入住外科加護病房對於醫療資源以及病人結果之分析與討論

ADMISSION TO SURGICAL INTENSIVE CARE UNITS: IMPACT ON THE RESOURCE UTILIZATION AND THE PATIENT OUTCOME

背景與目的：許多醫學會的照顧指南都擬訂入住加護病房的參考標準且發表於文獻上。然而外科病人有其特殊性因而無法完全根據這些入住標準決定是否應收治到外科加護病房。因此，本研究探討目前本院入住外科加護病房的執行模式是否會影響醫療資源的運用與分配以及病人臨床之結果。 研究方法：我們依照前瞻性的方式收集所有在2013一月一日至2014年六月30日入住台北市某家醫學中心的外科加護病房之外科病人的相關資料。我們根據入住加護病房的時間分成短期住院（小於48小時）與常規住院（大於48小時）兩組，兩組病人的背景資料以及臨床結果作分析與比較。統計學上有意義的標準則訂在p<0.05。 研究結果：在這十八個月當中，一共有1,278病人入住外科加護病房，而其中有408位病人入住時間短於48小時（平均20.73±5.30小時)。這些短期入住外科加護病房的病人族群有較高的比率是手術後的病人同時入住的病情嚴重度（APACHEII）分數也比較低。 同時，再次入住加護病房的比率也顯著的較低（1.69% vs. 4.04%, p<0.05）。當外科加護病房有短期入住病人時，比較多的急診外科病人必須轉入住到內科加護病房或是燙傷中心。 結論：根據本研究的初步結果發現，若外科加護病房有空床時，且病人之醫師認為有需要入住時，多能入住到加護病房。但是這樣的運作模式也有一些缺失，包括較多的嚴重病人必須轉住其他加護病房，造成外科加護病房較多的護理照顧壓力，花費更多的醫療資源。解決這些問題的根本在於訂定適用於外科病人的入住加護病房的標準外，醫院應該積極設置高階的監控病床（step-down units）來放置無法轉至普通病房但不需流置於外科加護病房之病人才是。

 

Introduction: Despite many published guidelines for appropriate admission to the intensive care unit (ICU), surgical patients are frequently admitted to the surgical ICU without following these criteria. The purpose of this study was therefore to examine the impact of our practice of the SICU admission on the utilization of hospital resources and patient outcomes. Methods: We prospectively collected information of all surgical patients admitted to SICU between January 1, 2013 and June 30, 2014. We compared demographic data and clinical outcome of those admitted for less than 48 hours (short stay) with data of those staying in SICU for longer than two days (regular stay). Results: There were 408 out of 1,278 patients admitted to SICU for less than 48 hours (mean=20.73±5.30 hours). These short stay patients were more likely to have operations and with lower admission APACHE II scores. The readmission rates to SICU within 48 hours were significantly lower for short stay patients (1.69% vs. 4.04%, p<0.05). Finally, more emergency room patients were admitted to the MICU or burn unit due to lack of available SICU beds when the unit had short stay patients. Conclusion: Our policy of liberal admission of surgical patients to SICU has its merit especially when SICU beds are available. However, it does have some drawbacks including diverting patients to nonsurgical ICUs, placing more pressure on nurse staffing, and spending more medical resources. It is time to develop more stringent criteria for SICU admission and to design stepdown units to serve as a gap between ICU and wards in order to free SICU beds for more critical patients.