內科加護病房非計畫性再轉入影響因素之評估與探討

Abstract

加護病房是收治病情嚴重與危急病患的醫療單位，所消耗著醫療健保資源，高達醫療院所支出成本的20~30%。加護病房非計劃性重返不僅耗用更多的醫療資源，更可能導致醫療照護不良或失誤的事件，造成病患的傷害。民國88年8月，財團法人醫院評鑑暨醫療品質策進會推行之台灣醫療品質指標計畫，針對加護病房提出了『非計畫性重返』的指標。要將病情穩定的重症病患移轉至普通病房，多是以該加護單位負責的專責重症專科醫師的主觀判斷為多。有專責重症專科醫師負責照護的加護病房，對於加護病房照護品質的提升有所助益。 本研究以北部某醫學中心之4個內科加護病房為主，自民國95年9月1日~97年8月31日，為期2年之住院病患資料作為分析，依收案條件及排除條件後，最終共收案2835人次。本研究收案病患以男性居多，平均年齡為66.52歲，>65歲人次佔總收案人次的62.33%，以急診為主要的病患來源，轉入時APACHE II score-I平均為23，加護病房住院天數平均為10.11天，轉出時APACHE II score-II平均為13，以轉至普通病房為最多，以脫離呼吸器為主，死亡率約為30.34%。 非計畫性重返有226位病患，往返加護病房510人次，重返率平均為14.83%。重返收案病患以男性居多，平均年齡為67.94歲，年齡>65歲約68.58%，以普通病房為主要病患來源，轉入時APACHE II score-I平均為21，加護病房住院天數平均為11.45天，轉出時ACHE II score-II平均為15，以脫離呼吸器為主，死亡率為33.63%。加護病房重返時間間距平均為15.85天，距離上一次離開加護病房時間以大於72小時為最多。 多變項Logistic regression分析後發現，年齡>65歲以上者加護病房重返的風險是≦65歲者的1.56倍；來自急診或其他加護病房的病患加護病房重返的風險，是來自病房或呼吸照護中心／病房的病患之0.49倍；轉入加護病房時APACHE II score-I >23的病患加護病房重返風險是APACHE II score-I ≦23者的0.64倍；轉出加護病房時APACHE II score-II >13的病患加護病房重返風險是APACHE II score-II ≦13者的1.76倍。 在本研究中，各組研究專責重症專科醫師，在非重返組及重返組收案病患，各變項統計皆無統計上的差異，這與國外學者之結論並不完全相同。可能的原因應與醫院整體制度有關，因研究醫學中心之內科加護病房，實施加護病房專責重症專科醫師制度多年，在重症照護經驗上，經由定期的文獻與案例討論，專責重症專科醫師們彼此交換照護心得，累積經驗，這並不限制於個人年資，因此，本研究無法判斷『專責重症專科醫師』的年資對加護病房病患照護的助益。 當加護病房的使用為因應不同的醫院制度與需求而有個別差異時，單純以加護病房重返率，作為評估專責重症醫師的效能，或加護病房之品質照護指標似乎並不恰當。因此，若能合併其他相關指標，如：住院死亡率、病危自動出院率等，並考量各醫療院所加護病房的病患特質，將能更有效反應出整體加護病房之照護品質，及醫療資源運用的效率。

As an important facility to treat critically ill patients in the hospital, the operation of the intensive care units (ICUs) may result in a substantial consumption of medical resources of the hospital, edtimated up to 20% ~ 30% of the hospital expenditure. Among the adverse conditions concerning ICU operations, non-planned readmission to the ICUs might not only consume additional medical resources, but might also increase the risk for adverse events to the patients during the transfer process. Since August of 1999, the Taiwan Joint Commission on Hospital Accreditation and Quality Improvement had established the Taiwan Quality Indicator Project for measurement of the healthcare quality, and one of the important indicators regarding critical care was the “Unscheduled returns to the ICUs”. Although the decision on transfer of ICU patients to the general wards depends mostly on the intensivists, we hypothesized that a careful understanding of factors associated with unscheduled ICU return might provide useful information for the intensivists care unit to improved their transfer decisions as well as the quality of ICU care. This study was conducted in 4 medical ICUs in a referred medical center at northern Taiwan. During a 2-year study period, from September 1, 2006 to August 31, 2008, patients admitted to those ICUs were evaluated for inclusion into this study, and when eligible, their pertinent data were analyzed. A total of 2,835 cases were included in this study, with an average age of 66.5 years, and of whom 62.3% were older than 65 years. The emergency department was the most common source of admission to the ICUs; the APACHE II score on admission to the ICU was 23. The average length of stay in the ICU was 10.1 days, while the APACHE II score upon tranfer out from the ICU was 13. The most common destiny of transfer was the general ward. The in-hospital mortality rate was 30.34%. A total of 226 cases were found to have non-planned readmission to the ICU, who accounted for a readmission rate of 14.8%. The average age of these patients was 67.9 years, with 68.6% of them more than 65 years of age; the general ward accounted for the the main source of readmission. The APACHE II score of of them upon first admission to the ICU was 21, with an ICU length of stay of 11.5 days, while the APACHE II score upon tranferring out from ICU was 15. The in-hospital mortality rate was 33.63%. The average interval from ICU transfer out to readmission was 15.9 days. Multivariate logistic regression analysis showed that an age of older than 65 years is independently associated with an increased risk of readmission to ICU (odds ratio 1.56), whereas patiens admitted from the emergency department had less risk for readmission than those admitted from the general ward (OR = 0.49). Furthermore, patients with an admitting APACHE II score of more than 23 points had a less risk of readmission than those with a score of less than 23 (OR = 0.64), while those with an APACHE II score of more than 13 upon transfer-out from ICU had more risk for readmission than those with point of less than 13 (OR = 1.76). In this study, there was no significant difference of the variables among different intensivists; this finding was not similar to the findings reported by other investigators in the literature. One possible reason that might explain this finding is the difference of system design for physicians that dedicate for caring patients in the ICU in the hospital. Despite the call for dedicated intensivist for ICU for many years, as frequently proposed and discussed in the literure, it appeared that there had remained limited exchange of experience and knowledge between intensivists. Therefore, is remained difficult to evaluate the contribution of dedicated intensivists in the improvement of critical care quality, especially based on this indicator, unplanned readmission to the ICU. It is important that we should be very judicious to use unplanned return to the ICU as a quality indicator when the issue is to assess the quality of care in the intensive care units, since the hospitals might modify the structure and process of care, based on the mission of the institute, patient flow/volume, and the relative risks. This indicator should also be used very carefully as a tool to evaluate the performance of dedicated intensivists, since there might be multiple factors contributing to the risk for readmission to the ICU. It is therefore highly recommended that simultaneous use of multiple indocators, such as in-hospital mortality rate, the rate of critical discharge against medical advice, as well as adjustment according to the characteristic of ICU and case mix, might provide more information concerning the overall quality of care in the ICUs and reflect the performance of the intensivists. This will also help to achieve better resource allocation of the healthcare system.