Hospitalist照護制度在提昇病人安全的角色

內科部林世昌 部主任

105.10.11

多重疾病患者照護需求增加

老年人口增加，高齡社會的病人常有多重慢性疾病

急診常有較難判科的情形

需要更有臨床經驗的醫師來照護

住院醫師人力短缺

Why Hospitalist Program

1

照護團隊

主治醫師: attending physician加specialist 專門從事住院病人之照顧

護理師轉任的醫師助理（專科護理師）

其他醫事人員

輪班制度: 彈性排班以保障醫師合理工時

跨團隊整合照顧住院病人的模式

Hospitalist Program

2

照護團隊以主治醫師為主

主治醫師臨床經驗較豐富

有較長的時間花在住院病人照護

較有時間與病人溝通

專科護理師輔助臨床照護

增加專科護理師培育與訓練

提供住院病人更優質的整合醫療，提升照護效率，共創醫病雙贏

Hospitalist制度的特色

3

臨床照護 發展不分科而可以照顧病人整體狀況的hospitalist專科醫師 因應醫師納入勞基法 高齡化患者疾病複雜

協調角色 為患者病況照會其他專科醫師 協調出院後的居家照顧

提高住院醫療品質 患者提早出院

擔起教學、訓練新血的行政工作 醫院整合醫學專科醫師

The Roles of Physicians in Hospitalist Program

4

Challenges

Physician recruitment and retention: the incentives

Workload and work-life balance

Hospital demands

Certification or accreditation towards a uniform definition of a “hospitalist” ?

Supports

Nurse practitioners

Clinical nurse specialists or physician assistants

Challenges and Supports for Hospitalists

5

Key Roles and Responsibilities of Hospitalists

6

Hospitalist Program Assessment Approach

7

The Quality of Inpatient Care in Hospitalist Program

8

Do hospitalist physicians improve the quality of inpatient care delivery?

Better Health-Care Quality Provided by Hospitalists

9

Hospitalists are trained specialists who are more senior than residents.

Hospitalists have enhanced on-site availability and additional time spent on service.

Hospitalists can provide the same quality of clinical care in shorter periods of time, as evidenced by reductions in patients' average length of hospital.

Patient processing is enhanced in hospitalist program.

Patient Safety: Avoiding health care Errors

10

The definition of a health care error Preventable adverse effect of care; the prevention of

harm to patients

Patients can be harmed by the misuse of technology, poor communication between different health-care providers, delays in receiving treatment or adverse drug reactions.

To error is the human nature

Reasons for Causing Medical Errors

11

The system of health care is so complex that the successful treatment and outcome for each patient depends on a range of factors

There are many people and different types of health-care providers, including doctors, nurses, pharmacists, social workers, dieticians and others

The numerous “handoffs” take place during hospitalization

The Goals of Patient Safety

12

Prevent errors

Learn from the errors that do occur

Develop a culture of safety that involves health care professionals, organizations, and patients

Causes of Health Care Error

13

Human Factors Variations in healthcare provider training and experience Exhaustion, fatigue, depression and burnout Diverse patients, unfamiliar settings, time pressures Failure to acknowledge the prevalence and seriousness of medical

errors Increasing working hours

Medical complexity Complicated technologies and drugs Prolonged hospital stay

System failures Poor communication; drug names that look alike or sound alike Poor patient to nurse staffing ratio Disconnected reporting systems within a hospital; inadequate systems

to share information about errors Numerous hand-offs of patients; lack of coordination and errors Lack of the analysis of contributory causes and improvement strategies Environment and design factors

The Dynamics of Accident Causation

14James Reason, Human Error (Cambridge University Press, 1990), p. 208.

The Role of Hospitalist in Patient Safety

15

Hospitalist is a physician who focuses his practice on the care of hospitalized patients

Hospitalist is responsible for the coordination and safety of hospitalized patients.

Hospitalists can provide better coordination and communication Treating the patient is a team effort. Orchestrating the team effectively is the responsibility of an attending

physician. Better coordination of handoffs among many specialists is needed. The numerous “handoffs” that take place during hospitalization, the

potential for medical errors increases exponentially. Hospitalists can cope with high intensity of illness and pressures

to reduce length of stay . Hospitalists can deliver to the patients the essential care that

patients need, both while in the hospital and after they are discharged.

Handoffs and Patient Safety

16

In-hospital handoffs are a frequent occurrence Handoffs during hospitalization from one provider to another

represent critical transition points in patient care Handoffs are considered a vulnerable time for patient safety.

No studies of hospitalist handoffs Recommendations for hospitalist handoffs during shift change

and service, based on existing literature from related disciplines and expert opinion support

The use of a verbal handoff supplemented with written documentation in a structured format or technology solution.

Technology solutions are associated with a reduction in preventable adverse events, improved satisfaction with handoff quality, and improved provider identification.

Focusing on ill patients and actions required. Content should be updated daily to ensure communication of the

latest clinical information.

Major Types of Patient Safety Incidents in Some Major Types of Patient Safety Incidents in Primary Care

17

Many incidents are related to diagnosis and treatment (delayed or inappropriate)

Failures in the doctor–patient relationship

Failure in communication between healthcare professionals

Failures of coordination of care

Patients with multi-morbidity in primary care are potentially at greatest risk of patient safety issues

Process of Root Cause Analysis for Preventing Medical Errors

18

Hospitalists may need to learn how to perform a root cause analysis for workup and future prevention of medical errors

配合國家政策: 病人安全目標

19

提升醫療照護人員間的有效溝通

落實病人安全事件管理

提升手術安全

預防病人跌倒及降低傷害程度

提升用藥安全

落實感染管制

提升管路安全

鼓勵病人及其家屬參與病人安全工作

參考資料來源: 財團法人醫院評鑑暨醫療品質策進會

加強團隊溝通技能

20

參考資料來源: 財團法人醫院評鑑暨醫療品質策進會

鼓勵醫療人員主動與病人及其家屬建立合作夥伴關係

21

參考資料來源: 財團法人醫院評鑑暨醫療品質策進會

Create Checklists for Improving Patient Care

22

Adverse drug events

Catheter-associated urinary tract infections

Central line-associated blood stream infections

Injuries from falls and immobility

Hospital-acquired pressure ulcers

Preventable readmissions

Surgical site infections

Ventilator-associated pneumonias and ventilator-associated events

Conclusions

23

Hospitalist制度的照護團隊以主治醫師為主，而主治醫師臨床經驗較豐富，且有較長的時間花在住院病人照護與病人溝通，應可提升臨床照護品質和病人安全。

Hospitalist應接受更多病人安全的教育訓練，主導病人安全政策的執行。

Hospitalist主治醫師應扮演照護人員間之協調與溝通的角色，並建立完善的交班的制度，因此更能提升病人安全。

Hospitalist應建立提升病人安全的注意事項和工作目標，並配合國家政策。

Thank You For your Attention