內科病人14天內非計畫性再住院相關因素之回溯性研究

本研究目的主要以人口學特性、共病因素、前次出院狀況及出院後照護情形、對醫療團隊、護理師提供前次出院準備服務及對前次出院後入住機構之滿意度，探討內科病人14天內非計畫性再住院情形、相關影響因素及預測因子。本研究於北部某醫學中心進行，連續收集2014年1月1日至同年12月31日期間出院之內科病人為研究對象，透過品管中心提供14天內非計畫性再住院病人資料、病歷查閱方式及出院後電話追蹤之｢出院準備服務評值表｣進行資料收集及分析，研究對象分為病例組與對照組各135人。結果發現：（1）內科病人14天內非計畫性再住院之影響因素包括，再住院者其平均年齡高於未再住院者（t = 2.199, p < .05）且已婚者再住院比率較少（χ2 = 8.690, p < .05），Charlson Comorbidity Index加權總分越高者越容易再住院（χ2 = 7.368, p < .05）且再住院者平均加權總分較高於未再住院者（t = 2.005, p < .05），再住院者之前次平均住院天數多於未再住院者（t = 2.097, p < .05），而前次出院後主要照顧者為外傭者較易發生再住院（χ2 = 16.476, p < .001）。（2）多變量邏輯式分析結果顯示，內科病人14天內非計畫性再住院之獨立預測因子包括「前次住院主診斷」為惡性腫瘤（OR = 2.903, 95% CI = 1.136-7.419, p <.05）、「前次住院天數」越多（OR = 1.028, 95% CI = 1.000-1.056, p <.05）以及「主要照顧者關係」為外傭者（OR = 4.260, 95% CI = 1.725-10.51, p < .05）較傾向發生非計畫性再住院，反之｢已婚｣者較｢未婚/喪偶/離婚｣不易傾向發生非計畫性再住院（OR = 0.422, 95% CI = 0.179-0.996, p < .05）。本研究顯示應將年齡、婚姻狀況、Charlson Comorbidity Index加權總分、住院天數及出院後主要照顧者，做為出院準備時篩檢非計畫性再住院高危險群的重要項目，針對未婚、喪偶、離婚者及老年者，應於住院期間儘早規劃提供出院準備服務，可採「及早主動式」及運用｢出院評估單｣的評估與介入，對於「前次住院主診斷」為惡性腫瘤及前次住院天數較多者，應有專任疾病個管師，針對疾病個別性給予特殊衛教及後續出院追蹤，此外「主要照顧者關係」為外傭者，護理師應每日執行日常照顧技巧之護理指導及讓照顧者不斷回覆示教，並提供多國語言之衛教單張及多媒體教學，護理師於出院後電訪追蹤，瞭解病人出院後之照護情形，必要時提供協助及轉介，以降低內科病人14天內非計畫性再住院發生。

關鍵字

非計畫性再住院；危險因子；內科病人；主要照顧者；回溯性研究

並列摘要

The purpose of this study was to investigate the relevant factors and independent predictors for unplanned readmission within 14 days of previous hospital discharge in medical patients by exploring the demographic characteristics, comorbid medical conditions, discharge status and care following previous hospital discharge, satisfaction toward care of the medical team, the previous discharge planning and the length of stay of previous hospitalization of study patients. This retrospective, case-control study was undertaken in a medical center in northern Taiwan. This study enrolled 135 unplanned readmission patients who were discharged from medical ward of the study hospital between January 1, 2014 and December 31, 2014. Data were collected through the Quality Control Center, inspection records after discharge and telephone follow-up of "discharge planning services evaluation scale" data and were compared to the data of 135 control patients who did not have readmission in 14 days of hospital discharge. The results showed that: (1) medical patients of unplanned readmission within 14 days were older (t = 2.199, p <.05), more single or widowed marital status (χ2 = 8.690, p <.05), higher Charlson comorbidity Index score (χ2 = 7.368, p <.05; t = 2.005, p <.05), longer length of stay of previous hospitalization (t = 2.097, p <.05), higher percentage of foreign domestic helper (FDH) as primary caregivers (χ2 = 16.476, p < .001). (2) Independent predictors for unplanned readmission within 14 days of hospital discharge included malignant disease (OR = 2.903, 95% CI = 1.136-7.419, p < .05), the length of stay of previous hospitalization (OR = 1.028 , 95% CI = 1.000-1.056, p < .05) and FDHs as primary caregiver (OR = 4.260, 95% CI = 1.725-10.51, p < .05). On the contrary, married status was negative predictor for unplanned readmission in multivariate logistic regression analysis (OR = 0.422, 95% CI = 0.179-0.996, p < .05). This study showed that age, marital status, Charlson Comorbidity Index weighted score, hospital length of stay and the primary caregivers after discharge were important items for discharge planning in screening high risk patients for readmission after discharge. Discharge planning services should be provided as early as possible to the patient who is elderly, single or widowed marital status, cancer patients, known FDHs as primary caregivers, or has longer hospital length of stay. An integrated strategies including the use of Discharge Assessment Checklist, special health education, case management services, guidance of care skills, providing health education leaflets in multiple languages, subsequent discharge follow-up and when necessary, assistance and referral information, are crucial in an effort to reduce unplanned readmission within 14 days of hospital discharge in medical patients.