雖然加護病房是緊急醫療照護中不可或缺的角色，挽救了不少重症病患的生命，但是付出的醫療資源也節節升高。不管在國內外，加護病房是個耗費大量醫療人力及醫療資源的單位；如何能照護品質與醫療資源兼顧一直是大家關心的議題。近年來許多國內外的研究發現，加護病房實施專責重症主治醫師制度可有效地改善醫療照護品質與降低醫療資源耗用，同時可提升病患及家屬的滿意度。
這篇研究的目的是對一所區域教學醫院內科加護病房，實施合併式專責主治醫師制度前後，對於醫療照護品質和醫療資源利用之差異。本研究以個案醫院實施合併式專責主治醫師制度前後各三年，設計採用類實驗研究法，收集了自2006年4月-2012年3月共5241名病患為研究樣本，其中共有3511 位男性及1730位女性患者，平均年齡為68.6歲。使用獨立樣本T檢定、卡方檢定、單因子變異數分析比較兩組樣本之人口特質、疾病特質、疾病型態、照護品質、醫療資源耗用；使用邏輯與線性迴歸分析來探討死亡率與住院天數之相關因素。結果顯示，在實施了合併式專責重症醫師照護後，平均住院天數與呼吸器使用天數上升，死亡率下降，但皆不呈現統計上的差異。而影響加護病房死亡率和住院天數之風險因子包含APACHE Ⅱ分數、疾病型態、ICU住院天數的長短，及設置專責重症專科醫師等因子。

Although the intensive care unit(ICU) is a indispensible role in the critical care. It save a lot of life of critical patients, but the cost of medical source increases steadily. Whether at home and abroad, the ICU consume a great manpower and medical resources. It is a important subject about how to give consideration to both care quality and medical resouces. Many reserches in recent years found that it is effective of full-time intensivists system of ICU on improving quality of medical care and utilization of medical resources, and also increases the satisfaction of the patients and the family.
The purpose of this study is to evaluate the effects of combined care, full-time intensivists system of intensive care unit(ICU) on quality of medical care and utilization of medical resources during Apr., 2006 to Mar., 2012 at a Southern Regional Teaching Hospital. A quasi-experimental study design method was used to study total 5241 patients including 3511 males and 1730 females. The average age is 68.6 years old. The gender, age, APACHE II score, disease patterns, ICU mortality rate, ICU stay, ventilator days, mean ICU expenditures, and mean daily ICU expenditures of the two groups were analysised by a Independent samples t-test, Chi-swuare test, and one way ANOVA TEST. And the risk factors of ICU mortality rate and ICU stay were also studied by the use of Logistic restression and linear regression analysis. The results revealed the ICU stay, ventilator days, and mean ICU expenditures increased, and the ICU mortality rate and mean daily ICU expenditures reduced after intensivist staffing, but there was no significant difference in statistics.

