探討新制醫院評鑑專責胸腔專科醫師在呼吸照護中心之結果

Explore the Outcome of New Hospital Accreditation Specific Duty Chest Physician in the Respiratory Care Center

目的：100年版的醫院評鑑規範呼吸照護中心（respiratory care center, RCC）應由具備胸腔醫學訓練之內科專責專科醫師（specific duty chest physician）及醫療照護團隊提供呼吸照護服務。文獻證明加護病房設置全職專責主治醫師（intensivist）可改善病患照護品質，降低醫療資源。本研究比較RCC設置intensivist、非專責胸腔專科醫師及專責胸腔專科醫師之結果差異，並討論影響RCC病患死亡及呼吸器脫離之風險因子。方法：本研究收集某醫學中心2004-2005年設置intensivist（全職在RCC執行醫療業務，無兼任門診者）、2008-2009年設置非專責胸腔專科醫師（兼顧門診、普通病房及RCC業務）及2011-2012年6月設置專責胸腔專科醫師（限制每週至多3個半天門診，其餘時間皆在RCC執行業務）所有RCC病患之回溯性資料。結果：共收集2,575位RCC病患，平均年齡69歲。APACHE II分數16.68。RCC死亡率23.90%、呼吸器脫離率50.68%。intensivist設置時，呼吸器使用天數、RCC天數、費用及下轉率均低於非專責胸腔專科醫師及專責胸腔專科醫師設置時（p ＜ 0.001），但呼吸器脫離率及共病症比率則高於非專責胸腔專科醫師及專責胸腔專科醫師設置時（p ＜ 0.05）。結論：intensivist的設置與非專責胸腔專科醫師及專責胸腔專科醫師設置之結果，在整體病患資源利用及呼吸器脫離率上有差異，但在校正後之死亡率則沒有差異。

Objectives: According to the Latest Hospital Accreditation Standards, specific duty chest physician and the healthcare team should deliver the respiratory care provided by the Respiratory Care Center (RCC). It has been shown in literatures that full-time intensivists improve the quality of patient care and reduce medical resource utilization. The study compares the quality of care in RCC staffed by full-time intensivists, part-time responsible chest physicians and nearly fulltime responsible chest physicians and analysis risk factors for mortality and weaning rates in RCC patients. Methods: Retrospective data were collected and analyzed from all RCC patients in a medical center cared for by full-time intensivists (no ambulatory clinics) from 2004 to 2005, part-time responsible chest physicians (no limitation of ambulatory and in-patient care and RCC) from 2008 to 2009, and nearly full-time responsible chest physicians (allow 3 half-day outpatient clinics or less per week) from 2011 to June 2012. Results: There were 2,757 RCC patients in the study with an average age of 69 years, APACHE II scores of 16.68, RCC mortality of 23.90%, weaning rates of 50.68%. Patients cared for by the full-time intensivists had a shorter RCC and ventilator days, lower RCC costs, lower RCC transfer rates (p＜0.001), and higher weaning and less complication rates mortality incidence (p＜0.05) than those cared for by the part-time and nearly full-time responsible chest physicians. Conclusion: There were differences in the overall use of healthcare resources and weaning rates among the patients cared for by full-time intensivitsts, part-time responsible chest physicians, and nearly full-time responsible chest physicians but no difference in mortality rate.