뇌지주막하 출혈 환자의 사례관리를 위한 Critical pathway 개발 및 적용효과 Development of A Critical Pathway for the Management of the Subarachnoid Hemorrhage and Its Application원문보기
현재 의료계는 국민들의 생활수준 및 교육수준 향상으로 건강개념을 생활의 기본권으로 인식하게 되었고, 전국민 의료보험 실시에 따른 국민의 의료수요증가, 인구의 노령화 및 질병구조의 만성화에 따른 의료비 상승, 의료자원의 제한 과 비효율적인 활용 및 국민의 건강요구 증대에 대한 부응이라는 문제를 안고 있다. 반면 포괄 수가제, 의약분업 및 의료서비스 평가제 실시 등의 의료정책의 변화는 의료기관의 수익을 계속 감소시킬 것으로 예상되어, 각 의료기관에서는 의료비용을 절감시켜야 함과 동시에 의료서비스의 질적 향상을 도모해야 한다. 이에 의료계는 의료서비스의 질을 높이고 비용을 낮추어 생산성을 향상시킬 수 있는 새로운 의료전달체계를 탐색하게 되었고 이러한 방법 중 하나가 CriticalPathway(주진료경로: 이하 ...
현재 의료계는 국민들의 생활수준 및 교육수준 향상으로 건강개념을 생활의 기본권으로 인식하게 되었고, 전국민 의료보험 실시에 따른 국민의 의료수요증가, 인구의 노령화 및 질병구조의 만성화에 따른 의료비 상승, 의료자원의 제한 과 비효율적인 활용 및 국민의 건강요구 증대에 대한 부응이라는 문제를 안고 있다. 반면 포괄 수가제, 의약분업 및 의료서비스 평가제 실시 등의 의료정책의 변화는 의료기관의 수익을 계속 감소시킬 것으로 예상되어, 각 의료기관에서는 의료비용을 절감시켜야 함과 동시에 의료서비스의 질적 향상을 도모해야 한다. 이에 의료계는 의료서비스의 질을 높이고 비용을 낮추어 생산성을 향상시킬 수 있는 새로운 의료전달체계를 탐색하게 되었고 이러한 방법 중 하나가 CriticalPathway(주진료경로: 이하 CP)를 도구로 사용하는 Case management(사례관리)이다. 더불어 간호계에서도 새로운 환자간호전달 체계의 필요성이 대두되어전문간호사 제도의 도입을 시도하고 조기퇴원에 따른 가정 간호사업을 활성화시키는 등 여러 가지 방안을 모색하고 있다. 신경외과 뇌혈관 질환 중 뇌동맥류 직접 결찰술은 다빈도 수술로 응급상황, 합병증, 고비용 처치가 많고 치료과정이 복잡하며, 즉각적인 처치가 요구 되어지는 반면 경과와 예후에 대한 예측이 어렵고, 치료과정을 정형화하기 어려워조기에 적절한 처치를 체계적으로 시행한다면 치료과정의 향상과 합병증을 감소시킬 수 있을 것으로 기대한다. 본 연구는 뇌동맥류 파열로 인한 뇌지주막하 출혈로 뇌동맥류 직접 결찰술을 받은 환자에게 의료의 질 향상과 의료기관 효율적인 운영을 목적으로 CP를 개발하여 적용하였다. 서울시 소재 일개 전문종합병원 신경외과 중환자실과 신경외과 병동에 입원하여 지주막하 출혈로 동맥류 직접 결찰술을 받은 환자 중 Hunt-Hess gradeⅠ∼ Ⅲ, 연령 70세 이하 군을 대상으로 2000년 8월부터 2001년 8월까지 26명에게 CP를 적용하였고, 대조군으로 1999년 9월부터 2000년 7월까지 31명을 선정하였다. CP 적용군/대조군 모두 입원당일부터 퇴원시점까지의 의료의 질 평가를 위해 간호의 질 수준과 합병증 발생빈도를, 의료기관 운영의 효율성 평가를 위해 재원일수는 총 재원일수, 중환자실 재실기간, 수술전 대기시간으로 진료비는 환자 1인당 진료비, 일당 진료비, 보험삭감률을, CP운영상 변이분석등을 전산자료 및 의무기록 분석을 하였다. 실무자들의 CP적용에 대한 의견을 설문지를 이용하여 조사를 하였다. 자료분석방법은 다음과 같다. 대상자의 일반적 특성은 빈도와 백분율로, 대상자의 일반적 특성간의 동질성 분석은 X²-test로 분석하였다. 합병증 발생빈도는 X²-test로, 간호의 질평가,총재원일수, 중환자실 재실기간, 수술전 대기시간, 환자 1인당 진료비, 일당 진료비 및 보험삭감률의 차이는 t-test검증으로 실시 하였다. 변이분석과 CP적용에 대한 실무자들의 의견는 빈도와 백분율로 분석하였다. 본 연구결과를 요약하면 다음과 같다. Ⅰ. Critical Pathway 개발 환자가 응급실에 도착하여 퇴원시까지 의료진이 적용할 수 있도록 환자관리계획을 도식화한 정형화하여 CP를 개발하였다. 먼저 문헌고찰과 벤치마킹을 통하여 개발의 필요성을 느끼고 CP개발팀을 구성하였으며, 115문항에 대한 의무기록 분석을 74례에서 시행하여 이를 바탕으로 예비 CP를 작성하였다. 예비CP는 신경외과 의사와 간호사로 구성된 전문가 집단의 검토 후 수정/보완 하였으며 5례에서 타당도 검증을 마친 후 의료인용 CP를 확정하였다. 다학제적중재내용을 결정하여 종축에 측정 및 관찰, 활동과 안전, 식이/영양, 투약, 검사, 치료/처치, 협진, 교육/평가 등으로 결정하였고 횡축에는 시간틀로 수술을 중심으로 전후 일자를 기록하도록 하였다. 환자용 CP는 의료인용 CP를 중심으로 환자/보호자가 이해하기 쉬운 용어를 사용하여 작성하여 치료과정에 대한정보를 제공하도록 하였다. 또한 교육자료를 만들어 사용함으로써 만족도 향상을 도모하였다. 변이가 발생되었을 때 변이 종류와 등급을 기록할 수 있는 변이발생 기록지를 개발하였다. Ⅱ. Critical Pathway 적용효과 1. 의료의 질 측면 (1) 간호의 질 평가점수 간호의 질 평가점수는 CP 적용군에서 평균 0.77점으로 대조군 평균 0.71보다 통계적으로 유의한 차이가 있는 것으로 나타났다(p=.001). (2) 합병증 발생빈도 수술 전 과 입원기간 동안 합병증 발생빈도를 분석한 결과 수술 전 합병증은 두군간에 통계적으로 유의한 차이가 없는 것으로 나타났으며(p=.110∼.910), 입원기간동안 호흡기계(p=.042∼.075) 및 혈액학적(p=.004∼.006) 합병증은 통계적으로 유의한 차이가 있는 것으로 나타났다. 