論文審定書 i
致 謝 詞 ii
中文摘要 iii
Abstract iv
第一章 緒 論 1
第一節 研究背景動機 1
第二節 研究目的 1
第三節 研究流程 2
第四節 研究範圍與限制 3
第五節 論文架構 3
第二章 文獻探討 4
第一節 專有名詞解釋 4
第二節 加護病房照護模式類型 7
第三節 國內外有關專責重症專科醫師現況 8
第四節 專責重症專科醫師對醫療照護品質、醫療資源利用之影響 10
第五節 加護病房使用呼吸器之病患對醫療資源利用的影響 15
第六節 整體醫療環境趨勢 16
第一節 研究架構和研究假說 20
第二節 研究設計和研究樣本 21
第三節 資料收集方法 22
第四節 研究變項 22
第五節 統計分析 24
第四章 統計結果與分析 27
第一節 個案醫院及加護病房簡介 27
第二節 加護病房設置合併式專責重症專科醫師前後病患之基本特質描述分析比較 30
第三節 加護病房設置合併式專責重症專科醫師前後，其醫療照護品質指標差異性比較 31
第四節 加護病房設置合併式專責重症專科醫師前後，其醫療資源耗用差異性比較 32
第五節 影響加護病房死亡率、加護病房住院天數的風險因子探討 33
第五章 研究結論與建議 37
第一節 研究結果 37
第二節 研究結論與建議 40
第三節 未來研究方向 43
參考文獻 44
(一)、中文部分 44
(二)、英文部分 45
(三)、網站部分 48
附錄 49
個人簡歷 59

(一)、中文部分
　王俊凱，2007，「臨床診療指引系統 提升急性醫療品質」，資訊尖兵，76期專題。
　財團法人醫院評鑑暨醫療品質策進會，2012，醫院緊急醫療能力分級評定基準。
　高靖秋，2011，「台灣護理人力面面觀」，澄清醫護管理雜誌，7卷3期：41~46。
　廖憲華、吳志隆，2009，「專責重症專科醫師對外科加護病房患者的照護品質提升之探討」，重症醫學雜誌，10卷1期：2~7。
　鄭高珍、蔡素貞、侯清正，2005，「專責重症專科醫師對加護病房重症病患照護之成效」，中華民國急救加護醫學會雜誌，16卷3期：93~98。
　鍾月枝、邱亨嘉、侯清正、蔡素貞、呂僅立、鄭高珍等人，2007，「加護病房設置專責重症專科醫師對照護品質和醫療資源使用之影響」，中華民國急救加護醫學會雜誌，18卷4期：139~218。
(二)、英文部分
　Arabi,& Al-Shimemeri,A.2003.Improving resource utilization in the intensive care units. A challenge for Saudi Hospitals. Sandi Med.J., 24(2)：131-7.
　Arzu Topeli,M.D., FrancoLaghi,M.D., MartinJ.Tobin,M.D. 2005. Effect of closed unit policy and appointing an intensivist in a developing country. Crit.Care Med.,33：299-306.
　Bach, P.B.,Carson, S.S.,Leff A. 1998. Outcomes and resource utilization for patients with prolonged critical illness managed by university-based or community-based subspecialists. Am.J.Respir.Crit.Care Med., 158：1410-1415.
　Bellomo,R., Cole,L., Reeves,J., Silvester,W. 1997. Who should manage CRRT in the ICU? The intensivist's viewpoint. Am. J. Kidney Dis.,30(5 Suppl 4): S109-11.
　Bluln,M.C.,& K.R.Burchett. 2000. Out-of-hours consunallt cover and case- mix-adjusted mortality in intensive care. Lancet,356(9231)：735-6.
　Bohrer,H.,& R.Thiele. 1997. Experience of the intensive care physician and patient outcome. Zentralbl Chir.,122(7)：522-7.
　Brown,J.J.,& Sullivan,G. 1989. Effect on ICU mortality of a full-time critical care specialist. Chest,96:127-129.
　Burchardi,H.,& Moerer,O. 2001. Twenty-four hour presence of physicians in the ICU. Crit. Care,5(3):131-7.
　Constantine,A., Manthous,M.D., Yaw Amoateng-Adjepong,M.D.,Ph.D., Tamim Al-Kharrat,M.D. 1997. Effects of a Medical Intensivist on Patient Care in a Community Teaching Hospital. Mayo Clinic Proceedings,72(5): 391-399.
　Dimick,Justin B.,M.D., Pronovost,Peter J.,M.D. 2001.Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection. Critical Care Medicine,29(4):753-758.
　Dobb,G.J. 1998. Critical care medicine in the Western Pacific region. Ann. Acad.Med.Singapore,27(3):381-6.
