臺灣博碩士論文加值系統

研究背景
台灣全民健保開辦以來，國家提供了醫療的可近性、醫療科技使得國民平均餘命增加，醫療的需求與日俱增，醫院醫師人力因而無法負荷健康問題需求，照護品質呈現供不應求狀況，國家衛生發展政策引進專科護理師，承接醫師的部分角色，減少臨床醫師及住院醫師的業務量，未來醫師納入勞基法後，臨床醫師或住院醫師因工時受限，人力資源將會更加不足，目前人力選擇仍以專科護理師為主要考量。台灣醫院加護病房的制度有好幾種不同的模式，到底哪一種制度比較好，目前還沒有一個有一定的答案。故此研究目的為探討重症病患照顧品質的決定因素。
研究方法
採納2015年1月1日至2015年12月31日入住三家不同制度醫院(一家醫學中心及兩家區域醫院)的加護病房制度資料及病患資料。使用Cox 比例風險模型統計方法調整病患APACHE II疾病嚴重度分數、性別、年齡、住加護病房診斷等變項，來比較三家醫院病患在加護病房的死亡風險。最後用加護病房病患死亡風險及標準化死亡比(Standardized mortality ratio, SMR)來比較三家醫院的加護病房照護品質。
研究結果
三家醫院共收納了2926筆資料。結果顯示整天的主治醫師人力，A醫院有6位、B醫院2.2位、C醫院2位；在白班主治醫師與病患比，A醫院1:7.5、B醫院1:25、C醫院1:16；夜班主治醫師與病患比，A醫院1:15、B醫院1:30、C醫院1:16； 整天的住院醫師及專科護理師人力，A醫院有6位、B醫院7位、C醫院1位；白班住院醫師及專科護理師與病患比，A醫院1:7.5、B醫院1:7.5、C醫院1:10.6；夜班住院醫師及專科護理師與病患比，A醫院1:15、B醫院1:10、C醫院無夜班人力；在加護病房病患死亡風險方面，B醫院及C醫院都比A醫院較高的(B醫院 VS. A醫院 HR=1.544倍，P<0.001；C醫院 VS. A醫院 HR=2.768倍，P<0.001)；而在APACHE II分組後的SMR可以發現，A醫院在APACHE II分組 0~14分的SMR為0.34 (CI: 0.13 ~ 0.69)，跟C醫院一樣 (SMR = 0.34，CI:0.19~0.54)，比B醫院要低(SMR = 0.65，CI:0.44~0.92)，A醫院在另外兩組APACHE II分組的SMR分數均較其他兩家醫院低。 在敗血性休克的死亡率，APACHE II 0~14分組別中，A醫院死亡率12.5%，B醫院死亡率2.9%，C醫院死亡率12.8%，P=0.117；APACHE II 15~25分組別中，A醫院死亡率16.1%，B醫院死亡率13.1%，C醫院死亡率44.4%，P<0.001；APACHE II ≧26分組別中，A醫院死亡率34.8%，B醫院死亡率34.8%，C醫院死亡率60.5%，P=0.017。
研究結論
本研究結論發現結構面上，有較多人力資源的醫院相對有較好的醫療照護品質，在這三家醫院的人力制度中以A醫院(醫學中心)人力資源最充足，照護品質比其他兩家醫院好；兩家區域醫院互相比較，主治醫師人力較缺乏的B醫院，其加護病房病患死亡風險比C醫院還要低，而專科護理師人力較充足的B醫院是可以降低病患在加護病房的死亡風險；在過程面，B醫院有較低在敗血性休克死亡率，其中一個原因是B醫院對於敗血症指引的監測頻率較密切，另一個原因可能是因為專科護理師對於臨床指引的完成度比較高。因此本篇研究認為人力資源的使用對於病患的結果面有很大的影響，但是在臨床醫療決策的策略也會對病患的結果面有影響。

BACKGROUND
Ever since National Health Insurance system was implemented in Taiwan, the government has provided medical accessibility, and medical technologies have increased the average life expectancy of people in Taiwan. Medical needs have been increased day by day, and hospitals’ doctor manpower cannot meet the need of health problems, which results in the short supply of healthcare and affects care quality. National health development policies introduce nurse practitioners to play a part of role of doctors and reduce the workload of clinical doctors and residents. After doctors are included in the Labor Standards Act in the future, due to the limited working hours of clinical doctors or residents, the lack of human resources will be even more serious. At present, in terms of manpower choices, nurse practitioners are still the priority choice. There are many different types of intensive care unit systems in hospitals in Taiwan, and it is still uncertain which one is better. Therefore, the purpose of this study is to investigate the decisive factors affecting the care quality of critically ill patients.

METHODS
This study collected the ICU system data and patient data of 3 hospitals implementing different systems (1 medical center and 2 regional hospitals) from January 1, 2015 to December 31, 2015 to perform a retrospective analysis. This study used Cox Proportional Hazard Regression Model to adjust variables, such as patients’ APACHE II score, gender, age, and ICU diagnosis to compare the death risk of patients at ICUs in 3 hospitals. In the end, this study used death risk of patients at ICU and standardized mortality ratio (SMR) to compare the care quality of ICUs in 3 hospitals.