신경계(p=.173∼.556), 순환기계(p=.155), 위장계(p=.187)합병증 및 감염(p=.377)에서 통계적으로 유의한 차이는 없었으나 발생빈도는 낮게 나타났다. 2. 병원운영의 효율성 측면 (1) 재원일수 CP 적용군에서 재원일수는 9.68일이 감소되어 통계적으로 유의한 차이를 보였다(p=.021). 중환자실 재실기간은 2.65일 감소(p=.107), 수술 전 대기시간은 19.68시간이 감소(p=.128) 되었으나 통계적으로 유의한 차이는 없었다. (2) 진료비 CP 적용군에서 환자 1인당 진료비는 3,333,482원(22.0%)이 감소되어 통계적으로 유의한 차이가 있는 것으로 나타났다(p=.042). 일당 진료비는 통계적으로 유의한 차이는 없었으나(p=.197) 32,401원(5.8%)이 증가하였고, 보험 삭감률은 83,095원(47.8%)이 감소되었으나 통계적으로 유의한 차이는 없었다(p=.262). 3. 운영측면 (1) 변이 분석 CP적용군 26명이 CP를 적용하는 동안 발생한 변이는 총 172건이며 발생종류에 따라 환자측면이 117건(69.2%)으로 가장 많았으며, 의료진 측면이 46건 (25.8%), 병원측면이 9건(5.1%)이었다. 내용에 따라 약물 70건(40.6%), 검사 53건(30.6%)으로 많았다. 또한 변이의 등급을1,2,3으로 나누었을때 CP가 약간 변화하나 내용에는 변화가 없는 1등급이 165건(96.0%), CP와 조금 다르게 진행되지만 CP적용이 가능한 2등급은 7건(4.0%)이었으며, CP적용이 불가능한 3등급은 없었다. (2) CP 적용에 대한 실무자 의견분석 CP적용에 대해 만족 하는가에 대해 64%이상이 매우만족 또는 만족한다라고 대답하였다. 본 연구에서 CP모형의 개발과 적용을 통하여 환자관리 과정을 표준화하여 의료의 질 향상과 의료기관 운영의 효율성 향상에 큰 기여를 하는 효과적인 의료전달체계임을 검증하였다. 일개 종합병원에서 신경외과 뇌동맥류 파열로 인한 지주막하 출혈환자만을 대상으로 시행하였기 때문에 본 연구결과를 타 의료기관이나 타 질환에 그대로 적용하기에는 제한점이 있을 것이나, 본 연구결과는 관련분야 및 환자사례관리 모형 적용시 유용한 자료로 활용 될 것으로 전망된다.
현재 의료계는 국민들의 생활수준 및 교육수준 향상으로 건강개념을 생활의 기본권으로 인식하게 되었고, 전국민 의료보험 실시에 따른 국민의 의료수요증가, 인구의 노령화 및 질병구조의 만성화에 따른 의료비 상승, 의료자원의 제한 과 비효율적인 활용 및 국민의 건강요구 증대에 대한 부응이라는 문제를 안고 있다. 반면 포괄 수가제, 의약분업 및 의료서비스 평가제 실시 등의 의료정책의 변화는 의료기관의 수익을 계속 감소시킬 것으로 예상되어, 각 의료기관에서는 의료비용을 절감시켜야 함과 동시에 의료서비스의 질적 향상을 도모해야 한다. 이에 의료계는 의료서비스의 질을 높이고 비용을 낮추어 생산성을 향상시킬 수 있는 새로운 의료전달체계를 탐색하게 되었고 이러한 방법 중 하나가 CriticalPathway(주진료경로: 이하 CP)를 도구로 사용하는 Case management(사례관리)이다. 더불어 간호계에서도 새로운 환자간호전달 체계의 필요성이 대두되어전문간호사 제도의 도입을 시도하고 조기퇴원에 따른 가정 간호사업을 활성화시키는 등 여러 가지 방안을 모색하고 있다. 신경외과 뇌혈관 질환 중 뇌동맥류 직접 결찰술은 다빈도 수술로 응급상황, 합병증, 고비용 처치가 많고 치료과정이 복잡하며, 즉각적인 처치가 요구 되어지는 반면 경과와 예후에 대한 예측이 어렵고, 치료과정을 정형화하기 어려워조기에 적절한 처치를 체계적으로 시행한다면 치료과정의 향상과 합병증을 감소시킬 수 있을 것으로 기대한다. 본 연구는 뇌동맥류 파열로 인한 뇌지주막하 출혈로 뇌동맥류 직접 결찰술을 받은 환자에게 의료의 질 향상과 의료기관 효율적인 운영을 목적으로 CP를 개발하여 적용하였다. 서울시 소재 일개 전문종합병원 신경외과 중환자실과 신경외과 병동에 입원하여 지주막하 출혈로 동맥류 직접 결찰술을 받은 환자 중 Hunt-Hess gradeⅠ∼ Ⅲ, 연령 70세 이하 군을 대상으로 2000년 8월부터 2001년 8월까지 26명에게 CP를 적용하였고, 대조군으로 1999년 9월부터 2000년 7월까지 31명을 선정하였다. CP 적용군/대조군 모두 입원당일부터 퇴원시점까지의 의료의 질 평가를 위해 간호의 질 수준과 합병증 발생빈도를, 의료기관 운영의 효율성 평가를 위해 재원일수는 총 재원일수, 중환자실 재실기간, 수술전 대기시간으로 진료비는 환자 1인당 진료비, 일당 진료비, 보험삭감률을, CP운영상 변이분석등을 전산자료 및 의무기록 분석을 하였다. 실무자들의 CP적용에 대한 의견을 설문지를 이용하여 조사를 하였다. 자료분석방법은 다음과 같다. 대상자의 일반적 특성은 빈도와 백분율로, 대상자의 일반적 특성간의 동질성 분석은 X²-test로 분석하였다. 합병증 발생빈도는 X²-test로, 간호의 질평가,총재원일수, 중환자실 재실기간, 수술전 대기시간, 환자 1인당 진료비, 일당 진료비 및 보험삭감률의 차이는 t-test검증으로 실시 하였다. 변이분석과 CP적용에 대한 실무자들의 의견는 빈도와 백분율로 분석하였다. 본 연구결과를 요약하면 다음과 같다. Ⅰ. Critical Pathway 개발 환자가 응급실에 도착하여 퇴원시까지 의료진이 적용할 수 있도록 환자관리계획을 도식화한 정형화하여 CP를 개발하였다. 