TQIP对外科预防性抗生素使用之影响.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,书山有路勤为径，学海无涯苦作舟,书到用时方恨少，事非经过不知难,09 十一月 2026,TQIP对外科预防性抗生素使用之影响,Model of a National Health System,Health Result,Management,Organization,Economic,support,Resources,Services delivery,Health Needs,Limited Medical Resources,vs.,Optimal Healthcare Quality,Low Cost vs High Effectiveness=Cost-effective,(The relationship between achieving certain objectives and consumption of resources，costs vs outcomes),Efficacy vs Effectiveness,Efficacy,is a measure of the extent to which objectives(result,cure)are achieved in real,practice settings,.,Effectiveness,concerns generalizability of results of treatment.,Healthcare Cost as%of GNP,13.4%-13.7%,(5.4%Taiwan),US Healthcare Cost in$,1.491 Trillion,Predicted increase of 10%in 2000 2.2 Trillion by 2008,Cost-Effectiveness,CLIENT,PROVIDER,PAYER,SOCIETY,Cost of Surgical Operations,Expendable supplies,Instruments,Equipment,Implants,Facility Cost,Employees,Pre-op testing,Expendable supplies,Laparotomy package,Gown,gloves and towels,Prep,EKG and oxygen finger pads,Anesthesia gases and masks,Local anesthesia and antibiotics,Medical(Year 2000),Hospital 40%,Professional 42%,Pharmacy 18%,(25%Taiwan,),Full Time Employee,Receptionist,Preop nurse,Circulating nurse,Surgical tech,Recovery room nurse,OR supervisor,COO facility-$22/hr for 9-9/5hrs for each case,$209/hr.for every case,品質成本,預防性成本：教育訓練,資格認定,指標建立,治療共識,評鑑成本：定期監測,稽核,滿意度調查,內部失敗成本：,執行前或執行中失敗之成本,外部失敗成本：錯誤導致醫療糾紛與賠償,Effectiveness-Outcome measurement,病人方面：Audit of patient outcomes(併發症,死亡率,住院日,病假日,回復工作能力,生活品質,長期結果,再發率,存活率),第三付費者：健保支出,TQIP對外科預防性抗生素使用之影響,抗生素費用是全院藥品費用支出之大宗,合理使用抗生素可避免藥物副作用,89年衛生署提出本院清淨手術抗生素之使用量偏高,院內缺乏系統性收集外科預防性抗生素使用指標,設定目標,合理化外科預防性抗生素之使用,不影響外科病患感染率為前提下,掌握使用時效,降低抗生素使用量,方 法,立意取樣：TQIP II b：CABG、THR、TKH、ATH、APP.五種術式收案對象之預防性抗生素使用,對象：醫療服務提供者,方法：Cost/Effect iveness ratio,成本效益指標,使用量,使用費用,使,用時間（過程）,院內感染率（結果）,平均住院天數（結果）,Independent t-test,分科檢討改善,修正工作流程，,例:,術前預防性抗生素改至手術室施打,(心臟外科優先，再推廣至他科),醫師準時上刀(配合醫品圈)，訂出賞罰規則,以婦產科為例,參考文獻，依據數據，全力溝通,原有CQI團隊共識,主治醫師會議修正臨床路徑,資訊公開適時回饋,醫品會議,檢視每季趨勢,比較世界、台灣、同等級醫院,檢討異常值，相關科部提出說明,科主任會議:公開資訊、共同協商改進,提供科部相關指標書面資料,全院業務會議:加強共識,使用量的降低,TKR、THR、CABG、APP、ATH,各術式抗生素使用量與費用曲線圖,各術式抗生素,使,用量年度比較,各術式抗生素費用年度比較,t-test得到的p-value,改善情況TKR抗生素之,使,用,季別,加入TQIP,使用支數,金,額,TKR抗生素,使,用量同期比較,季別,支 