RESULTS
This study collected a total of 2,926 pieces of data from 3 hospitals. The results showed that, in terms of the manpower of attending physicians, there were 6 attending physicians in Hospital A, 2.2 attending physicians in Hospital B, and 2 attending physicians in Hospital C. For the proportion of attending physicians on day shift to patients, that in Hospital A was 1:7.5, that in Hospital B was 1:25, and that in Hospital C was 1:16; the proportion of attending physicians on night shift to patients in Hospital A was 1:15, that in Hospital B was 1:30, and that in Hospital C was 1:16; number of residents and nurse practitioners on 24-hour shift in Hospital A was 6, that in Hospital B was 7, and that in Hospital C was 1. The proportion of residents and nurse practitioners on day shift to patients in Hospital A was 1:7.5, that in Hospital B was 1:7.5, and that in Hospital C was 1:10.6; the proportion of residents and nurse practitioners at night shift to patients in Hospital A was 1:15, that in Hospital B was 1:10, and that in Hospital C was 0 (no residents and nurse practitioners on night shift). The death risk of patients at ICU in both Hospital B and Hospital C was higher than that in Hospital A (Hospital B VS. Hospital A HR=1.544, P<0.001; Hospital C VS. Hospital A HR=2.768, P<0.001). For the SMR after the division of APACHE II score groups, the SMR of APACHE II scope group 0~14 points in Hospital A was 0.34 (CI: 0.13 ~ 0.69), which was the same as that in Hospital C (SMR = 0.34, CI:0.19~0.54) and was lower than that in Hospital B (SMR = 0.65, CI:0.44~0.92). The SMR of other two APACHE II score groups in Hospital A was lower than that in other two hospitals. For APACHE II score group 0~14 points, the mortality of septic shock in Hospital A was 12.5%, that in Hospital B was 2.9%, and that in Hospital C was 12.8%, P=0.117. For APACHE II score group 15~25 points, the mortality in Hospital A was 16.1%, that in Hospital B was 13.1%, and that in Hospital C was 44.4%, P<0.001. For APACHE II score group ≧26 points, the mortality in Hospital A was 34.8%, that in Hospital B was 34.8%, and that in Hospital C was 60.5%, P=0.017.

CONCLUSIONS
The results showed that, in terms of structure, the medical care quality of hospitals with more human resources was relatively better. For the manpower system in these 3 hospitals, the human resources of Hospital A (medical center) were most sufficient, and its care quality was better than that of other two hospitals. For the comparison between the two regional hospitals, the death risk of patients at ICU in Hospital B where there were fewer attending physicians was even lower than that of those at ICU in Hospital C. Therefore, more sufficient manpower of nurse practitioners in Hospital B could reduce the death risk of patients at ICU. In terms of process, the mortality of septic shock in Hospital B was lower. One of the reasons might be that the monitoring frequency of sepsis guidance in Hospital B was higher, and another reason might be that the complete rate of clinical guidelines of nurse practitioners was higher. Therefore, this study suggested that the use of human resources has a significant influence on the outcome of patients. However, the strategies of clinical medical decision-making also have an influence on the outcome of patients.

目錄
目 錄 i
誌謝 ii
中文摘要 iii
Abstract v
圖目錄 viii
表目錄 ix
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究問題 4
第三節 研究重要性 5
第四節 研究目的 6
第二章 文獻探討 8
第一節 醫療品質 8
第二節 專科護理師制度 10
第三節 第二代急性生理與慢性生理健康評分 12
第四節 第二代急性生理與慢性生理健康預測死亡率及標準死亡比 14
第五節 文獻查證總結 15
第三章 研究設計與方法 24
第一節 研究架構 24
第二節 研究假設 26
第三節 研究對象與資料來源 27
第四節 研究設計 29
第五節 研究變項操作型定義 31
第六節 分析方法 33
第四章 研究結果 34
第一節 描述性統計分析 34
第二節 推論性統計分析 36
第五章 討論 49
第六章 結論 51
第一節 研究結論 51
第二節 研究建議與限制 52
參考文獻 53
附錄 57

圖目錄
圖3-1 研究架構圖 25
圖3-2 風險相關調整後研究架構圖 25
圖3-3 樣本篩選流程圖 30

表目錄
表1-1 三家醫院類別及人力分佈表 7
表2-1 加護病房醫師與病患比例(結構面影響結果面)文獻整理表 16
表2-2 醫學中心與區域醫院照護品質比較(結構面影響結果面)文獻整理
表17
表2-3 使用臨床指引(過程面影響結果面)文獻整理表 18
表2-4 專科護理師與住院醫師在加護病房照護品質之(結構面影響結果
面)文獻整理表 19
表2-5 專科護理師與住院醫師在加護病房照護品質(結構面影響結果面)
之其他文獻整理表 20
表2-6 APACHE II 評分表 21
表2-7 APACHE II 診斷加權表 23
表4-1 三家醫院照顧人力比、床數、病患量及周轉率 40
表4-2 三家醫院樣本基本分析表 41
表4-3 各變項與死亡風險關係表 42
表4-3 各變項與死亡風險關係表(續) 43
表4-4 用Cox Regression 控制醫院、性別、診斷、APACHE II變項後
與死亡風險的關係表 44
表4-5 在控制變項後比較A醫院與其他兩家區域醫院的死亡風險表 45
表4-6 用SMR來分析三家醫院分別在不同APACHE II 分組下的照護結果
表 46
表4-7 用SMR來分析三家醫院分別在不同疾病診斷下的照護結果表 47
表4-8 經APACHE II 分3組後三家醫院的敗血性休克死亡率比較表 48

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