먼저 문헌고찰과 벤치마킹을 통하여 개발의 필요성을 느끼고 CP개발팀을 구성하였으며, 115문항에 대한 의무기록 분석을 74례에서 시행하여 이를 바탕으로 예비 CP를 작성하였다. 예비CP는 신경외과 의사와 간호사로 구성된 전문가 집단의 검토 후 수정/보완 하였으며 5례에서 타당도 검증을 마친 후 의료인용 CP를 확정하였다. 다학제적중재내용을 결정하여 종축에 측정 및 관찰, 활동과 안전, 식이/영양, 투약, 검사, 치료/처치, 협진, 교육/평가 등으로 결정하였고 횡축에는 시간틀로 수술을 중심으로 전후 일자를 기록하도록 하였다. 환자용 CP는 의료인용 CP를 중심으로 환자/보호자가 이해하기 쉬운 용어를 사용하여 작성하여 치료과정에 대한정보를 제공하도록 하였다. 또한 교육자료를 만들어 사용함으로써 만족도 향상을 도모하였다. 변이가 발생되었을 때 변이 종류와 등급을 기록할 수 있는 변이발생 기록지를 개발하였다. Ⅱ. Critical Pathway 적용효과 1. 의료의 질 측면 (1) 간호의 질 평가점수 간호의 질 평가점수는 CP 적용군에서 평균 0.77점으로 대조군 평균 0.71보다 통계적으로 유의한 차이가 있는 것으로 나타났다(p=.001). (2) 합병증 발생빈도 수술 전 과 입원기간 동안 합병증 발생빈도를 분석한 결과 수술 전 합병증은 두군간에 통계적으로 유의한 차이가 없는 것으로 나타났으며(p=.110∼.910), 입원기간동안 호흡기계(p=.042∼.075) 및 혈액학적(p=.004∼.006) 합병증은 통계적으로 유의한 차이가 있는 것으로 나타났다. 신경계(p=.173∼.556), 순환기계(p=.155), 위장계(p=.187)합병증 및 감염(p=.377)에서 통계적으로 유의한 차이는 없었으나 발생빈도는 낮게 나타났다. 2. 병원운영의 효율성 측면 (1) 재원일수 CP 적용군에서 재원일수는 9.68일이 감소되어 통계적으로 유의한 차이를 보였다(p=.021). 중환자실 재실기간은 2.65일 감소(p=.107), 수술 전 대기시간은 19.68시간이 감소(p=.128) 되었으나 통계적으로 유의한 차이는 없었다. (2) 진료비 CP 적용군에서 환자 1인당 진료비는 3,333,482원(22.0%)이 감소되어 통계적으로 유의한 차이가 있는 것으로 나타났다(p=.042). 일당 진료비는 통계적으로 유의한 차이는 없었으나(p=.197) 32,401원(5.8%)이 증가하였고, 보험 삭감률은 83,095원(47.8%)이 감소되었으나 통계적으로 유의한 차이는 없었다(p=.262). 3. 운영측면 (1) 변이 분석 CP적용군 26명이 CP를 적용하는 동안 발생한 변이는 총 172건이며 발생종류에 따라 환자측면이 117건(69.2%)으로 가장 많았으며, 의료진 측면이 46건 (25.8%), 병원측면이 9건(5.1%)이었다. 내용에 따라 약물 70건(40.6%), 검사 53건(30.6%)으로 많았다. 또한 변이의 등급을1,2,3으로 나누었을때 CP가 약간 변화하나 내용에는 변화가 없는 1등급이 165건(96.0%), CP와 조금 다르게 진행되지만 CP적용이 가능한 2등급은 7건(4.0%)이었으며, CP적용이 불가능한 3등급은 없었다. (2) CP 적용에 대한 실무자 의견분석 CP적용에 대해 만족 하는가에 대해 64%이상이 매우만족 또는 만족한다라고 대답하였다. 본 연구에서 CP모형의 개발과 적용을 통하여 환자관리 과정을 표준화하여 의료의 질 향상과 의료기관 운영의 효율성 향상에 큰 기여를 하는 효과적인 의료전달체계임을 검증하였다. 일개 종합병원에서 신경외과 뇌동맥류 파열로 인한 지주막하 출혈환자만을 대상으로 시행하였기 때문에 본 연구결과를 타 의료기관이나 타 질환에 그대로 적용하기에는 제한점이 있을 것이나, 본 연구결과는 관련분야 및 환자사례관리 모형 적용시 유용한 자료로 활용 될 것으로 전망된다.
The present medical system recognizes general concepts of health to be the basis of daily life, with emphasis placed on the improvement of the citizen's level of education and daily activities. In addition, the medical system is aware that it will have to face problems of increased medical expenses,...
The present medical system recognizes general concepts of health to be the basis of daily life, with emphasis placed on the improvement of the citizen's level of education and daily activities. In addition, the medical system is aware that it will have to face problems of increased medical expenses, an increase in the aging population, an increase in the people's medical needs, as well as ineffective utilization of medical resources. It has been predicted that continuous changes in the medical system, including evaluation of the medical service system , medical law and inclusive cost effective systems, will continue to decrease the medical institution's benefits. Therefore