數/人次,TKR抗生素費用同期比較,季別,元/人次,89,Mean,+,SD,90,Mean,+,SD,91,Mean,+,SD,p-value,Q1,34.27,+,13.06,27.37,+,12.51,0.61,Q2,34.81,+,12.56,31.54,+,14.67,0.34,Q3,24.76,+,11.86,28.29,+,11.07,0.65,Q4,44.15,+,59.64,20.82,+,10.30,0.13,TKR抗生素使用量,89,Mean,+,SD,90,Mean,+,SD,91,Mean,+,SD,p-value,Q1,4738.25,+,1897.36,2731.37,+,1192.04,0.39,Q2,3522.42,+,1261.18,3144.23,+,1498.98,0.24,Q3,2490.36,+,1228.74,2976.41,+,1146.79,0.80,Q4,6358.30,+,8595.15,2154.23,+,1042.84,0.09,TKR抗生素費用,改善情況THR抗生素之,使,用,季別,加入TQIP,使用支數,金,額,THR抗生素,使,用量同期比較,季別,支 數/人次,THR抗生素費用同期比較,季別,元/人次,89,Mean,+,SD,90,Mean,+,SD,91,Mean,+,SD,p-value,Q1,34.27,+,13.06,27.26,+,13.47,0.85,Q2,30.67,+,7.99,27.70,+,15.80,0.30,Q3,26.68,+,8.19,29.82,+,11.81,0.08,Q4,44.55,+,12.07,32.82,+,35.92,0.10,THR抗生素使用量,89,Mean,+,SD,90,Mean,+,SD,91,Mean,+,SD,p-value,Q1,4738.25,+,1897.36,2751.70,+,1369.77,0.35,Q2,3205.90,+,991.79,2809.52,+,1615.55,0.50,Q3,2691.74,+,870.95,3091.06,+,1183.94,0.15,Q4,9804.6,+,1808.38,4337.05,+,7752.43,0.08,THR抗生素費用,改善情況CABG抗生素之,使,用,季別,加入TQIP,使用支數,金,額,CABG抗生素,使,用量同期比較,季別,支 數/人次,CABG抗生素費用同期比較,季別,元/人次,89,Mean,+,SD,90,Mean,+,SD,91,Mean,+,SD,p-value,Q1,63.26,+,50.42,45.58,+,14.29,0.11,Q2,56.50,+,22.68,48.83,+,21.51,0.63,Q3,50.67,+,20.78,39.31,+,20.12,0.62,Q4,71.77,+,59.86,58.50,+,28.12,0.31,CABG抗生素使用量,89,90,91,p-value,Mean,+,SD,Mean,+,SD,Mean,+,SD,Q1,12402.98,+,16464.78,5318.92,+,2914.66,0.08,Q2,8335.23,+,2908.48,5180.22,+,2111.06,0.08,Q3,6072.93,+,3258396,4413.00,+,2517.47,0.42,Q4,14891.34,+,26166.63,7665.00,+,4383.87,0.12,CABG抗生素費用,改善情況APP抗生素之,使,用,季別,加入TQIP,使用支數,金,額,APP抗生素,使,用量同期比較,季別,支 數/人次,APP抗生素費用同期比較,季別,元/人次,89,Mean,+,SD,90,Mean,+,SD,91,Mean,+,SD,p-value,Q1,29.70,+,39.06,21.82,+,13.14,0.00,Q2,24.83,+,16.91,23.53,+,9.88,0.02,Q3,20.78,+,17.40,21.78,+,8.83,0.00,Q4,30.04,+,20.05,22.02,+,11.14,0.00,APP抗生素使用量,p.01,p.05,89,90,91,p-value,Mean,+,SD,Mean,+,SD,Mean,+,SD,Q1,Q2,Q3,Q4,4630.09,+,4354.19,3972.84,+,7783.55,2578.24,+,2263.22,2106.53,+,3039.06,2255.18,+,1286.89,2177.07,+,1419.53,2459.81,+,1115.65,2199.52,+,1015.13,0.00,0.00,0.00,0.00,APP抗生素費用,p.01,改善情況ATH抗生素之,使,用,季別,加入TQIP,使用支數,金,額,ATH抗生素,使,用量同期比較,季別,支 數/人次,ATH抗生素費用同期比較,季別,元/人次,改善成效,使,用時間,掌握使用時效,劃刀前30分鐘內之預防性抗生素使用情況,劃刀前,2小時,之預防性抗生素使用情況,使用期限,24小時,TKR,THR,CABG,APP,ATH,百分比,II-b:Surgical