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  • 學位論文

外科病患及老年病患重返加護病房之臨床特性及結果之研究

Readmission to the Intensive Care Units: Clinical Characteristics and Outcomes of Surgical and Elderly Patients

指導教授 : 李孟智

摘要


研究背景與目的: 病患“重返加護病房”是反映加護病房照護品質的重要指標。病患重返加護病房,不但提升醫療費用造成醫療浪費,而且延長病患的住院天數,造成病患死亡率及罹病率增加。有關重返加護病房的研究雖然許多文獻曾經探討過,但是大多數的研究所探討的都是異質性的族群,對於研究結果的發現進行策略改善時,其成效有限。而有關同質性的族群如外科重症病患或是老年病患鮮少被提及和討論。為了解這兩群重症病患重返加護病房之臨床特性及相關的結果,本論文分成兩個研究分別對這兩個族群做深入的探討。 研究方法: (一)研究一: 本研究以回溯性方法於2003年在台灣某醫學中心具40床之外科加護病房收集病患作為研究對象。在同一住院療程中,入住加護病房至少兩次以上的病患為收案條件。以病歷回顧的方式記錄病患的人口學資料、臨床特性及結果。同時,也進一步辨別重返加護病房病患的危險因子及重返病患中死亡的相關因子。 (二)研究二: 以回溯性方法於2003年在台灣某醫學中心具79床之加護病房收集年齡超過65歲以上的老年人。以病歷回顧的方式記錄病患的臨床特性及結果。同時也進一步的比較重返加護病房的病患中死亡與存活者的差異。 研究結果: (一)研究一: 在945名轉出外科加護病房的病患中,有110名為重返加護病房的病患,重返率為11.6%。相較於未重返的病患,重返加護病房的病患第一次住加護病房的天數較長(8.05 ± 7.17 vs. 5.22 ± 4.95, p<0.001)、年齡較長(64.10 ± 16.98 vs. 58.66 ± 17.42, p=0.02)、而且疾病嚴重度較高,包括較高的APACHE II 分數 (12.80 ± 6.69 vs. 11.36 ± 7.31, p=0.046)及 TISS (28.95 ± 8.93 vs. 26.74 ± 8.88, p=0.015).同時,重返加護病房的病患也有較高的住院天數 (59.49 ± 53.41 vs. 18.40 ± 12.47, p<0.001)及死亡率(40% vs. 3.6%, p<0.001)。重返加護病房的病患中,26.4%為早期重返(<48小時),早期重返的病患有較低的死亡率(24.1% vs. 45.7%, P=0.049)。46.4%的病患重返的原因與第一次的原因相同。其中呼吸道原因為重返加護病房患的最主要原因,且占了新併發症的66.1%。重返加護病房的個案中,相較於存活的個案,死亡的個案在重返時有較高的疾病嚴重度,其中有較高的APACHE II 分數 (22.1 ± 8.8 vs. .14.6 ± 7.4, P<0.001)及TISS (30.1±8.7 vs. 24.7 ±7.6, P=0.001)。另外,死亡的個案與第一次住加護病房的天數也較長(10.4 ± 9 days vs. 6.4 ± 5 days, P=0.010)。多變項分析的結果顯示第一次住加護病房的天數及重返加護病房時的APACHE II 分數是重返病患死亡的危險相關因子。 (二)研究二: 老年病患加護病房的重返率為12.0%。其中83名為男性,占了56.5%。研究個案的平均年齡為74.7 ± 6.1歲。呼吸道原因為老年病患重返加護病房的最主要原因,占了所有重返原因的46.4%。而老年病患重返加護病房的死亡率為38.1%。在重返加護病房的個案中,死亡的個案有較高的APACHE II(25.8 ± 9.5 vs 19.1 ± 7.8, p=0.036)及TISS分數(29.3 ± 9.4 vs 23.1 ± 6.7, p=0.019),然而其GCS分數(9.6 ± 6.7 vs 11.6 ± 13.4, p=0.002)卻是較低的。至於住院天數方面,死亡個案在重返加護病房時有較長的加護病房住院天數(11.6 ± 13.4 vs 9.6 ± 6.7, p=0.002),但在住院的總天數方面,卻較存活個案為短(38.6 ±28.3 vs 55.4 ± 55.9, p=0.010)。多變項分析顯示重返加護病房時的APACHE II (勝算比為1.085, 95% 信賴區間為1.003-1.172, p=0.041)及TISS 分數(勝算比為1.114, 95% 信賴區間為1.040-1.193, p=0.002)為老年病患重返加護病房的危險相關因子。 研究結論: (一) 研究一: 外科病患重返加護病房的死亡率相當高,其中呼吸道疾病為病患重返加護病房的主要原因。外科病患的第一次住加護病房的天數及重返加護病房時的APACHE II分數是外科病患重返加護病房時死亡的危險相關因子。(二) 研究二: 老年病患重返加護病房有較高的死亡率及罹病率。老年病患重返加護病房時,其疾病嚴重度愈高表示病患有著較高的死亡率。在重返加護病房的原因中,以呼吸道疾病為最主要的原因。至於如何辨別高危險群病患,降低外科及老年病患加護病房重返率,為未來進一步的研究。

