台灣長期呼吸器依賴病患IDS整合性照護計畫下呼吸照護病房(RCW)照護結果之分析-以中部地區七間醫院為例

Outcome Evaluation of the Respiratory Care Ward under Integrated Delivery System (IDS) for Long-term Ventilator-dependent Patients in Taiwan- Experiences from Seven Regional Hospitals in Central-Taiwan

林燕堂(Yen-Tang Lin)

指導教授 ： 譚秀芬

長榮大學/健康科學學院/醫務管理學研究所/碩士(2007年)

https://doi.org/10.6833/CJCU.2007.00091

摘要

背景: 健保局自1998年起推動「呼吸器依賴患者整合性照護」(IDS)，給付論人計酬(Capitation)後，呼吸照護病房(Respiratory Care Ward)如雨後春筍般的劇增；由2001年的1,046床，2003年10月3,256床，增加至2005年11月的4,511床。長期使用呼吸器重大傷病卡的病患，由1998年1月6,111人至2003年8月增加為25,805人，成長約3.2倍。致使中央健保局採用定額論人計酬，並於2004年再推出呼吸照護病房(RCW)品質審查分級制度。呼吸照護病房之醫療服務，在面對給付制度的變革之後極可能產生較大變化。關於呼吸照護病房照護之品質與現況調查，美國雖於1985年之後，陸續已有多篇文獻報告，但反觀國內相關之文獻報告尚付之闕如，為能瞭解新制度下之呼吸器依賴患者之照護結果，及評估整合性照護試辦後之影響，本研究進行深入之研究分析，希望藉此瞭解此類病患之長期發展和預後，以提供衛生單位作為未來健康照護之預估、規劃及管理等政策之制定；更希望可以提供健康醫療機構施行照護時之參考。

目的: 本計畫之目的在於希望藉由回溯性的資料整理與統計後，得以瞭解健保局自1998年起推動的四階段呼吸衰竭病患的照護系統(通稱Integrated Delivery System; IDS)，且於2000年施行「呼吸器依賴患者整合性照護試辦計畫」後，長期呼吸器依賴病患之結果。主要藉以瞭解病患呼吸器之脫離率、脫離所需之間期、死亡率、存活曲線、回轉ICU之比例以及下轉Home Care之比例。此外；更深入探查此類病患照護階段中常見之合併症，如院內感染密度、常見感染部位、菌株，及三級以上(含三級)壓瘡盛行率等。希望藉此建立未來評估長期呼吸器依賴病患健康照護之可能指標，以及提供健康照護機構改善照護品質時之參考。

方法: 採回溯性長期縱貫型研究(Retrospective Longitudinal Study)，研究對象包括過去兩年（2005-2006）中區七個地區醫院呼吸照護病房(RCW)(分屬健保局呼吸器照護品質審查分級A級與B級)，院內符合IDS收案之所有住院中之病患。研究資料為院內登錄每名病患之病歷資料，包括病情指標、院內感染監控記錄、檢驗室結果、病況統計月報表等。預計評估之變項將包括病患呼吸器脫離率、脫離間期、三級以上(含三級)壓瘡盛行率、院內感染發生密度、院內感染次數、部位別與菌株分佈情形、回轉ICU之比例以及下轉Home Care之比例。此外，本研究將估算此類長期呼吸照護病患之呼吸器脫離率與死亡率，使用SPSS 10.0版軟體之Kaplan-Meier 統計分析其病患呼吸器脫離曲線與病患存活曲線。並且利用Cox Regression 統計，分析疾病因子總數以及多重疾病因子與個案住院後存活之相關性。