each medical institution should strive towards improving the quality of the medical service, while at the same time decreasing medical expenses. As a result of searching for a new type of system, one that would raise the quality of service, while at the same time reduce costs, the case management using the CP as a tool, was selected. In addition, it was also deemed necessary to develop a new type of nursing delivery system, one that included the idea of the clinical nurse specialist. Several new plans such as the home visiting nurse program, were devised to encourage early discharging of patients. Anuerysm clipping operation, a type of cerebrovascular disease in the Neurosurgery department, results in emergency situations, complications, and treatment at high prices, as well as a complicated treatment process. It is therefore difficult to predict the progression of the disease, due to the need for emergency treatment to be done right away. Therefore an improvement in the treatment process, as well as a decrease in complications would be seen, if appropriate treatments were to be performed in a more systematic manner from the beginning. This study was conducted to develop a case management program using the CP as an intervention for patients who had received the anuerysm clipping operation due to aneurysmal subarachnoid hemorrhage, to improve the quality of medical care and for effective management of the medical institutions. The CP was applied from August 2000 to August 2001, to 26 subjects less than 70 years old, diagnosed with Hunt-Hess grade I-III, among patients who had received the anuerysm clipping operation due to aneurysmal subarachnoid hemorrhage, and who were admitted at the NSICU or neurology department, of University hospitals located in Seoul. 31 members of the control group were selected as subjects from September 1999 to July 2000. To evaluate the quality of medical service for all the subjects from day of admission to the day of discharge, the quality of nursing care and the frequency of complications were analyzed. To rate the effectiveness of hospital management, the number of days of admission, the number of days admitted in the intensive care unit, the waiting period before each operation, the medical cost for each patient, the cost per day, the amount of curtailment from the insurance, variance analysis were all analyzed through computerized data and other literature. Questionnaires were used to evaluate the level of satisfaction regarding CP application. The following is an analysis of the data. The subject's general characteristics was analyzed according to frequency and percentage. Analysis of the subjects homogenous characteristics was done using the X² -test. The t-test as used to analyze the quality of nursing