days(OR 0.44). Surgery(P=0.041), abnormal leukocytes(P=0.006), durations of mechanical ventilation(P<0.001), durations from the admission date to the infection date(P<0.001) durations from the start date of mechanical ventilation to the infection date(P<0.001) had significant impacts on LOS.Heart diseases(P=0.012), surgery(P<0.001), use of antibiotics(P=0.045), durations of mechanical ventilation(P<0.001), durations from the admission date to the infection date(P<0.001), durations from the start date of mechanical ventilation to the infection date(P<0.001) and being a surgical patient(P=0.044) all had an effect on the total hospital costs.Kidney diseases(P=0.004), bleeding of the upper gastrointestinal tract(P=0.003), and artificial airways with intubation and tracheostomy(P=0.001) all significantly increased mortality rates during hospitalizations.Kidney diseases(P=0.011), blood transfusions(P<0.001), artificial airways with intubation and tracheostomy (P<0.001)as well as durations from the start date of mechanical ventilation to the infection date(P<0.001) were found to greatly affect ventilator dependence as well. Artificial airways with intubation and tracheostomy(P=0.025) and being a surgical patient(P=0.047) are both highly associated with the rates of patients transferred to respiratory care ward (RCW).
Conclusions and Suggestions
We identified the key factors that affect medical resource utilization and medical efficiency. It is hoped that the results obtained may help to improve the quality of medical care by providing healthcare providers with the information to implement precise policies as well as to provide guidance on the training of healthcare professionals.

並列關鍵字

ventilator-associated pneumonia (VAP) ； medical resource utilization ； medical efficiency ； long-term longitudinal study ； intensive care unit (ICU) ； regional hospital

參考文獻

參考文獻

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