結果：本研究全體樣本625人，總住院人次771人次。病患平均年齡為72.4歲(±13.8)
，男性占62.1％(n=388)，女性為37.9％(n=237)。呼吸照護病房(RCW)之照護結果，
以625人統計,呼吸器脫離成功47人，呼吸器脫離率是7.5％，平均成功脫離呼吸器之
天數是174天(±194)；住院死亡與病危自動出院共205人，病患死亡率為32.8％，平
均死亡天數是323天(±417)。以總住院771人次計算，轉出繼續治療者有234人次
(30.35％)，其中包括回轉ICU治療182人次(23.61％)，平行轉其他RCW和一般病房
有44人次(5.71％)，回轉急診處理後再入院者有5人次，轉入護理之家1人次(0.13
％)，下轉居家呼吸照護(Home Care)治療者 2人次(0.26％)。平均每人次住院天數為
395天(±441)。
47位成功脫離呼吸器之個案中，有51％病患(n=24人)是於轉入RCW三個月內成功
脫離，半年內脫離者約有65％(n=31人)。若依病患轉入來源不同分成ICU轉入與非ICU轉入，比較此二組之呼吸器脫離曲線，則結果並無統計學上顯著之差異(Log Rank:1.75， df:1，P:0.1854)。
住院合併症以771住院人次計算，三級(含以上)壓瘡之盛行率是12.97％，平均每
人次治療月數需1.82個月，但實際於機構內產生之壓瘡發生比率為3.76％。RCW總體院內感染發生密度2005年是4.82?漶A2006年為7.79?漶C2005年與2006年呼吸照護病房(RCW)之院內感染部位，連續二年均為泌尿道感染最常見，其次是呼吸道，以及皮膚
及軟組織。前三名的感染菌株依序是為G(-) Escherichia coli、G(-) Proteus
mirabilis、和G(-)Pseudomonas aeruginosa。
呼吸照護病房(RCW)病患之總體存活率，於入院6個月時為84％，一年存活率為77％，二年存活率63％，三年存活率57％，五年存活率為45％。總體中位存活(存活率為50％時)之平均存活年數為4.1年。若依病患轉入來源不同分成ICU轉入與非ICU轉入組兩組之Kaplan-Meier分析結果，並無統計學上顯著之差異 (Log Rank: 10.79, df:1 , P=0.2958)。若依個案進入ICU時之原始使用呼吸器診斷分成1.急性肺疾2.COPD (慢性阻塞性肺疾) 3.神經肌肉性疾病4.重大手術後.5.心血管疾病6.感染性疾病等六個群組，此六組病患於RCW之存活曲線，在統計學上並無顯著之差異(Log Rank: 10.95，df:5，P:0.0558)。但是以第一年存活率來看，慢性肺疾(COPD)組最高(91％)，心血管疾病最低(42％)；二年存活率則是感染疾病組(75％)高於其他組，最低仍是心血管疾病組的31％。存活中位數則是以重大手術後組之5.36年為最長；心血管疾病組的0.95年為最短。
以Cox Regression 統計分析，呼吸照護病房(RCW)病患入院時存有之疾病數與住院後之存活，無統計學上顯著之相關；但是以多重疾病因子分析其與病患之存活，則結果發現1. 在其他條件相同下，年齡因子與住院後之存活有顯著相關，年齡每增加一歲其住院後之死亡危險比增高1.020倍(P<0.01)。2.當其他條件相同下，存有腎疾疾病與住院後之存活，統計學上有顯著之相關(P< 0.05)，當性別與年齡相同條件下，病患入院時有腎疾者其住院後死亡危險比是無腎疾者之1.719倍。3.當其他條件相同下，存有COPD與住院後之存活，統計學上有顯著之負相關(P< 0.05)，當性別與年齡相同條件下，病患入院時有COPD者其住院後死亡危險比是無COPD之0.725倍。---
結論: 台灣施行「呼吸器依賴患者整合性照護」(IDS)制度下，由於呼吸照護病房(RCW)
收案之個案許多基本資料面，以及健康保險支付制度，與美國長期呼吸照護機構迥異，
因此兩者照護結果，無法適切地相互比較。RCW三級壓瘡之盛行率為12.97％，平均每人次治療月數需1.82個月，壓瘡預防流程宜列入呼吸照護病房照護重點；本研究發現實際於機構內產生之壓瘡發生比率則是3.76％，若以現存的壓瘡人數計算盛行率，未區分病患是轉入前發生或轉入後在機構內發生，此僅可以反應呼吸照護病房壓瘡的現況，但並無法真實的反應該醫療機構的照護品質。呼吸照護病房(RCW)之院內感染部位，連續二年均是以泌尿道感染為首，因此照護此類長期呼吸器依賴病患，泌尿道之感染防制是首要目標。本研究中總體之一年存活率77％；依病患轉入來源不同分成ICU轉入與非ICU轉入，此二組病患之存活曲線，並無統計學上顯著之意義 。若依個案進入ICU時之原始使用呼吸器診斷分成六個群組，其存活分析在統計學上雖無顯著之差異 (Log Rank:10.79，df:5，P:0.0558)；但第一年存活率最高者為COPD組，最低者為心血管組。中位存活年數最高則是重大手術後組5.36年，最低者為心血管組之0.95年。以Cox Regression 統計，作多重疾病因子與病患之存活分析，則結果發現病患入RCW時的年齡與是否存有腎疾和COPD與住院後之存活均有顯著之相關(P=0.002，P=0.013)。

