護理人力不同配置比例對病人安全、照護品質和護理照護成本之影響

The Effect of Different Proportion of Nurse staffing on Patient Safety, Quality of Care, and Nursing Cost

楊佩瑄(Pei-Hsuan Yang)

指導教授 ： 洪志秀

高雄醫學大學/護理學院/護理學系研究所/博士(2013年)

https://doi.org/10.6832/KMU.2013.00026

摘要

背景: 護理人力短缺是全球醫療機構向來所面臨的棘手問題，而且隨著全球人口老化，照護需求提高，此問題有日漸惡化的趨勢。全球為了因應護理人力短缺與醫療成本控制，不斷透過醫院政策改革、照護模式改變等策略來加以因應。採用技術混合照護模式不但可以降低人力成本和改善護理人力短缺，而且避免因人力不足造成病人安全異常事件，因而提高醫療成本。然而，在考量病人安全與照護品質之下，護理人員和照顧服務員的適當比例配置仍然不明確。
目的: 探討技術混合照護模式中不同護理人力配置比例與病人安全(給藥疏失和非預期氣管內管自拔)，照護品質(壓瘡發生、尿道感染、呼吸道感染、血流感染、平均住院天數、呼吸器脫離成功和病人死亡數)，以及護理照護成本的差異。
研究方法: 採用回溯性方式，針對2006至 2010年南台灣某呼吸照護中心之護理品質監測紀錄、病患病歷記錄以及護理人力成本進行統計分析。
結果: 共計667位病人依照不同照護人力配置，區分為三組，第一階段自2006年7月1日至2007年6月30日共計11個月(排除1月份)，護理人員比為76%之照護模式，病人總數為213位，平均每個月護理人員數為19人，照顧服務員為6人；第二階段自2008年2月1日至
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2008年12月31日共計11個月，護理人員比為100％，病人總數為209位，平均每個月護理人員數23人，照顧服務員為0人；第三階段自2010年2月1日至2010年12月31日共計11個月，護理人員比為92％的照護模式，病人數為245位，每個月平均護理人員數是23人，照顧服務員為2人。三種不同照護人力之病人特性，包括年齡、性別、轉入科別、呼吸衰竭原因以及疾病嚴重度均未達顯著差異。在護理人員特性，護理人員工作年資、大學教育程度及加護病房經驗均達顯著差異。調整病人轉入前呼吸器使用天數及護理人員年資之變項後，在病人照護結果方面，包括非預期氣管內管自拔、壓瘡發生率、呼吸道感染率、平均住院天數及死亡率均未達顯著差異；但是在給藥疏失、泌尿道感染、血流感染、呼吸器脫離成功以及照護成本均達顯著差異。
結論: 運用照顧服務員之組別泌尿道感染率及照護人力成本高於未運用照顧服務員之組別，而血流感染率以及呼吸器脫離成功病人數也較低。本研究提供呼吸照護中心之護理照護人力配置對照護結果影響之實證資料，以作為健保政策制定或醫療院所對呼吸照護人力資源管理之參考。

關鍵字

呼吸照護中心 ； 照護人力 ； 病人安全 ； 照護成果

並列摘要

Background: Nursing manpower shortage has been a thorny issue for global medical institutions. The problem shows a deteriorating trend with the increase of global aging population and resulting care needs. Hospitals worldwide have constantly adopted new strategies on policy reforms and changes in nursing model to cope with nursing manpower shortage and health care cost control. Nursing skill mix models can not only reduce manpower costs and improve manpower shortage but also prevent patient safety incidents that might result from manpower shortage and thus result in rising health care costs. However, under consideration of patient safety and quality of care, the optimal proportion of registered nurses (RNs) to nurse aides is still unclear.
Aim: The aim of this study was to explore the differences in patient safety (medication errors and unplanned endotracheal self-extubation), quality of care (pressure ulcer, urinary tract infection, respiratory tract infection, bloodstream infection, days of stay, ventilator weaning, and number of deaths), and nursing costs between different nursing manpower allocations by applying nursing skill mix models.
Methods: Retrospective data obtained from the monitoring records of nursing care quality, patient records, and nursing manpower costs in a RCC in southern Taiwan from 2006 to 2010 were analyzed.
Results: A total of 667 patients were categorized into three groups according to the mix of nursing staff as follows: 213 cared by RNs and nurse aides (proportion of RNs = 76%) for 11 months from July 1, 2006 to June 30, 2007 (excluding January), with an average number of 19 RNs
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and 6 nurse aides per month; 209 cared by RNs (proportion of RNs = 100%) for 11 months from February 1 to December 31 in 2008, with an average number of 23 RNs and 0 nurse aide per month; 245 cared by RNs and nurse aides (proportion of RNs = 92%) for 11 months from February 1 to December 31 in 2010, with an average number of 23 RNs and 2 nurse aides per month. No significant differences were found between three groups in patients’ demographic characteristics, including age, gender, transfer-in division, respiratory failure, and disease severity, yet significant differences existed in characteristics of RNs, including years of work experience, university education and ICU experience. After adjusting variables such as patients’ length of ventilator use prior to transfer-in and RNs’ years of work experience, in terms of patient outcomes, no significant differences were found in unplanned endotracheal self-extubation, pressure ulcer, respiratory tract infection, days of stay, and mortality, yet significant differences existed in medication errors, urinary tract infection, bloodstream infection, ventilator weaning, and nursing costs.
Conclusions: The groups that applied nurse aides had higher urinary tract infection rates and nursing manpower costs as well as lower bloodstream infection rates and number of patients weaned from ventilator than the group that did not apply nurse aides. This study adds evidence to the effects of nursing manpower allocations on patient outcomes in a RCC and could serve as a reference in health insurance policy formulation and respiratory care human resource management.
Key words: respiratory care center (RCC), nursing manpower, patient safety, patient outcomes.

並列關鍵字

respiratory care center (RCC) ； nursing manpower ； patient safety ； patient outcomes

參考文獻

顏芳慧、顧艷秋、伍麗珠、歐惠容、王琪(2011)．台灣南部某醫學中心護理人員對工作環境滿意之調查．高雄護理雜誌，28(1)，11-22。

中文部分

中華民國護理師護士公會全國聯合會新聞稿(2010)．棄血汗創磁力醫護病都有力．2012年3月20日取自http://www.nurse.org.tw / getFiles.ashx?file=97.

中華民國護理師護士公會全國聯合會新聞稿(2011)．棄血汗創磁力醫護病都有力．2012年3月20日取自http://www.nurse.org.tw / getFiles.ashx?file=97.

中華民國護理師護士公會全國聯合會(2012年2月)．台閩地區護理人員統計表．2012年3月20日取自http://www.nurse.org.tw/ DataSearch/ Manpower.aspx.