care, the total number of patients admitted, the waiting time period before each operation, the number of days admitted in the intensive care units, the medical cost for each patient, the cost per day and the amount of curtailment from the insurance. Frequency and percentage was used to analyze the degree of variation and the level of satisfaction of the subjects based on application of the CP. The results of the research are as follows: 1. Development of critical pathway A critical pathway , one put in the form of diagrams so that it could be used by the medical staff members from the moment the patient arrives at the emergency room to the moment the patient is discharged. First the critical development team was formed after visiting other sites and reviewing various literature. The preliminary critical pathway was developed using as a framework, retrospectively reviewed medical records of 74 from 147 patients with subarachnoid hemorrhage in the year 1998 for useful information, then corrected and preserved after being investigated by a professional group composed of neurologists and nurses. The CP for medical staff members was selected as the preliminary CP, after passing the test for appropriateness at level 5. Since a system that emphasized education was unanimous, the vertical scale consisted of measurement and observation, activity and safety, diet, medication, tests, treatment/management, consult to other department, patient education and evaluation. The Horizontal scale on the other hand, consisted of a time line, in which the recordings were done in a straight line, with the operation kept as a midpoint. The patient centered CP, by keeping the CP for the medical staff as a framework, used words that could be easily understood by patients and guardians, and provided information about the treatment process. The educational materials and resources also helped to increase the level of satisfaction. In addition, the recording form to record the occurrence of variation was developed to write down the type and class of variation, each time the variation occurred. 2. Outcomes of the Critical Pathway (1) Outcomes from the perspective of increasing the quality of medical care 1) Rating the quality of nursing care. According to the CP, the quality of nursing care received a high score of 0.77, compared to 0.71 of the control group, showing a statistical significance increase of p=.001. 