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| 題 名 | 臺灣住院病患抗生素使用適當性及相關問題的調查結果=Propriety of the Use of Antibiotics for Hospitalized Patients in Taiwan |
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| 作 者 | 許清曉; 王立信; 王任賢; 楊祖光; | 書刊名 | 院內感染控制雜誌 |
| 卷 期 | 11:5 2001.10[民90.10] |
| 頁 次 | 頁273-288 |
| 分類號 | 418.281 |
| 關鍵詞 | 抗生素; 適當使用; 衛生署醫院; 病歷稽核; 健保局; 醫療品質; Antibiotics; Appropriate use; Department of health hospitals; Chart audit; National health insurance bureau; Quality of medical care; |
| 語 文 | 中文(Chinese) |
| 中文摘要 | 在民國八十九年，我們對散佈全臺灣23冢中小型醫院的 960 本病歷做稽核，詳細瞭解病情，來調查目前臺灣中小型醫院抗生素使用的適當性。病歷的稽核由四位資深感染專科醫師分兩組，分別到十至十二家醫院查驗，每家任選十本在最近幾個月內出院、使用過抗生素的病歷。前半年及後半年各一次。抗生素之使用適當與否分為以下五個項目，每項給一至三分，每本病歷共有滿分十分：細菌培養是否作業有缺失 (兩分) 、選藥是否考慮週全 (三分) 、劑量是否合宜 (兩分) 、用藥期間長短是否適當(兩分) 、及追蹤檢查療效或其他共存疾病的調查是否足夠 (一分)。在後半年，主持人到全部二十三家稽核，更細分稽核內容為十二項，詳查用藥或處理失誤的狀況。如此，每一家每半年至少有二十本病歷被兩位稽核委員抽查，有十家在後半年的第二次稽核共被三位查驗三十本。結果，雖然在兩次稽核之間，主持人到各醫院說明抗生素之使用，但是比較兩次總平均分數幾乎足沒有變化；分別為 67.4 及 69.2 。如果比較個別醫院兩次的分數，則四家醫院有 10 分以上的進步。主持入細項分析稽核的結果顯示在23 家共 230 本病歷中，近一半沒有體重記錄；近四成選藥太輕或不全；各有近四分之一之案例是使用抗生素之期間太短、或追蹤調查不足。而至少有 11.3％ 是正以寬鬆、替主治醫師當時的可能情況著想之下，判斷其為被延誤給予適當的治療三天以上(一般是延誤五到七天)。和主治醫師對談的結果，選藥、選劑量、或決定治療期間，過於保守，檢驗調查不足，其原因幾乎一致地，郡定因為王治醫師擔心用藥費用會受到健保審查時剔除及罰款，影響醫院或自己的收入所致。抗生素使用是否得當，是醫療品質的最重要指標之一。醫阬過份地強調業績、抗生素正確使用的教學普遍地缺乏、病歷書寫不清楚等，也都是直接或間接地使這醫療品質指標低落的原因。健保局審查剔退費用的標準常依審查醫師的水準及能力而有很大的差別。這些審查醫師之間、及和健保局之間實有更頻繁地檢討、改進、建立共識的必要。(感控雜誌2001；11:273-88) |
| 英文摘要 | During the year 2000, we audited 960 medical records of 23 small-to medium-sized hospitals scattered around the country, to investigate the suitability of the use of antibiotics among hospitalized patients. Four experienced infectious disease specialists were divided into two groups, and each reviewed 10 charts of recently hospitalized patients from each of 10-12 hospitals. The audits were carried out twice a year, one in the first part of the year and the other during the latter. Evaluation of the antibiotic usage was made on the appropriateness of five following items with 1-3 points for each: bacterial culture (2 points); the choice of antibiotics (3 points); dosages of the drugs (2 points); duration of the therapy (2 points); and follow-up or other necessary clinical tests (1 point). During the latter part of the 3'ear, one of us (Hsu) audited all 23 hospitals and further divided the five items into 12, which would more clearly define the problems in the propriety of the antibiolic usage. Although lectures were given on the antibiotic usage at each hospital in between the. two audits, there was virtually no improvement in the average points gained by all hospitals as a whole, 67.4 versus 69.2. [:our hospitals showed a gain of 10 points or more. Thc more detailed evaluation indicates that 22.6% of the total of 230 charts were deemed inappropriate in carrying out the bacterial culture (not done, done after antibiotics were given, or the blood culture taken only once, etc); 37.8% in the choice of antibiotics (in- adequate coverage, such as: the use of 1s,' generation rather than the 2nd or the 3rd generation cephalosporins, for thc elderly respiratory infections, septic shock, or nosocomial infections; the lack of coverage of anaerobes, etc); 47.0 % had no record of body weight; 19.5% erred tn giving antibiotics at an improper interval without explanations; 24.3% gave 1oo short a course of antibiotic therapy (less than seven days for septicemia or for severe pneumonia, two weeks for osteomyelitis, etc): 24.7% lacked follow-up tests or other necessary studies (such as CBC; renal functions; studies for anemia, diabetes mellitus, possible hepatic tumor, or possible pulmonary tuberculosis, etc). In 11.3% of all cases the proper antibiotics were withheld (inappropriate drugs were given) for more than 3 days, most often 5-7 days, resulting in the worsening or the lack of improvement in the clinical conditions. The direct or indirect causes of the current battery of problems, (i.e. the improper choice of lower-priced drugs; inadequate dosages; too short a course of therapy; and the lack of follow-up and other necessary clinical laboratory tests), include the following: 1) too much emphasis by the hospital on the quantity rather than the quality of patient care; 2) doctors' insufficient knowledge of the proper antibiotic usage; 3) impertinent, or the lack of progress notes that result itl the rejection of the payment by the National Health Insurance Bureau (NHIB); and 4) concerns of the attending physicians for the rejection of the payment of the cost of antimicrobials with additional penalties by the NHIB which is often carried out unpredictably and sometimes erroneously. (Nosocom Infect Control d 2001;11:273-88) |
本系統中英文摘要資訊取自各篇刊載內容。