關鍵字

呼吸照護病房 ； 長期呼吸器依賴 ； 照護品質 ； 院內感染

並列摘要

Background
Since 1998 when the Bureau of National Health Insurance (NHI) launched the Integrated Delivery System (IDS) for ventilator-dependent patients, respiratory care services have been paid by capitation and respiratory care wards have increased from 1,046 beds in 2001 to 3,256 beds in October 2003, and then to 4,511 beds in November 2005. The number of holders of IC Card for Severe Illness (Long-term Ventilator Dependence) increased from 6,111 in January 1998 to 25,805 in August 2003, or 3.2 times growth. Hence, NHI adopted co-payment and capitation, and in 2004 NHI launched the Respiratory Care Ward (RCW) Quality Assessment and Rating System. Medical services provided in respiratory care wards are likely to change considerably in the face of a payment system reform. Several papers on the profile and care quality of respiratory care wards were published in the United States after 1985 but none in Taiwan. In this study, we shall analyze the outcome of respiratory care provided for ventilator-dependent patients under the new system and assesses the effect of integrated delivery system with a view to gain insight into long-term care and prognosis of the patients, and in hopes of improving future policymaking by the health authority regarding prediction, planning, and management of health care, and providing clinical references for health care institutions.

Objectives
An objective of this study is to conduct a retrospective study and statistical analysis in order to investigate long-term ventilator-dependent patients’ prognosis after NHI launched the 4-phase Integrated Delivery System (IDS) for respiratory failure patients in 1998 and launched the Preliminary Integrated Delivery System (IDS) for ventilator-dependent patients in 2000. The ventilator weaning rate, time required for weaning, mortality, survival curve, ICU readmission rate, reasons for readmission to ICU, and home care referral rate are the analytic factors. Another objective of this study is to further investigate common complications in ventilator-dependent patients, such as nosocomial infection density, common sites of infection, bacterial strains, and prevalence rate of pressure sores of the third degree or higher. Hopefully, possible indices for future assessment of the respiratory care provided for long-term ventilator-dependent patients can be created, and clinical references can be provided for health care institutions in enhancing care quality.

Methods and Materials
This study was retrospective longitudinal study, and the subjects consisted of all the patients admitted to respiratory care wards (RCW) of seven regional hospitals in central Taiwan under the Integrated Delivery System (IDS) over the past two years ( 2005-2006 ). Research is conducted on medical records kept by the hospitals, including monthly statistics, nosocomial infection monitoring records, laboratory data, etc. Variables for assessment are, namely ventilator weaning rate, prevalence rate of pressure sores of the third degree or higher, nosocomial infection density, distribution of bacterial strains, ICU readmission rate, and home care referral rate. Also, this study performs statistical analysis of the patients’ ventilator weaning curve and survival curve by the Kaplan-Meier method using SPSS 10.0 statistical software, providing the ventilator weaning rates and mortality of the long-term ventilator-dependent patients. The post-admission survival correlation between the total number of diseases, multiple risk factors is studied by Cox regression analysis.