2) The frequency of complications After analyzing the frequency of complications before surgery, and during the admission period, it was concluded that there was no significant difference between the two groups, when compared before the operation(p=.110∼.910). A statistically significant difference was noted between the 2 groups when comparing pulmonary(p=.042∼.075) and hematology(p=.004∼.006) complications during the admission period. No significant difference was noted between the two groups when comparing neurology(p=.173∼.556), cardiovascular (p=.115) and the gastrointestinal (p=.187) departments, and infectious diseases(p=.377), however the frequency of occurrence was also very low. (2) Outcomes from the perspective of effectiveness of hospital management 1) Length of stay The mean length of stay of the CP application group was 9.68 days, shorter than that of the control group, showing a significant difference (p=.021) Although the main length of stay in the intensive care units was decreased by 2.65 days(p=.107), and the waiting time before surgery was also decreased by 19.68 hours, no significant difference was noted statistically (p=.128) 2) Medical charge for one patient The medical charge for the patients in the CP application group was seen to decrease to 3,333,482won(22.0%) and therefore a significant difference was noted (p=.197). Although there was also an increase of 32,401won(5.8%) with an increase in the hospital profit, no significant difference was noted statistically (p=.197) In addition, although a decrease in 83,095 won(47.8%) in the amount of curtailment from insurance was seen, no significance difference was seen statistically(p=.262) 3. Outcomes from the management perspective (1) Analysis of the variable There were total of 172 variances with 117cases (69.2%) with patients factor, 46 cases(25.8%) with medical care providers factor, and 9 cases(5.1%) with hospital materials. Depending on the subjects, 70 cases(40.6%) with medication and 53 cases (30.8%) with tests were the highest. When the variancy was classified according to 3 grades, 165 cases (96.0%) were seen with grade 1 with minimal or no change of the CP, 7 cases (4.0%) were seen with grade 2, with some variances applied to the CP. Grade 3, a grade unable to be applied to the CP itself, didnot even exist (2) Analysis of the level of satisfaction, regarding CP application More than 64% replied highly satisfied to satisfied, in regards to CP application. This research has verified an effective medical delivery system, one that contributes to the improvement of an effective management system, as well as the improvement in the quality of medical care, by standardizing the patient management process through the development of the CP model, and its application. Since the subjects of this research were those who had received the anuerysm clipping operation due to aneurysmal subarachnoid hemorrhage, it would be difficult to apply the results of this CP to other medical institutions or other types of diseases. The results of this research when applied as models in related departments, will be used appropriately as deemed necessary.
