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  • 學位論文

台灣南部某醫學中心24小時內非計劃性重返加護單位現況之探討

Exploring the Current Situation of Unplanned Readmission to the Intensive Care Units within 24 Hours in A Medical Center in Southern Taiwan

指導教授 : 陳清惠

摘要


研究背景: 加護病房是收治病情較嚴重與危急病人醫療救護單位,配有特殊儀器,耗用醫院大量資源的地方。在整體醫療資源有限的狀況下,如何更有效率的利用加護醫療,以提供有品質的醫療服務,實為重要的議題。國內外針對病人進行非計劃性重返加護病房相關研究探討甚少,尤其是24小時內非計劃性重返加護病房,在如此短暫時間內即返回,代表可能未控制好急性病況即予轉出,不但可能造成醫療浪費,亦使病人生命受到威脅。 研究目的: 本研究的目的為以下三項:1.瞭解南部某醫學中心24小時內非計劃性重返加護病房發生率。2.瞭解南部某醫學中心24小時內非計劃性重返加護病房病人的特性。3.瞭解南部某醫學中心24小時內非計劃性重返加護病房病人重返後,停留加護病房天數、總住院天數及死亡率。 研究方法: 本研究屬調查性研究設計,針對南部某醫學中心,2014年1月至2015年12月,24小時內非計劃性重返加護病房病人為研究對象。運用自擬調查問卷,且經過專家效度檢測的問卷,進行資料收集,內容包括三部份:第一部份:病人入加護病房時狀態;第二部份:病人出加護病房時狀態;第三部份:病人24小時內非計劃性重返狀態。三部份細節內容包含有:基本資料、臨床數據、檢驗數據及其它。研究資料將採描述性統計分析。 研究結果: 24小時內非計劃性重返加護病房率為0.40%,24小時內非計劃性重返加護病房死亡率為16.6%,停留加護病房天數平均為10.72天(標準差, standard deviation, SD=10.64)﹔此次住院總住院天數平均為26.50天(SD=12.88)。在性別分佈,男性佔64.0%,在年齡分佈當中,65歲以上佔81%。24小時內重返病人,58%有至少一種共病診斷,同時含有4種疾病佔了8位(22%),且共病診斷中前3名內含有糖尿病佔22位(61%)、高血壓佔20位(55%)、心血管系統疾病佔16位(44%)。病人初次入加護病房時的APACHEⅡ(Acute Physiology and Chronic Health EvaluationⅡ):16.64分、TISS(治療性措施計分系統, Therapeutic Intervention Scoring System):26.00,24小時內重返APACHEⅡ:16.75分、TISS:26.33 。意識狀態部分,病人出加護病房時意識平均13.88分,重返時11.02分,有下降現象。肌肉分數沒有相差很多,但非計劃性重返病人肌肉力量分數0分者有3位。此外,營養狀況方面,病人首次入加護病房白蛋白平均為2.2 g/dl,再重返時為2.74 g/dl;SGA分數有高達78%在B級以下。個案中有27位(73%)順利出院。 研究結論: 24小時內非計劃性重返加護病房病人傾向為高齡、有高血壓、糖尿病、或心血管系統的共病症。與初入加護病房時比較,再返回時出現意識狀態及肌肉力量變差現象,反映出臨床對意識狀態變化之看重。雖然本研究無法確認24小時內返回加護病房之特性,但由極高比率營養狀況不佳之現象,值得未來臨床關注重症病人對營養之維護。與收案醫院之數據比較,本研究個案有較高的死亡率,但順利出院者亦高達73%,推論可能因為及早轉回加護病房,反而強化了對病況的控制。 研究限制及建議: 本研究為調查性研究,未能作統計分析比較,特性描述也無法推論,建議未來還可以再做近一步研究及驗證。期望能由24小時內非計劃性重返加護病房病人特性及醫療服務的現況,做為未來初步探討可能原因,期能進一步建立有效的因應措施,以減少24小時內非計劃性重返加護病房的發生率。

並列摘要


Abstract Research Background: Intensive Care Unit (ICU) in a hospital possess special medical equipments, consumes large health resources and manpower for the patients whom are seriously injured or ill. How to effectively utilize intensive care service in order to provide quality medical care in a situation of limited health resources is an essential topic of discussion. There are few topic of discussion aiming at the unplanned readmission of ICU patient’s, especially in a time frame of 24 hours. In such a short time patients needing to be back to ICU, means that the patients probably are released before the acute conditions have been in control. Such an incident not only wastes more medical expenses and resources, but also causes a potential threat to the patients. Research Objectives: The objects of this research regarding to the patient's unplanned readmission to ICU in 24 hours at a Medical Center in the South are as below: 1. The occurrence rate 2. The characteristics of the illness of the patients3. The days of ICU stay, the total days of hospitalization and the death rate. Research Method: The method of this research is a survey format designing to examine the unplanned patient readmission to ICU IN 24 hours from Jan. 2014 to Dec. 2015. By using self-draft questionnaires as well as by confirming with the expert's validity questionnaires for the purpose of collecting data which contains three parts (1) the condition of patient when entering ICU (2) the condition of patient when transferring out of ICU (3) the condition of patient when readmission to ICU unplanned in 24 hours. The detailed information includes: basic history, clinic data, test report and others. Research results will be presented by descriptive statistics and analysis. Research result:    The occurrence rate of unplanned patient readmission in 24 hours was 0.40%; the death rate was 16.6%. The average number of days in intensive care units was 10.72 days; the average hospital stay was 26.50 days. Sixty four percent were male, 81% were 65 years and older. For unplanned readmission patients, 58% have at least one comorbidity, 8 persons (22% ) retain four diagnosed diseases. The three most common diseases: diabetes 22 persons (61%), Hypertension 20 persons (55%),Cardiovascular diseases 16 persons (44%). Patients first entering ICU APACHE II(Acute Physiology and Chronic Health EvaluationⅡ): 16.64, TISS: 26.00. Patient readmission in 24 hours: 16.75, TISS(Therapeutic Intervention Scoring System): 26.33. For the conscious status, the mean score of patient conscious level was 13.88 while leaving the ICU and downed to 11.02 points at readmission. The muscle power was similar between admitted and readmitted to ICU, but there were three patients showed zero score at readmission. In addition, for nutritional status, at first entered the ICU, patients the mean of albumin was 2.2 g / dl, in admission was 2.74 g / dl. The SGA scores, up to 78% of patients were lower than B level at admission. Finally, 73% of patients were able to discharge. Research Conclusion:    Unplanned readmission to ICU in 24 hours patients tends to be elderly, with co-morbid conditions of hypertension, diabetes, or the cardiovascular diseases. Comparing at admission in ICU, the conscious level and muscle power were deterioration at readmission. Although this study was unable to identify the risk factors of readmission to ICU, this study presents the high rate of poor nutritional status among patients which should be concerned and worthy of future clinical attention to maintain the nutrition of critically ill patients. Compared with the statistics of the data collection hospital, this study had a higher mortality rate, but the number of patients who had successfully discharged was as high as 73%. It is possible that the earlier readmission to ICU has enhanced the control of the critical conditions. Limitation and Suggestion:    This research is by nature a survey, neither form by comparison in statistics and analysis, nor concludes by the description of characteristics. Suggesting that further research and verification in the topic's characteristics and their coordinating medical services will be able to provide factors and reasons for the future research as well as the establishment of an effective measure for reducing the occurrence of the unplanned patient readmission to ICU.

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