探討醫師因素所導致72小時非預期返診入住加護病房患者的醫療品質及資源耗用分析

目的：主要探討因醫師判斷因素導致患者72小時返診入住加護病房的患者1.其急診處置流程是否影響醫師判斷。 2.對醫療資源的耗用，如加護病房住院天數，健保費用…等。 3.醫療品質分析探討。方法：本研究設計採回溯性研究設計法(Retrospective study)，本資料以南部某一準醫學中心自2012年1月至2017年12月之72小時非預期返診入住加護病房之個案資料為收集樣本，由急診品質專家三人共同審視病歷分析，鎖定病人返診的主因包含醫師無法第一時間做出正確診斷或給予不完整的處置因而返診並入住加護病房，歸為醫師判斷因素，具體條件須符合1.初診與返診之主訴、臨床症狀相似。 2.入住加護病房診斷與主訴相關。 3.分析病人處置過程具有明顯錯誤或可改善空間，並運用描述性統計及推論統計方法加以分析。結果：醫師判斷因素對患者72小時非預期返診入住加護病房結果有影響，醫師判斷因素。個案數為35人（23.8%）；非醫師判斷因素佔112人（76.2%），發生率約萬分之一。醫師判斷因素與患者72小時非預期返診入住加護病房的急診處置流程有關，初診停留時間小於兩小時，醫師誤判風險比停留兩小時以上患者高4.837倍。醫師判斷因素與患者72小時非預期返診入住加護病房的資源耗用有關，相較於非醫師因素所需的資源耗用較少，原因為本研究族群醫師對不同疾病敏感度不同。嚴重的疾病、資源耗用高的呼吸胸腔疾患相對誤診率低，而對神經系統疾患的誤診斷率較高。醫師判斷因素與患者72小時非預期返診入住加護病房的死亡與否無關聯性。醫師判斷因數導致72小時非預期返診病患確實存在，醫療人員確實有責任應避免或減少任何可能發生醫療疏失的機會，故需建議急診醫師及醫療管理者不能輕忽其潛藏的風險。

關鍵字

72小時；返診入住加護病房；醫師因素；醫療資源耗用；醫療品質

並列摘要

Aim: Primarily to examine physician judgment factors that result in patient’s readmission to the intensive care unit within 72 hours: 1. Whether or not emergency treatment procedures affected physician judgment. 2. Consumption of medical resources such as length of intensive care unit stay, national health insurance costs, etc. 3. Analysis and examination of medical quality. Methods: A retrospective study design was employed. Data for this study was obtained between January 2012 to December 2017 from patients with unplanned readmission to the intensive care unit within 72 hours in a medical center in southern Taiwan. Three emergency department quality experts were jointly responsible for reviewing and analyzing medical records. The focus for primary cause for readmission of patients was physician judgment factors, which were defined as incorrect diagnosis by the physician initially or incomplete treatment resulting in readmission to the intensive care unit. Specific criteria included: 1. the chief complaint and clinical symptoms of the initial consultation and re-consultation were similar. 2. The diagnosis for admission to the intensive care unit was associated with the chief complaint. 3. Analysis of the patient’s management process showed significant errors or room for improvement and descriptive statistics and inferential statistics were used for analysis. Results: Physician judgment factors were found to be associated with unplanned readmission to the intensive care unit within 72 hours. There were 35 cases associated with physician judgment factors (23.8%) and 112 cases associated with non-physician judgment factors (76.2%), and the incidence was around 1 out of 10,000. Physician judgment factors was associated with the emergency treatment procedure for patients who were readmitted to the intensive care unit within 72 hours. The risk of physician misjudgment was 4.837 times higher for patients who were retained for less than 2 hours for the initial diagnosis compared to those that were retained for more than 2 hours. Physician judgment factors was associated with resource consumption in patients who were readmitted to the intensive care unit within 72 hours, and less resources were consumed than those of non-physician factors. The reason for this was that the study population of physicians had different sensitivities towards different diseases. Respiratory and thoracic disease patients with severe disease and high resource consumption had a relatively lower misdiagnosis rate while the misdiagnosis rate for patients with neurological diseases was higher. Physician judgment factors were not associated with mortalities in patients that were readmitted to the intensive care unit within 72 hours. Physician judgment factors that led to unplanned readmission to the intensive care unit within 72 hours do exist. Medical staff was responsible for avoiding or reducing any opportunities for medical negligence. Therefore, it was recommended that emergency physicians and medical managers should not underestimate the potential risks.