Prophylaxis,Rate-Knee Arthroplasty Surgical Prophylaxis,Within 30 minutes Prior to Incision,(2001q1),(8/18),(8/26),(13/31),(13/20),(13/25),百分比,II-b:Surgical Prophylaxis,Rate-Hip Arthroplasty Surgical Prophylaxis,Within 30 minutes Prior to Incision,(2001q1),(5/15),(3/20),(7/26),(10/30),(6/26),百分比,II-b:Surgical Prophylaxis,Rate-CABG Surgical Prophylaxis,Within 30 minutes Prior to Incision,(2001q1),(,5/22,),(12/36),(3/15),(4/25),(7/28),百分比,II-b:Surgical Prophylaxis,Rate-Appendectomy Surgical Prophylaxis,Within 30 minutes Prior to Incision,(2001q1),(9/79),(5/104),(3/101),(6/70),(5/68),百分比,II-b:Surgical Prophylaxis,Rate-Abdominal Hysterectomy Surgical Prophylaxis,Within 30 minutes Prior to Incision,(2001q1),(33/57),(43/57),(50/68),(34/36),(34/43),百分比,II-b:Surgical Prophylaxis,Rate-Knee Arthroplasty Surgical Prophylaxis,Within 2 hours Prior to Incision,(17/22),(17/18),(25/26),(27/31),(20/20),(24/25),百分比,II-b:Surgical Prophylaxis,Rate-Hip Arthroplasty Surgical Prophylaxis,Within 2 hours Prior to Incision,(18/22),(12/15),(19/20),(21/26),(30/30),(22/26),百分比,II-b:Surgical Prophylaxis,Rate-CABG Surgical Prophylaxis,Within 2 hours Prior to Incision,(,31/33,),(,21/22,),(35/36),(15/15),(25/25),(28/28),百分比,II-b:Surgical Prophylaxis,Rate-Appendectomy Surgical Prophylaxis,Within 2 hours Prior to Incision,(80/87),(67/79),(92/104),(88/101),(61/68),(68/70),百分比,II-b:Surgical Prophylaxis,Rate-Abdominal Hysterectomy Surgical Prophylaxis,Within 2 hours Prior to Incision,(50/57),(73/74),(50/57),(67/68),(35/36),(43/45),百分比,II-b:Surgical Prophylaxis,Rate-Abdominal Hysterectomy Surgical Prophylaxis,for 24 hours or less,(2001q1),(17/57),(53/57),(51/58),(34/36),(40/45),改善成效感染率,全院院內感染率,各種院內感染率,各術式相關院內感染率,TKR,THR,CABG,APP,ATH,改善成效每季,全,院院內感染率,季別,改善成效,每,季各手術式感染率,(BSI、SSI、UTI、LRI),季別,百分比,改善成效,平,均住院天數,天數,院內感染率確無顯著差異,成效,使用時效改進排序：ATH、TKR、THR、CABG、APP.,使用量減少情況：Cost=Cost,1,-Cost,2,APP.(-2500)ATH (-800),CABG(-10000)TKR (-3500),THR (-6800),結果,成本效益分析,Cost,TQIP年費,人事成本未增加,教育訓練成本未增加,Effectiveness,感染率無顯著差異,平均抗生素使用量下降,平均抗生素使用費用下降,平均住院天數下降,Cost/Effectiveness Ratio,結論與建議,標準化手術成本，多了解我們正在使用何種抗生素，為何使用，結果為何,具信效度之監測是品管的根本,持續性、系統性監測可提昇品質並降低成本,實證醫學是降低疑慮，提升臨床照護品質之最大助力,