The present medical system recognizes general concepts of health to be the basis of daily life, with emphasis placed on the improvement of the citizen's level of education and daily activities. In addition, the medical system is aware that it will have to face problems of increased medical expenses, an increase in the aging population, an increase in the people's medical needs, as well as ineffective utilization of medical resources. It has been predicted that continuous changes in the medical system, including evaluation of the medical service system , medical law and inclusive cost effective systems, will continue to decrease the medical institution's benefits. Therefore each medical institution should strive towards improving the quality of the medical service, while at the same time decreasing medical expenses. As a result of searching for a new type of system, one that would raise the quality of service, while at the same time reduce costs, the case management using the CP as a tool, was selected. In addition, it was also deemed necessary to develop a new type of nursing delivery system, one that included the idea of the clinical nurse specialist. Several new plans such as the home visiting nurse program, were devised to encourage early discharging of patients. Anuerysm clipping operation, a type of cerebrovascular disease in the Neurosurgery department, results in emergency situations, complications, and treatment at high prices, as well as a complicated treatment process. It is therefore difficult to predict the progression of the disease, due to the need for emergency treatment to be done right away. Therefore an improvement in the treatment process, as well as a decrease in complications would be seen, if appropriate treatments were to be performed in a more systematic manner from the beginning. This study was conducted to develop a case management program using the CP as an intervention for patients who had received the anuerysm clipping operation due to aneurysmal subarachnoid hemorrhage, to improve the quality of medical care and for effective management of the medical institutions. The CP was applied from August 2000 to August 2001, to 26 subjects less than 70 years old, diagnosed with Hunt-Hess grade I-III, among patients who had received the anuerysm clipping operation due to aneurysmal subarachnoid hemorrhage, and who were admitted at the NSICU or neurology department, of University hospitals located in Seoul. 31 members of the control group were selected as subjects from September 1999 to July 2000. To evaluate the quality of medical service for all the subjects from day of admission to the day of discharge, the quality of nursing care and the frequency of complications were analyzed. To rate the effectiveness of hospital management, the number of days of admission, the number of days admitted in the intensive care unit, the waiting period before each operation, the medical cost for each patient, the cost per day, the amount of curtailment from the insurance, variance analysis were all analyzed through computerized data and other literature. Questionnaires were used to evaluate the level of satisfaction regarding CP application. The following is an analysis of the data. The subject's general characteristics was analyzed according to frequency and percentage. Analysis of the subjects homogenous characteristics was done using the X² -test. The t-test as used to analyze the quality of nursing care, the total number of patients admitted, the waiting time period before each operation, the number of days admitted in the intensive care units, the medical cost for each patient, the cost per day and the amount of curtailment from the insurance. Frequency and percentage was used to analyze the degree of variation and the level of satisfaction of the subjects based on application of the CP. The results of the research are as follows: 1. Development of critical pathway A critical pathway , one put in the form of diagrams so that it could be used by the medical staff members from the moment the patient arrives at the emergency room to the moment the patient is discharged. First the critical development team was formed after visiting other sites and reviewing various literature. The preliminary critical pathway was developed using as a framework, retrospectively reviewed medical records of 74 from 147 patients with subarachnoid hemorrhage in the year 1998 for useful information, then corrected and preserved after being investigated by a professional group composed