Result
This study shows that the subjects totaled 625, admissions totaled 771, aged 72.4±13.8 on average, 62.1% male (n=388), and 37.9% female (n=237). As regards the outcome of care delivery in respiratory care wards (RCW), among the 625 patients, 47 (7.5%) were successfully weaned from ventilator after a mean time of mechanical ventilation of 174±194 days, 205 either died in hospital or were discharged from hospital for being dying, and, with a mortality rate of 32.8%, the patients had lived for 323±417 days on average before their decease. Among the 771 admissions, 234 (30.35%) were discharged from hospital for continued treatment, including 182 (23.61%) readmissions to ICU, 44 (5.71%) referrals to other respiratory care wards and general wards, five readmissions to ER immediately followed by readmission to hospital, one (0.13%) referral to a nursing home, and two (0.26%) referrals to respiratory home care.
Among the 47 patients who were weaned from ventilator successfully, 24 (51%) were weaned from ventilator within three months after admission to RCW, and 31 (65%) were weaned from ventilator within six months after admission to RCW. According to admission sources, the patients were classified into two groups, namely “patients from ICU” and “patients not from ICU”. There were no statistically significant difference on the ventilator weaning curves between the two groups’ (Log Rank: 1.75, df:1, P=0.1854).
As regards complications arising from hospitalization, the prevalence rate of third-degree pressure sores was 12.97%, and treatment for the pressure sores took 1.82 months per person-time on average. Nosocomial infection density was 4.82?? in 2005 and 7.79?? in 2006. As for the sites of nosocomial infection in the respiratory care wards (RCW) of the regional hospitals during the two straight years of 2005 and 2006, the urinary tract infection were the mostly common, followed by the respiratory tract, skin and soft tissue. The three frequent bacterial strains were G(-) Escherichia coli, G(-) Proteus mirabilis, and G(-)Pseudomonas aeruginosa.
The patients survival in respiratory care wards (RCW) were, namely a 6-month survival rate of 84%, a 1-year survival rate of 77%, a 2-year survival rate of 63%, a 3-year survival rate of 58%, and a 5-year survival rate of 45%; the median survival time was 4.1 years. According to admission sources, the patients were classified into two groups, namely “patients from ICU” and “patients not from ICU”, Kaplan-Meier survival analysis of the two groups did not reveal any statistically significant difference (Log Rank: 1.09, df:1, P=0.2985). When the patients were classified according to the primary diagnosis given to the ventilator-dependent patients by ICU into six groups accordingly, namely acute lung diseases, chronic obstructive pulmonary diseases (COPD), neuromuscular diseases, after major surgery, cardiovascular diseases, and infectious diseases, survival analysis of these six groups in RCW did not reveal any statistically significant difference (Log Rank: 10.79, df:5, P=0.0558). However, 1-year survival rate turned out to be the highest in the COPD group (91%) and the lowest in the cardiovascular disease group (42%), whereas 2-year survival rate turned out to be the highest in the “infectious diseases” group (75%) and the lowest in the cardiovascular disease group (31%).
Cox regression analysis also did not reveal any statistically significant correlation between the total number of diseases the patient had at admission to
RCW and the patients’ post-admission survival. However, in multi-variants Cox regression analysis for the multiple risk factors, the findings were shown as followed: first, given the same conditions, there was a statistically significant correlation (P<0.01) between age and post-admission survival, as the patients’ mortality hazard ratio during hospitalization increased by 1.020 times when the patients’ age increased by one year; second, given the same conditions, there was a statistically significant correlation (P<0.05) between the renal disease and post-admission survival, as mortality hazard ratio of patients of the same sex and the same age and suffering from the renal disease at the time when the patients were admitted to hospital was 1.719 time that of those free of the renal disease at the time when admitted to hospital ; third, given the same conditions, there was a statistically significant correlation (P<0.05) between the COPD disease and post-admission survival, as mortality hazard ratio of patients of the same sex and the same age and suffering from the COPD disease at the time when the patients were admitted to hospital was 0.725 time that of those free of the renal disease at the time when admitted to hospital.

Conclusion
Working with the Integrated Delivery System (IDS) for ventilator-dependent patients, Taiwanese respiratory care wards (RCW) differ from their American counterparts in terms of case features and health insurance policy, and thus any attempt to compare the two in respect of care delivery is inappropriate. Given a 12.97% prevalence rate of third-degree pressure sores and 1.82 months treatment for the pressure sores per person-time on average, procedures for prevention of pressure sores should be adopted by respiratory care wards. This study discovers a 3.76% incidence rate of institution-based pressure sores. Calculating the prevalence rate of institution-based pressure sores from the number of patients currently having pressure sores is merely useful for describing the extend to which pressure sores affect the respiratory care wards but is not useful for describing the care quality of a respiratory care institution. In the respiratory care wards (RCW), the urinary tract infection is the mostly common nosocomial infection over the past two straight years, and thus the primary goal for long-term ventilator-dependent patients is to prevent urinary tract infections. Where the patients are classified according to the primary diagnosis given to the ventilator-dependent patients by ICU, and then the patients are divided into six groups, survival analysis of the six groups in RCW does not reveal any statistically significant difference (Log Rank: 10.79, df:5, P=0.0558). However, 1-year survival rate turned out to be the highest in the COPD group , and the lowest in the cardiovascular disease group. Cox regression analysis between multiple risk factors and post-admission survival reveals a statistically significant correlation on the patent’ age and whether the patient suffered from the renal and COPD diseases when the patients were admitted to RCW (P=0.002, P= 0.013, P= 0.042).

並列關鍵字

respiratory care ward ； long-term ventilator-dependent ； care quality ； nosocomial infection.

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