| Summary: | 碩士 === 國立陽明大學 === 醫務管理研究所 === 105 === 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.
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