臺中某醫學中心實施專任重症專科醫師制度與否對其外科加護病房死亡率之評估與分析

加護病房實施專任的重症專科醫師制度已是目前的趨勢，許多國內外的研究均證實專任的重症專科醫師制度確實可以改善重症病患的預後,縮短加護病房的滯留日數,也因此降低伴隨而來的醫療成本。而評估加護病房患者嚴重度的量表,現今最廣為使用的是為Acute Physiology and Chronic Health Evaluation (APACHE ) II評估表,它的發展已有近20年左右的歷史。當然各醫院的現有設備與病患的特色，都難免會有所差異，所以分析醫院本身的數據，了解醫院本身病患的性質,才能有所根據的訂定適合的歸範及治療，以減少加護病房病患的合併症和死亡率。同時,我們藉由專任重症專科醫師制度的推行,以更有效率的方式來運用加護病房資源, 創造最大的經濟效率;尤其目前全民健保財政日漸捉襟見肘,根據中央健康保險局網站資料,全民健康保險財務收支分析表顯示,累計至2009年10月份的健保收支短絀已達532.10億元,面對如此龐大的健保財政缺口,如何將有限且昂貴的加護病房醫療資源予以妥善運用,更是刻不容緩的重要課題。本研究的對象為臺灣中部某醫學中心的外科加護病房，團隊成員中有兩名重症專科醫師,收案自2008年1月份到2009年10月份，共計1441名患者，排除17名資料有所遺漏的患者之後，共有1424名患者，依患者住院日期分成2008年1月份到2008年11月份與2008年12月份到2009年10月份兩組，前一組為專任的重症專科醫師參與加護病房夜間第一線值班，後一組則無。比較兩組之間年齡、性別、APACHE II的分數、加護病房滯留日數與患者的死亡率,探討專任的重症專科醫師參與夜間第一線值班的有無和這些變項之間的關聯性，並以線性迴歸分析各個變項的勝算比(Odds ratio)。數據分析的結果發現，在APACHE II分數超過25分的高危險族群患者中，當有專任的重症專科醫師參與加護病房夜間第一線值班時，在降低重症患者的死亡率上,呈現統計學上的差異, 也因此我們可以強烈的建議, 在照顧這些高風險及高死亡率的患者時，不論是白天或是夜間的照顧,團隊中都應有學有專精的重症專科醫師參與第一線的照顧,也就是推行專任的重症專科醫師制度,以降低重症患者的死亡率。

關鍵字

加護病房；專任重症專科醫師； APACHE II評估表；死亡率

並列摘要

Intensive care unit physician staffing (intensivist) is now a public concern for using the high cost intensive care unit resources efficiently in Taiwan and many other countries. Many studies have concluded that intensivists in intensive care unit actually reduce the length of stay of intensive care unit and also improve the outcome of critical patients. Acute Physiology and Chronic Health Evaluation (APACHE ) II score system which is the most popular scoring system used in intensive care unit to quantify disease and predict outcome of critical patients has developed for more than 20 years. Each intensive care unit should set up an adequate treatment modality according to the characteristics of their patients to make the best cost- efficiency. Our study collected 1441 patients in a surgical intensive care unit of a medical center in Taichung, Taiwan. The collecting period was from January 2008 to October 2009. After 17 patients were excluded due to missed data collection , total included patient number was 1424 patients. These 1424 patients were divided into two groups by with or without full-time intensivist staffing. The APACHE II score of these patients were recorded within the initial 24 hours after they were admitted to the surgical intensive care unit. We statistically analysis the correlations between age, gender, APACHE II score, operation or not , the length of stay of intensive care unit and the mortality rate, to discuss whether full-time intensivist could improve the outcome of critical patients. Chi-square test, t-test, and analysis of variance (ANOVA) were used. Logistic regression was also used for the odds ratio of each variable. The odds ratios of mortality rate was 0.65 with full-time intensivist staffing for patients whose APACHE II score higher more than 25 points (95% CI: 0.44~0.94). In this surgical intensive care unit, full-time intensivist staffing do improve the outcome of these high risk critical patients .As for reduction of the length of stay of intensive care unit or overall mortality rate, there were no statistically difference in these two groups.

並列關鍵字

Surgical intensive care unit ； APACHE II scores ； Mortality rate ； Intensivist

參考文獻

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臺中某醫學中心實施專任重症專科醫師制度與否對其外科加護病房死亡率之評估與分析

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