　Emanuel Rivers,M.D.,M.P.H.,Bryant Nguyen,M.D.,Suzanne Havstad,M.A., Juue Ressler,B.S.,Alexandria Muzzin,B.S.,Bernhard Knobuch,M.D., Edward Peterson,PH.D.,and Michael Tomlanovich,M.D. 2001. Early Goal-Directed Therapy In The Treatment Of Severe Sepsis And Septic Shock. The New England Journal of Medicine,345(19): 1368-1377
　Goh,A.Y., Lum,L.C., Abdel-Latif M.E. 2001.Impact of 24 hour critical care physician staffing on case-mix adjusted mortality in paediatric intensive care. Lancet,357(9254):445-6.
　Groeger,J.S., Guntupalli,K.K., Strosberg,M., Halpem,N., Raphaely,R.C., Cerra,F., Kaye,W. 1993. Descriptive analysis of critical care units in the United States: patient characteristics and intensive care unit utilization. Crit.Care Med.,21:279-291.
　Hanson,C.W.,3rd., Deutschman,C.S., Anderson,H.L.,3rd., Reilly,P.M., Behringer,E.C., Schwab,C.W., Price,J. 1999. Effects of an organized critical care service on outcomes and resource utilization: a cohort study. Crit.Care Med.,27(2): 270-4.
　Knaus WA,Draper EA,Wagner DP,Zimmerman JE.1985. APACHE II: a severity of disease classification system. Crit Care Med.,13(10):818-29.
　K.C.Cheng, C.C.Hou, S.C.Tsai. 2004. Evaluation of Cost-Effective of Full-Time Intensivists in Intensive Care Unit (ICU) in Taiwan. Paper presented at American Thoracic Society Annual conference.
　Kollef, M.H.1995. The identification of ICU-specific outcome predictors: A comparison of medical, surgical, and cardiothoracic ICUs from a single institution. Heart Lung,24(1): 60-66.
　Leaks,C. 1977. Percival’s medical Ethics. Baltimore: Williams and Wilkins,67.
　Lustbader,D.,& Fein,A. 2000. Emerging trends in ICU management and staffing. Crit.Care Clin.,16(4):735-48.
　Marini,G.C., Nathan,J., McNelis,A., Jurkiewicz,H.H.Simms.2002. Closed Vs. Open Intensive Care Unit: Impact Of Full-time Surgical Intensivists. The Internet Journal of Emergency and Intensive Care Medicine,6(1) DOI:10.5580/8bd.
　Multz,A.S., Chalfin,D.B., Samson,I.M., Dantzker,D.R., Fein,A.M., Steinberg,H.N., Niederman,M.S., Scharf,S.M. 1998. A "closed" medical intensive care unit (MICU) improves resource utilization when compared with an "open" MICU. Am.J.Respir.Crit.Care Med., 157:1468-1473.
　Pronovost, Peter,J., Waters, Hugh. 2001. Impact of critical care physician workforce for intensive care unit physician staffing. Current Opinion in Critical Care,7(6):456-459.
　Pronovost,P.J., Angus,D.C., Dorman,T. 2002. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA,288(17):2151-62.
　Rollins,G. 2002. ICU care management by intensivists reduces mortality and length of stay. Rep.Med.Guidel Outcomes Res.,13(24):5-7.
　Safar,P.,& Grenvik,A. 1977. Organization and physician education in critical care medicine. Anesthesiology,47(2):82-95.
　Young,M.P.,& Birkmeyer, J.D. 2000. Potential reduction in mortality rates using an intensivist model to manage intensive care units. Eff.Clin. Pract.,3(6):284-9.
(三)、網站部分
　中央健康保險局醫務管理處，2002，「全民健康保險呼吸器依賴患者整合性照護試辦計畫之緣起與執行概況」，www.areahp.org.tw/upload/project/txt/ 951108A。
　台灣臨床成效指標系統，2011，http://tcpi.tjcha.org.tw/tcpi/。
　行政院衛生署衛生統計資料網，2010，「衛生統計重要指標」，http： //www.doh.gov,tw/statistic/index.htm。
　NGC.2013.http://www.guideline.gov/