加護病房醫療品質影響因素之探討

The Invsetigation of Factors Associated with ICU

本研究的目的在瞭解加護病房醫療品質現況，探討影響加護病房醫療品質的因素。以衛生署民國八十七年加護病房分級認定審查結果及相關資料進行分析。研究工具包括醫院基本資料調查表及加護病房分級認定審查評量表，量表內容含8大項：人力配置、人員素質、儀器設備、環境空間、業務量、品質管制措施、醫療處置適當性及在職訓練與發展。由重症加護專家研訂量表的項目共53細項及配分，每項以5等計分法，量表信度Cronbach’值為0.94。資料以描述性、卡方檢定、ANOVA及複迴歸分析做統計。研究結果：八十七年共審查399家加護病房，全國加護病床佔總病床7﹪，每個加護病房平均床數為10床。加護病房醫療品質審查得分高低與醫院評鑑等級有相同的趨勢，即醫學中心得分高於其他等級醫院；財團法人醫院之審查得分高於公立醫院及私立醫院；教學醫院得分較高。科別以內科得分最高，服務量越多，品質得分越高。迴歸分析顯示：1.加護病房特性：床位數、科別、業務量及佔床率，2.醫院特性：醫院評鑑類別、醫院大小、醫師病床數比，與加護病房醫療品質審查成績有顯著相關，此迴歸模型主要解釋力為70.4%。加護病房特性、醫院特性及品質審查成績之結構指標與過程指標與結果指標（死亡率、感染率及住院天數）的相關性，有正反向不同的發現。可能與採用醫院評鑑等級做控制變項，無法以病人疾病嚴重度做風險校正有關。本研究結果可提供臨床實務及管理決策抉擇之參考。

The purpose of this research was to establish the current status of ICU services and their quality and to identify the key factors associated with the quality of care. Data taken from the 1998 National ICU Accreditation Survey of all Taiwan?s hospitals covering structure and process indicators, formed the basis of this research. Eight quality of care constructs were measured by a total of 53 items including ICU staff allocations, qualifications, training, facility and equipment, environment and space, volume and occupancy rate (all structure indicators), quality assurance activities and medical management (process indicators) using five?scale response measures and weighting items in accordance with expert opinions.Outcome indicators included mortality rate, nosocomial infection rate and length of stay.The study showed that ICU beds represented 7% of all hospital beds in Taiwan. The average size of ICU units was 10 beds.Medical center ICUs had the highest overall ICU quality as compared with those in other hospital types. Multiple regression analysis showed that four ICU characteristics--ICU size, specialty, patient volume, and occupancy rate, as well as three hospital characteristics--type of hospital, hospital size, and physician to bed ratio, were significantly associated with overall ICU quality which explained 70.4% of variation in ICU quality in the 399 ICUs studied. Although significant associations were found among some of the outcome indicators and hospital characteristics, including ICU structure and process measures, the directions of associations were mixed. The contradictions were most likely due to an additional effect of patient severity not captured by the hospital type variable. Recommendations are now made to improve the current accreditation survey, and policy implications are briefly presented.