國立台北護理學院醫護管理學系碩士論文中文摘要
研究所別：醫護管理學系碩士班
論文名稱：臺北市立綜合醫院加護病患不同時段轉出的預後比較
指導教授：陳素秋
研究生：鄭聰美
研究提要內容：
老年人口的增加、慢性病的增多，增加加護病床的須求。Goldfrad and Rowan (2000)比較日、夜間轉出加護病房之死亡率，在統計上顯著差異，但調整非計劃性中因床位短缺而早期轉出之因素後，則無統計上顯著差異。故本研究以加護病患不同時段轉出的預後，比較了解夜間計劃性轉床其可行性，以利增加床位的應用。
本研究工具採回溯病歷調查追蹤方式，研究母群體為民國89年7月1日至90年6月30日入院台北市立各家綜合醫院內科加護病房符合資格之內科病患。研究樣本則為回函同意接受病歷調閱之四家醫院中的所有同時期同資格之病患，共1040人，並以邏輯斯迴歸、存活分析推論之。
研究結果發現三個不同時段（08時00分-11時59分、12時00分-15時59分、16 時00分-07時59分）轉出加護病房者其病房死亡率(Log-rank p = 0.1984)及重返加護病房率(Log-rank p = 0.8077) 在統計上並沒有顯著差異。比較由加護病房轉到病房三個不同時段其基本資料包括年齡、性別、病患來源、入院acute physiology Score（APS） 分數、轉出APS分數、有無慢性病，統計結果轉出APS分數，有顯著差異。加入其他調整變項年齡、入院APS、轉出APS、有無慢性病、病患來源、性別、加護病房住院天數、病房住院天數、轉入病房時段、醫院別後，三個時段之病房死亡機率及重返加護病房機率在統計上也無顯著差異。未來建議病患若符合轉出加護病房條件，則轉出時間不限於正式的上班時間（08時-16時）而能彈性於下班時間轉出，不但可以減少病患加護病房症候群且避免因滿床導致重症病患無加護病床的困境。

ABSTRACT
Graduate School：Department of Health Management, National Taipei College of Nursing.
Title：Prognostic Comparisons of different time patients’ discharges from Intensive
care units in Taipei municipal general hospitals
Advisor：Su-Chiu Chen
Author：Tsong-Mei Cheng
The increase of the life expectancy and chronic disease in human population has increased the demand of intensive care beds. Goldfrad and Rowan (2000) compared the mortality of the day and night time discharges in intensive care patients. They found that there was no statistical difference between the mortality of day and night time discharges after adjusting the planned discharges. Therefore, this research is to understand the practicability of planned night discharges by comparing the prognostics of various time discharges from patients in intensive care units.
This research design was a retrospectively prospective study by abstracting patients’ medical charts, following up in intensive care units, and also linking national death files. Research population was patients hospitalized in medical intensive care units of Taipei municipal general hospitals from July 2000 to June 2001. A sample of 1,040 available patients were from four of the above hospitals that the consent letter was signed. Logistic regression analysis and survival statistical analysis were performed.
The results showed that there was no statistical difference among three discharging times (08:00-11:59, 12:00-15:59, 16:00-07:59) for the morality (log-rank p = 0.1984) and readmission (log-rank p =0.8077). Only acute physiology Score (APS) in discharges showed a statistically significant difference among three discharging times, other variables such as age, gender, patients’ resources, APS in admission, and chronic diseases in 661 discharged patients in intensive care units were not. Moreover, there was no statistically significant difference among three discharging times form mortality and readmission after adjusting hospital, age, gender, patients’ resources, APS in admission, APS in discharge, and chronic diseases, length of stay (LOS) in intensive care unit, LOS in general ward.
For policy discussion, it is suggested that planned patient’ discharges from intensive care unit can be extended to the time after official hour (16:00-20:00) in order to increases the flexible utilization of the intensive care beds.

目錄
頁次
誌謝……………………………………………….……………………………….Ⅰ
中文摘要…………………………………………………………………………. Ⅲ
英文摘要…………………………………………………………………………. Ⅴ
目錄………………………………………………………………………………. Ⅶ
表目次……………………………………………………………………………. Ⅸ
圖目次……………………………………………………………………………. Ⅹ
第一章 諸論…………………………………………………………………….….1
第一節 研究背景與動機…………………………………………………….….1
第二節 研究目的…………………………………………………………….….3
第三節 研究問題…………………………………………………………….….3
第二章 文獻探討……………………………………………………………….….5
第一節 夜間轉出加護病房情形…………………………………………….….5
第二節 評分系統…………………………………………………………….….10
第三節 重返加護病房……………………………………………………….….17
第四節 總結………………………………………………………………….….24
第三章 研究架構…………………………………………………………….….…25
第一節 概念性架構……………………………………………………………..25
第二節 操作性定義………………………………………………………….….26
第三節 研究假設…………………………………………………………….….27
第四章 研究設計…………………………………………………………………. 28
頁次
第一節 研究材料…………………………………………………………….….28
第二節 資料處理及分析…………………………..…………………..…….….29
第三節 統計分析……………………………………………………………..….29
第五章 研究結果……………………………………………………………….….31
第一節 研究樣本描述……………………………………………………….….31
第二節 病房存活率及重返加護病房率比較…………………………….….…34
第三節 假說檢定………………………………………………………….….…51
第六章 討論與建議………………………………………………………….….…53
第一節 討論……………………………………………………………….….…53
第二節 政策討論………………………………………………………….….…54
第三節 研究推論………………………………………………………….….…56
第四節 研究限制………………………………………………………….….…57
第五節 未來研究方向與建議…………………………………………….….…58
參考文獻
中文部分…………………………………………………………………………59
英文部分…………………………………………………………………………60
附錄
附錄一 病歷調查……………………………………………………………..…63
附錄二 判定變項標準………………………………………………………..…67
附錄三 無母數分析…………………………………………………………..…70

