| 摘要: | 加護病房死亡率為台灣臨床成效指標(Taiwan Clinical Performance Indicator, TCPI)中綜合照護類別指標之一，係加護病房照護品質監控項目，是一項重要的結果面指標。透過該指標與其他照護監測指標間的分析與研究，可達到持續進行品質控制與監測及預防照護的疏失，進而提升重症加護單位病人照護品質與安全，持續作為醫院內部品質監測與管理成效之依據。
本研究採個案研究方式，以個案醫院中四區成人內科加護病房（46床）、三區外科加護病房（35床）於2014年至2016年期間，每月提報至TCPI系統中之加護病房死亡率及其相關17項監測指標，做為本研究之變數，合計18項變數，每項變數共36筆之數據，來探討不同屬性之加護病房與其監測指標間的差異與相關性。經研究分析後得到以下結果：
一、加護病房死亡率等七項監測指標於內、外科加護病房間達顯著差異。
二、呼吸器使用、中心導管相關血流感染(CLABSI)、留置導尿管相關尿路感染(CAUTI)三項指標皆呈現顯著差異，以內科加護病房顯著大於外科。中心導管使用、留置導尿管使用及呼吸器相關肺炎(VAP)三項指標亦呈現顯著差異，外科加護病房顯著高於內科。
三、內科加護病房死亡率與各項監測指標於不同季節間，僅「留置導尿管相關尿路感染」指標達顯著差異。外科加護病房死亡率與各項監測指標中，僅「壓瘡」指標於不同季節間，達顯著差異。
四、內科加護病房死亡率與各項監測指標中，僅「24-48小時內非計畫性重返加護病房」、「中心導管使用」、「呼吸器使用」與「約束」於不同住院日數(LOS)間，達顯著差異。
五、內科加護病房死亡率與各項監測指標中，僅「24小時內非計畫性重返加護病房」、「48小時以上非計畫性重返加護病房」，達顯著低度相關。
六、內科加護病房各17項監測指標中，僅「24小時內非計畫性重返加護病房」為內科加護病房死亡率之影響因子。外科加護病房各17項監測指標中，僅「留置導尿管使用」及「呼吸器使用」為外科加護病房死亡率之影響因子。
由本研究結果發現，個案醫院加護病房死亡率及部分監測指標於內、外科加護病房間有顯著差異；內、外科加護病房死亡率及部分監測指標在季節、住院日數間存在差異；但內、外科加護病房死亡率與不同監測指標間之相關性，尚無法於本研究中獲得證實；「24小時內非計畫性重返加護病房」、「留置導尿管使用」及「呼吸器使用」，分別為內科及外科加護病房死亡率之影響因子。建議內、外科加護病房依專科屬性差異，重新制定台灣臨床成效指標監控項目並建立定期調整機制，持續監控及檢討「24小時內非計畫性重返加護病房」、「24-48小時內非計畫性重返加護病房」、「中心導管使用」、「呼吸器使用」、「留置導尿管使用」、「氣管內管滑脫」與「約束」等指標，進而維護及提升重症加護單位病人照護品質與安全。
Intensive care unit mortality is one of the general care category indicators in the Taiwan Clinical Performance Indicator (TCPI). The intensive care quality monitoring project is an important outcome indicator. The analysis and study among those indicators could do continued quality control and monitoring and prevent carelessness then to improve the quality and safety of patient care in critical care units as the basis of internal quality monitoring and management effectiveness of hospital constantly.
We reviewed and collected 17 indicators of TCPI that were monitored for boht medical and surgical ICU from 2014 to 2016 by month. The mortality rate of both ICUs was also collected in this period. The association between these indicators and mortality rate was analyzed. The relationship among all indicators was examined. Furthermore, the comparison between medical (46 beds) and surgical (35 beds) ICU was performed. The main findings of our study are listed as below:
1. Significant difference in 7 performance indicators was noted between medical and surgical ICUs.
2. The use of ventilator, the incidence of central catheter-related bloodstream infection (CLABSI) and the incidence of catheter-related urinary tract infection (CAUTI) were higher in medical ICU than surgical ICU. The use of central venous catheters, the indwelling catheters and the incidence of ventilator-associated pneumonia (VAP) were higher in surgical ICU than medical ICU.
3. In medical ICU, except CAUTI, there was no significant difference among seasons in mortality and other indicators. It is only the incidence of pressure sore that revealed seasonal difference in all the indicators in surgical ICU.
4. Significant difference in the return to ICU unplanned within 24 to 48 hours, the use of central venous catheter, the use of ventilator and restraint was noted among the different length of stay (LOS).
5. The return to ICU unplanned within 24 hours, and the return to ICU unplanned more than 48 hours were lower but significant correlation with mortality rate in medical ICU.
6. Regression analysis indicated the return to ICU unplanned within 24 hours was the significantly independent factor associated with mortality rate in medical ICU. In surgical ICU, the indwelling catheter use and the use of ventilator use were two significantly independent factors related to mortality of surgical ICU.
Our results found the mortality rate and some indicators were significantly different between medical and surgical ICUs. With regards to the changes of season and the LOS, we noted some significant difference in terms of mortality rate and performance indicators. Several performance indicators: the return to ICU unplanned within 24 hours, the indwelling of catheter and the use of ventilator were significant factors of mortality rate of ICUs. In conclusion, due to the results of our study, it is suggested that the TCPI monitoring project adjustment and management mechanism be reformed based on the differences between medical and surgical ICUs. The continuous monitoring and review of those indicators of the return to ICU unplanned within 24 hours, the return to ICU unplanned within 24 to 48 hours, the use of central venous catheter, the use of ventilator, the indwelling catheter use, endotracheal tube removal unplanned and restraint could maintain and improve the quality and safety of patient care in critical care units. |