of neurologists and nurses. The CP for medical staff members was selected as the preliminary CP, after passing the test for appropriateness at level 5. Since a system that emphasized education was unanimous, the vertical scale consisted of measurement and observation, activity and safety, diet, medication, tests, treatment/management, consult to other department, patient education and evaluation. The Horizontal scale on the other hand, consisted of a time line, in which the recordings were done in a straight line, with the operation kept as a midpoint. The patient centered CP, by keeping the CP for the medical staff as a framework, used words that could be easily understood by patients and guardians, and provided information about the treatment process. The educational materials and resources also helped to increase the level of satisfaction. In addition, the recording form to record the occurrence of variation was developed to write down the type and class of variation, each time the variation occurred. 2. Outcomes of the Critical Pathway (1) Outcomes from the perspective of increasing the quality of medical care 1) Rating the quality of nursing care. According to the CP, the quality of nursing care received a high score of 0.77, compared to 0.71 of the control group, showing a statistical significance increase of p=.001. 2) The frequency of complications After analyzing the frequency of complications before surgery, and during the admission period, it was concluded that there was no significant difference between the two groups, when compared before the operation(p=.110∼.910). A statistically significant difference was noted between the 2 groups when comparing pulmonary(p=.042∼.075) and hematology(p=.004∼.006) complications during the admission period. No significant difference was noted between the two groups when comparing neurology(p=.173∼.556), cardiovascular (p=.115) and the gastrointestinal (p=.187) departments, and infectious diseases(p=.377), however the frequency of occurrence was also very low. (2) Outcomes from the perspective of effectiveness of hospital management 1) Length of stay The mean length of stay of the CP application group was 9.68 days, shorter than that of the control group, showing a significant difference (p=.021) Although the main length of stay in the intensive care units was decreased by 2.65 days(p=.107), and the waiting time before surgery was also decreased by 19.68 hours, no significant difference was noted statistically (p=.128) 2) Medical charge for one patient The medical charge for the patients in the CP application group was seen to decrease to 3,333,482won(22.0%) and therefore a significant difference was noted (p=.197). Although there was also an increase of 32,401won(5.8%) with an increase in the hospital profit, no significant difference was noted statistically (p=.197) In addition, although a decrease in 83,095 won(47.8%) in the amount of curtailment from insurance was seen, no significance difference was seen statistically(p=.262) 3. Outcomes from the management perspective (1) Analysis of the variable There were total of 172 variances with 117cases (69.2%) with patients factor, 46 cases(25.8%) with medical care providers factor, and 9 cases(5.1%) with hospital materials. Depending on the subjects, 70 cases(40.6%) with medication and 53 cases (30.8%) with tests were the highest. When the variancy was classified according to 3 grades, 165 cases (96.0%) were seen with grade 1 with minimal or no change of the CP, 7 cases (4.0%) were seen with grade 2, with some variances applied to the CP. Grade 3, a grade unable to be applied to the CP itself, didnot even exist (2) Analysis of the level of satisfaction, regarding CP application More than 64% replied highly satisfied to satisfied, in regards to CP application. This research has verified an effective medical delivery system, one that contributes to the improvement of an effective management system, as well as the improvement in the quality of medical care, by standardizing the patient management process through the development of the CP model, and its application. Since the subjects of this research were those who had received the anuerysm clipping operation due to aneurysmal subarachnoid hemorrhage, it would be difficult to apply the results of this CP to other medical institutions or other types of diseases. The results of this research when applied as models in related departments, will be used appropriately as deemed necessary.
AI-Helper
※ AI-Helper는 부적절한 답변을 할 수 있습니다.