參考文獻
中文部分
王榮德（1998）。流行病學方法論-猜正與否正的研究（第五版）。台北：健康文化。
陶阿倫(2000)。加護病房評估疾病嚴重度知之資料正確性性。醫療品質雜誌，1(1)，1-11。
英文部分
Angus, D. (2000). Scoring system fatigue and the search for a way forward. Critical Care Medicine, 28 (6), 2145-2146
Angus, D.C. (1998). Grappling with intensive care unit quality: Does the readmission rate tell us anything ? Critical Care Medicine, 26(11), 1779-1780.
Bosman, R. J., Oudemans, V. S. H. M., & Zandstra, D. F. (1998). The use of intensive care information systems alters outcome prediction. Intensive Care Medicine, 24(9), 953-958.
Brilli, R. J., Spevetz, A., Branson, R. D., Campbell, G. M., Cohen, H., Dasta, J. F., Harvey, M. A., Kelley, M., Kelly, K., Rudis, M. I., St. Andre, A. C., Stone, J. R., Teres, D., & Weled, B. J. (2001). Critical care delivery in the intensive care unit: Defining clinical roles and the best practice model. Critical Care Medicine, 29(10) 2007-2019.
Chen, L. M., Martin, C. M., Morrison, T. L., & Sibbald, W. J. (1999). Interobserver variability in data collection of the APACHE II score in teaching and community hospitals. Critical Care Medicine, 27(9), 1999-2004.
Chen, L. M., Martin, C. M., Keenan, S. P., & Sibbald, W. J. (1998). Patients readmitted to the intensive care unit during the same hospitalization: Clinical features and outcomes. Critical Care Medicine, 26(11), 1834-1841.
Cooper, G.S., Sirio, C. A., Rotondi, A. J. (1999). Are readmissions to the intensive care unit a useful measure of hospital performance? Medical Care, 37(4), 399-408.
Damiano, A. M., Bergner, M., Draper, E.A., Knaus, W. A., & Wagner, D. P. (1992). Reliability of a measure of severity of illness: Acute physiology and chronic health evaluation-II. Journal Clinical Epidemiology, 45(2), 93-101.
Dawson, S., & Runk, J. A. (2000). Right Patient? Right Bed? A Question of Appropriateness. Advanced Practice in Acute & Critical Care, 11(3), 375-385.
Durbin, C. G. & Jr, Kopel RF. A (1993). case-control study of patients readmitted to the intensive care unit. Critical Care Medicine, 21, 1547-1553.
Fery, L. E., Landais, P., Loirat, P., Kleinknecht, D., & Brivet, F. (1995). Evaluation of severity scoring systems in ICUs: Translation, conversion and definition ambiguities as a source of inter-observer variability in APACHE II SAPS and OSF. Intensive Care Medicine, 21(4), 356-360.
Goldfrad, C., & Rowan, K. (2000). Consequences of discharges from
intensive care at night. The Lancet, 355(9210), 1138-1142.
Gunning, K., & Rowan, K. (1999). ABC of intensive care: Outcome data and scoring systems. British Medical Journal, 319(7204), 241-244.
Holt, A. W., Bury, L. K., Bersten, A. D., Skowronski, G. A., & Vedig, A. E. (1992). Prospective evaluation of residents and nurses as severity score data collectors. Critical Care Medicine, 20(12), 1688-1691.
Konarzewski, W. (2000). Continuing to use APACHE II scores ensures consistency. British Medical Journal, 321(7257), 383.
Kramer, D. J. ( 2001). Intensive care unit frequent fliers: Morbidity and cost Critical Care Medicine, 29(1), 207-208.
Polderman, K. H., Thijs, L. G., & Girbes, A. R. J. (1999). Interobserver variability in the use of APACHE II scores. The Lancet, 353(9150). 380.
Rosenberg, A. L., & Watts, C.M. (2000). Patients readmitted to intensive care units: A systematic review of risk factors and outcomes. Chest, 118(2), 492-502.
Rosenberg, A. L., Hofer, T. P., Hayward, R. A., Strachan, C., & Watts, C. M. (2001). Who bounces back? Physiologic and other predictors of intensive care unit readmission. Critical Care Medicine, 29(3), 511-518.
Rosenberg, A. L., Zimmerman, J. E., Alzola, C., Draper, E. A., & Knaus, W. A. (2000). Intensive care unit length of stay: Recent changes and future challenges. Critical Care Medicine, 28(10), 3465-3473.
Shann, F. (2000). Mortality prediction model is preferable to APACHE. British Medical Journal, 320(7236), 714.
Thomas, J. W. (1996). Does risk-adjusted readmission rate provide valid information on hospital quality? Inquiry, 28, 258-264.
Tarnow-Mordi, E. O., Hau, C., Warden, A., & Shearer, A. J. (2000). Hospital mortality in relation to staff workload: A 4 year study in an adult intensive-care unit. The Lancet, 356(9225), 185-189.