某個案醫院2006~2011年計畫性與非計畫拔除氣管內管之加護病房病人醫療品質之探討

The Study of A Case Hopsital for 2006-2011 Intensive Care Unit Patients using Ventilators with Extubated Outcome

黃裕婷(Yu-Ting Huang)

指導教授 ： 林恆慶

共同指導教授 ： 黃崇謙(Chung-Chien Huang)

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2013年)

https://doi.org/10.6831/TMU.2013.00148

摘要

由於就醫可近逐漸提升、醫藥科技日益進步等種種因素，愈來愈多急重症病人接受緊急呼吸器處置，讓病人度過呼吸衰竭所產生的致命危機，進而維持或延長生命。隨著病情改善，呼吸器脫離被醫療團隊視為重要的照護程序，過早中斷機械通氣會造成拔管失敗、肺炎感染或增加死亡率；漸近式減少換氣支持，亦可能延遲拔管或造成非計劃拔管，因而增加病人住院天數、呼吸器使用天數、死亡率、及醫療成本。
經由個案醫院病人安全通報系統所收集之資料，管路事件是僅次於跌倒最常見之醫療意外事件，其中有62.2%為氣管內管事件，並有87%發生於加護病房，基於追求品質之決心與臨床脫離程序之參考，期望透過個案研究，精進臨床作業，並檢視品質指標監測與照護標準作業之適切性。
本研究中，有下述兩項主要的目的：
1.瞭解氣管內管計劃與非計劃拔除兩組病人出院是否死亡情形。
2.比較氣管內管計劃與非計劃拔除病人在住院天數、呼吸器使用天數及健保給付醫療總金額等三方面上之差異。
研究採行的是一項橫斷面、回溯性的比較研究，區分為計劃性拔管與非計劃性拔管兩組。非計劃性拔管病人自病人安全系統通報資料取得，合計196人；計劃性拔管病人則以立意取樣方式，選擇在2006年至2011年在加護病房插管的病人，以年齡，性別，和疾病嚴重度做為控制變項1:1進行篩選，合計195人。兩組研究個案確立後，由研究者串聯2006-2011年醫院臨床資訊系統與出院健保費用檔，從醫療記錄，呼吸照護表單和健康保險申報費用等層面進行資料收集，包括病人的人口學特徵，診斷，醫療品質指標，和嚴重程度等，並以SPSS18.0進行分析，描述和統計推論。
在這項研究中，發現以下結論：
1.計劃與非計劃拔除氣管內管與病人出院是否死亡無相關性。
2.無論是否控制人口學及疾病特性，使用呼吸器天數與拔除氣管內管之方式，均無相關性。
3.住院日數方面，非計劃性拔管較計劃性拔管住院天數為長，經控制人口學及疾病特性後，氣管內管移除方式與住院天數有顯著相關。
4.非計劃性拔管較計劃性拔管健保給付醫療金額為高，唯經人口學及疾病特性校正後結果則不影響健保給付醫療金額。

基於上述結論提出下述建議：
1.本研究係以年齡、性別、疾病嚴重度做為篩選條件，建議加入其他配對篩選條件（如使用呼吸器診斷、病房別等），讓兩組個案更趨同質性。亦可將臨床生化數據 (BUN、Ht等) 、呼吸器使用相關參數 (含脫離參數) 與呼吸道損傷情形納入資料搜集，使預測範圍更貼近臨床實務指引。
2.建議加護單位建立插管病人入院執行約束與鎮靜藥物之標準流程，俾能減少非計劃拔管之情形。
3.兩組昏迷指數 (GCS) 雖皆屬中度昏迷，經統計檢定後，計劃性拔管之GCS、住院日數與健保給付醫療金額皆較非計劃性拔管組為低，若能進一步增加其他資料之收集，以瞭解醫療資源耗用影響因子，找出健保給付醫療金額預測模式，或能為健保資源投入設立停損點，也可做為未來給付制度調整之參考。
4.依本研究發現，計劃性拔管與非計劃性拔管並不影響病人出院是否死亡情形，但會延長住院天數與較高之健保醫療總費用，建議可納入於醫療品質獎勵方案，讓醫療團隊合作更落實在臨床工作。

關鍵字

計劃拔管 ； 非計劃拔管 ； 呼吸器使用 ； 醫療指標

並列摘要

Thank to medical accessibility and technology improvement, lives with high severity are saved and prolonged by the application of respiratory ventilator in critical care. Studies have found problems related to ventilation, and have suggested the importance of a standard care procedure of ex-tubation for patients under ventilator. Inappropriate ventilator care can be an early or a late ex-tubation, where it may cause fetal infection of pneumonia and then increases patient fatality. Hence, either early or late ex-tubation will result in an increase of length of hospital stay, days of using ventilator, and medical expenditures.
Tube related accidents were ranked as the most occurring incidence next to fall in hospital; and 62% of them were related to tracheal tubes in patients under ventilators. And, intensive care unit was the place where 87% tracheal tubes incidents occurred in hospital. Despite patient safety had been long advocated, tube care with standard procedures remained an important issue in hospital. Therefore, this study aimed to explore the appropriateness of quality care index and standard care procedures of ex-tubation.
Two main/specific issues were examined in this study:
1.To understand the discharged status of patients with planned or unplanned ex-tubation.
2.To compare the length of stay, days of ventilator utilization, and medical expenditures reimbursed by National Health Insurance in both groups.

This study was a retrospective, cross-sectional comparative study. A total of 196 unplanned ex-tubation cases were collected from patients-safety reporting system from 2006 to 2011 . And, a total of 195 intubated patients in intensive care units were selected by matching age, sex, and severity during the same time period. Data including patients’ demographic characteristics, diagnosis, quality of care index, and severity were collected from medical records, respiratory care documents, and health insurance claims, and were analyzed by descriptive and inferential statistics with SPSS 18.0.
Following results were found in this study:
1.Planned or unplanned ex-tubation were not related to discharged status of patients.
2.The length of ventilator utilization was not related to planned or unplanned ex-tubation.
3.The length of hospital stay for unplanned extubated patients were longer than those with planned extubated. However, after controlling demographic characteristics and disease classifications, the length of hospital stay was significantly related to the methods of tracheal ex-tubation.
4.The average amount of medical expenditure reimbursements in the unplanned ex-tubation group was higher than that in the planned group, but it became no significant difference after the adjustment of demographic characteristics.

Suggestions:
1.Apart from patients’ demographic and severity data, factors such as laboratory data, type of ventilation may be added to improve the homogeneity of patients under ventilators.
2.A standard procedure or protocol in the usage of sedative medication and restrictive measures for patients under ventilators may reduce unplanned removal of tracheal tube.
3.Patients in both groups have mid-scores measured by GCS. But, the GCS, length of hospital stay, and medical reimbursements in planned ex-tubation patients are significantly lower than those in un-planned group. If more information can be collected to improve the predictive model of medical reimbursement, we may find the break-even point of resource inputs from medical insurance and contribute to future adjustment of medical reimbursement.
4.In this study, a planned or not planned removal of tracheal tube has no impact on discharged status of patients. However, both may lengthen hospital stay and result in unnecessary medical costs. This study suggests policy makers can include total medical expenses and hospital stay as indicators in promoting quality of care.

並列關鍵字

planned extubation ； unplanned extubation ； ventilator utilization ； medical care quality

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