關鍵字

老年 外科 重返 加護病房 臨床特性 預後 死亡率

並列摘要


Background and Objectives: ICU readmission, an important indicator of quality of care, has been identified as a reliable performance indicator in the intensive care. ICU readmission not only increases medical expenditure, prolongs the length of hospital stay but it also increases the mortality and morbidity of the patients. There were many literatures or research papers published for ICU readmission, however, only the heterogeneous groups of patients were studied. Thus the improvement strategy adopted based on these findings was found to be with limited benefit. In addition, studies of different homogeneous groups of patients, in particular surgical and elderly patients were rarely investigated. To address these issues, two studies are included in this thesis. Both of the studies are aimed to delineate the clinical characteristics and outcomes of ICU readmission of surgical and elderly patients, respectively. Methods: (1) Study 1: Patients were retrospectively collected for analysis from four surgical ICUs with 40 beds in a tertiary care center in Taiwan from January of 2003 to December of 2003. Medical charts of all the patients were reviewed. Patients who were admitted to the ICU more than once during the same hospitalization were included. Clinical characteristics and outcomes were recorded. Risk factors for ICU readmission and risk factors of mortality were evaluated. (2) Study 2: Patients with aged 65 years or above and admitted more than once to the ICU during the same hospitalization were retrospectively collected from 79 beds ICUs (including medical and surgical ICU) in a tertiary care center in the year 2003. Clinical characteristics and outcomes were recorded. Risk factors for mortality of ICU readmission were evaluated. Results: (1) Study 1: Of all the 945 ICU discharged surgical patients, 110 patients were readmitted, with a readmission rate of 11.6%. It was found, they had a longer initial ICU stay (8.05 ± 7.17 vs. 5.22 ± 4.95, p<0.001), age were older (64.10 ± 16.98 vs. 58.66 ± 17.42, p=0.02), in a more severe condition with higher APACHE II score (12.80 ± 6.69 vs. 11.36 ± 7.31, p=0.046) and TISS (28.95 ± 8.93 vs. 26.74 ± 8.88, p=0.015) than those non-readmitted patients. These patients had a longer hospital stay (59.49 ± 53.41 vs. 18.40 ± 12.47, p<0.001) and higher mortality rate (40% vs. 3.6%, p<0.001). A total of 26.4% of the readmitted patients had an early readmission (<48 hours), with a lower mortality rate than those with a late readmission (24.1% vs. 45.7%, P=0.049). 46.4% of the patients were readmitted with the same diagnosis while the rest were readmitted with a new complication. Respiratory disease was the most common diagnosis for patients readmitted with a new complication (66.1%). The non-survivors had a significantly higher APACHE II score (22.1 ± 8.8 vs. 14.6 ± 7.4, P<0.001) and TISS score (30.1±8.7 vs. 24.7 ±7.6, P=0.001) at readmission and a longer stay in the first ICU admission (10.4 ± 9 days vs. 6.4 ± 5 days, P=0.010). A multivariate analysis showed that the first ICU length of stay and the APACHE II score at the time of readmission were the two risk factors for mortality. (2) Study 2: The ICU readmission rate of the elderly patients was 12.0%. Eighty-three (56.5%) patients were male. The average age was 74.7 ± 6.1 years. Respiratory disease (46.3%) was the most common diagnosis for elderly patients readmission. The mortality rate was 38.1%. The non-survivors had significantly higher APACHE II scores (25.8 ± 9.5 vs 19.1 ± 7.8, p=0.036) and TISS (29.3 ± 9.4 vs 23.1 ± 6.7, p=0.019), but had a lower GCS (9.8 ± 5.1 vs 11.7 ± 3.6, p<0.001) during ICU readmission. The length of ICU stay was significantly longer for the ICU readmitted non-survivors group (11.6 ± 13.4 vs 9.6 ± 6.7, p=0.002). However, the length of hospital stay was longer for the survivors group (55.4 ± 55.9 vs 38.6 ±28.3, p=0.010). Multivariate analysis showed that the APACHE II scores (Odds ratio 1.085, 95% Confidence interval 1.003-1.172, p=0.041) and TISS of ICU readmission (Odds ratio 1.114, 95% Confidence interval 1.040-1.193, p=0.002) were the two risk factors for mortality. Conclusions: (1) Study 1: The mortality associated with surgical ICU readmission was high. Respiratory disease was the major reason for ICU readmission due to new complications. The initial ICU length of stay and the APACHE II score upon readmission are the two risk factors for the mortality of surgical ICU readmitted patients. (2) Study 2: ICU readmission is associated with high mortality and morbidity rate in elderly patients. The severity of the disease during readmission, high APACHE II scores and TISS, were correlated with the high mortality of these patients. Respiratory disease was the major reason for ICU readmission. Strategies for identifying the high risk patients and reducing the ICU readmission of surgical and elderly patients should be studied further.

參考文獻


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黃代泱(2013)。影響加護病房老年重症病人面臨疾病末期時期成年子女簽署DNR同意書意願因素〔碩士論文,長榮大學〕。華藝線上圖書館。https://doi.org/10.6833%2fCJCU.2013.00025

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