討論與結論 - 駐院專責主治醫師值班病房與住院醫師值班病房的成本與效益比較

傳統內科照護制度在縮短住院日期與控制住院費用的優勢(Lindenauer et al., 2007;

Scheurer, 2005; Shu, Lin, Lin, Hsu and Ko, 2011; Southern, Berger, Bellin, Hailpern and Arnsten, 2007)。在一篇比較整合醫療病房初創，只有三位主治醫師照護一個36 床病房的時期，與內科急診後送病房在2009年11月至2010年1月，三個月期間內兩 7A/D 13.9天)與健保申報點數(7B 5102177431點比7A/D 4503155210點)已經非常接近 (許甯傑，2016)。可見內科病房的營運效率是可以經由增加照護醫師人數解決，代價是人力成本的增加。

而比較三個時期(2009，2014，2015)的整合醫療病房的運作，可以發現其由急

診住院的病人平均住院日持續上升(2009年 9.3天，2014年 12.1天，2015年 12.8天)，

而平均健保申報點值卻逐漸降低(2009年73359 (2223美元)，2014年72360點，2015 年 45031點)，在疾病複雜度沒有增加(CCI 2009年 3.73.4，2014年為2.72.9)，而照護人力一致的情形下，比較適當的解釋是維持原來24小時由主治醫師照護所取 75-85%間，醫師的工作負荷及照護床數與住院是為拋物線關係，最適點為25RVU 及15床，當占床率高於85%時，出現J曲線，當工作負荷超過30RVU或照護床數超

國性，為期一年，採用隨機分配，具控制組設計的研究，探討外科住院醫師在2011

源、升遷、薪資與同儕比較的問題。當然，這樣對於內科部而言，必須在組織架構上增加一個新的功能分科－整合醫學科，以區隔現行運作上不需值夜班，只帶領住院醫師進行病房照護的主治醫師。但必須提供整合醫學科主治醫師可以接觸次專科業務，參與次專科的研究與服務，也考慮經過一定年資與符合某些條件之後，轉進次專科的功能分科，脫離整合醫學科。同時，也必須讓目前的內科部主治醫師了解駐院專責主治醫師的特色，以及其在新的醫療照護制度下的重要性，

建立彼此在協同照護同一位病人時的順暢溝通與默契，以減少在醫療端可能出現的困擾，維持好的醫療品質與病人預後。也讓各功能分科能接納駐院專責主治醫師，共同進行教學研究與服務。而引進整合醫學科的專科護理師，可以讓台大內科主治醫師熟悉加入專科護理師進行照護組合的作業方式，並與內科部現有的專科護理師整合後，提供更有效率與穩定的醫療兆赫。期望這一個新人事制度的引進，可以讓台大醫院內科部，不僅協助改善急診壅塞，改善病房營運，帶入新的病房照護文化，保障住院醫師工時，增益醫師與病人福祉，甚至未來有機會能讓駐院專責主治醫師成為一個新的專科，成為年輕醫師的選項。

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表一、比較兩個病房收案病人基本資料與品質指標

表二、兩個病房收案病人經過傾向分數(propensity score)配對後，品質指標的比較

表三、比較兩個病房肺炎病人基本資料與品質指標

表四、比較兩個病房泌尿道感染病人基本資料與品質指標

表五、比較兩個病房消化道出血病人基本資料與品質指標

表六、比較兩個病房腹腔內感染病人基本資料與品質指標

表七、病房成本、收入與損益

表八、兩個病房重要品質指標與損益比較

表九、虛擬病房之駐院專責主治醫師或主治醫師+住院醫師團隊照護的每日平均收益與每月病床週轉率

表十、虛擬病房的成本推估

表十一、虛擬病房在各種不同醫療團隊組合模式下的病房損益與收治急診病人數

表十二、加入夜間值班主治醫師(nocturnist)(C’模式)的病房損益與收治急診病人數

表十三、各種照護模式的優缺點與改進策略

附錄

表一、純駐院專責主治醫師模式，四位主治醫師+8位專科護理師表二、傳統內科模式，三組主治醫師+住院醫師

表三、傳統內科模式，四組主治醫師+住院醫師

表四、混合模式A：2組主治醫師+住院醫師負責18床，2位駐院專責主治醫師+4位專科護理師負責18

表五、混合模式B：2組主治醫師+住院醫師負責18床，2位駐院專責主治醫師+3位專科護理師負責18床

表六、混合模式C：2組主治醫師+住院醫師負責18床，2位駐院專責主治醫師+2位專科護理師負責18床

表七、混合模式D：3組主治醫師+住院醫師負責27床，1位駐院專責主治醫師+2位專科護理師負責9床

表八、混合模式E：2組主治醫師+住院醫師負責18床，1位駐院專責主治醫師+2位專科護理師負責18床

表九、混合模式C’：2組主治醫師+住院醫師負責18床，2位駐院專責主治醫師+2位專科護理師負責18床+1名夜間專責值班主治醫師(nocturnist)

表一、純駐院專責主治醫師模式，四位主治醫師+8位專科護理師

表二、傳統內科模式，三組主治醫師+住院醫師