臨床路徑運用於骨折患者體液管理及社區藥局發展之探討

研究背景：由四肢骨折患者的體液管理之平均輸液量及數據來探討國內健康保險財務方面的困難點。目的：這是回溯性的臨床研究，探討著骨折手術病人的體液管理其疾病診斷關係群(DRG) 付費論病例計酬制的例行性事務。這是針對全民健康保險體系為廣泛的評論觀點。材料與方法：由南區某教學醫院於西元2000年1月至2003年12月期間，研究統計接受骨折外科手術的患者總人數共6017位。健保之疾病診斷相關組群(DRG)付費論病例計酬制中離子在正常範圍的個案共有5902件（98﹪），而不在正常範圍則有115件（2%），且這些不在正常範圍因素包含嚴重情況、合併性創傷及營養貧乏。採取手術前後血液樣本並記錄其變化。對於須補充流失的體液是依據體液之電解質組成、血清電解質的測量法及臨床血管內容積的估算。結果：經研究顯示在健保之疾病診斷相關組群(DRG)付費論病例計酬制的個案中並無電解質明顯的差異變化，其平均點滴輸液量為1988.67 ml(1000-3000ml/day)，及合理的維持尿液輸出量0.5–1.0ml/kg/hour(1000-1500ml)。低血鈉是非DRG個案中最常見的情況。而2002年3月至2002年12月是亞洲傳染性SARS危險期，這因素主要影響著醫院的數據、資料以及拖延了住院天數。結論：大多數個案必須例行給予血管內所需的點滴輸液量，但對於嚴重個案就必須猶如營養補給般精算給予點滴輸液量來挽救生命。醫療的經費是一年又一年的支出、消耗，政府必須合理地制定規範來維持健康照護的品質，但這卻是相當難辛的工作。

關鍵字

手術；體液管理；臨床路徑；低血鈉；骨折

並列摘要

Background: The financial difficultly of National Health Insurance have revealed some points on the index and data of body fluid management of the case of fractured extremity. Objective: This retrospective study discusses a routine work about the fluid management of Diagnosis-Relate-Groups fractured cases in the regional hospital. There are extensive views to the whole national health insurance system. Materials and Methods: There were totally 6017 cases, during January-2001 and December-2003, accepted orthopedic operation. The Diagnosis-Relate-Groups cases were about 5902 (98%) people, the rest 115 (2%) cases got more severe condition、combined trauma and poor nutrition. The blood samplings were done before and after the operation. Replacement of prior fluid losses based on known electrolyte composition of the body fluid, serum electrolyte measurement, and clinical assessment of intravascular volume status. Result: In Diagnosis-Relate-Groups cases, there was no obvious change of electrolyte. Average maintenance fluids were 1988.67 ml (1000-3000 ml/day) and maintain urine output of 0.5-1.0 ml/kg/hour (1000-1500 ml) reasonable. Hyponatremia were the most common condition in the non-Diagnosis-Relate-Groups cases. The Asia infectious crisis, severe acute aspiratory syndrome (SARS), was a major influence about the hospital data and prolongs hospital days (from March-2002 to December-2002). Conclusion: Majority cases need the routine fluid input for intra-vascular dosage but the severe cases need the exactly fluid support for life saving even the nutrition support. The medical budget expenses year by year, the government must reasonably formulate the procedure to keep the quality of the health care. But it is very hard work.