Tension Pneumoperitoneum Following Upper Gastrointestinal Endoscopy

Tension pneumoperitoneum is a potentially lethal complication of numerous iatrogenic procedures, including upper gastrointestinal (UGI) endoscopy. We report a 69-year-old man with UGI bleeding who developed tension pneumoperitoneum and cardiac arrest after UGI endoscopy. He was successfully resuscitated with needle decompression. Emergency surgery revealed a perforated gastric ulcer, and subtotal gastrectomy with Billroth II anastomosis was performed. Recovery was smooth and he was discharged from the hospital 18 days later. Tension pneumoperitoneum should be suspected in all patients who develop circulatory collapse with acutely distended abdomen after UGI endoscopy. Early identification relies on a high index of suspicion. Prompt treatment with needle decompression should not be delayed for confirmatory radiography once the clinical diagnosis is made

Cost-effectiveness of Different Advanced Life Support Providers for Victims of Out-of-hospital Cardiac Arrests

Background/purposeThe survival rate of out-of-hospital cardiac arrest (OHCA) is only about 1.4% in Taiwan. The best configuration to achieve optimal outcomes in OHCA is still uncertain for many communities. The purpose of this study was to investigate the cost-effectiveness of two models of providing advanced life support (ALS) services, emergency medical technicians (EMTs) vs. emergency physicians (EPs), in a two-tiered emergency medical services (EMS) system.MethodsThis was a prospective, observational, multicenter study comparing ALS provided by EMTs vs. EPs for the management of victims of OHCA. The study population consisted of patients experiencing OHCA of non-traumatic origin in Taipei city, Taiwan, between November 1999 and December 2000, for whom ALS was activated. We performed a cost-effectiveness analysis to determine the economic attractiveness of these two ALS provider programs. The outcome measurements were aggregate costs, survival and incremental cost per life saved. Sensitivity analyses were performed on all variables.ResultsThe expected total cost per OHCA patient was US$2248.19 and US$832.07 for the EMT and EP programs, respectively. The overall survival rate was 4.4%. The survival rate was 9.3% for the EMT program and 2.6% for the EP program. The incremental cost-effectiveness ratio (ICER) of EMTs vs. EPs was US$21,136 per life saved. The ICER was sensitive to hospital admission cost changes and the probability of survival to discharge in patients admitted to hospital in the EMT program. The increased survival rate of OHCA patients in the EMT program may be attributable to the services of the hospital and/or the EMT program.ConclusionThe use of EMTs as ALS care providers for OHCA patients in the two-tiered EMS system resulted in a reasonable cost-effectiveness ratio. EMTs could be considered as the second tier of EMS systems in urban areas in Taiwan

SARS Exposure and Emergency Department Workers

Of 193 emergency department workers exposed to severe acute respiratory syndrome (SARS), 9 (4.7%) were infected. Pneumonia developed in six workers, and assays showed anti-SARS immunoglobulin (Ig) M and IgG. The other three workers were IgM-positive and had lower IgG titers; in two, mild illness developed, and one remained asymptomatic

Penetrating Chest Injury: Who Warrants Aggressive Treatment?

To determine the degree of severity in penetrating chest injuries that predicts survival, we conducted a logistic regression analysis. All patients suffering penetrating chest injuries (n = 310) admitted to an urban level I teaching hospital in the USA between January 1993 and December 1994 were evaluated. The Injury Severity Score (ISS ), Glasgow Coma Scale (GCS), Trauma Score (TS), and Revised Trauma Score were used to compare injury survivors with nonsurvivors. We used the trauma scores to create a logit to predict the outcome among 160 patients in 1993 and tested the validity of this logit in another 150 patients in 1994. With death = 0, survival = 1, the equation lnPd/Ps = b0 + b1 ISS + b2 GCS + b3 TS was obtained from logistic regression, where b0 was the constant of the equation and b1, b2, and b 3 were the coefficients of ISS, GCS, and TS, respectively. A logit score greater than 0.5 was found to be predictive of death with a sensitivity of 80.0%, a specificity of 97.5%, and an accuracy of 94.0%. Aggressive resuscitation should be aimed at patients with a logit score greater than 0.5 to reduce mortality. This knowledge may aid in the management of patients with severe chest injuries

Use Balanced Scorecard to Establish Hospital Management Performance – One National Medical Center

本研究採用個案研究方法，以某國立醫學中心為研究對象，主要的目的在評估個案醫院實行平衡計分卡之成效，同時比較個案醫院和國內醫學中心實施平衡計分卡之結果，進而提出具體的改進意見。 本研究採回溯性縱貫面研究，資料來源大部分由個案醫院提供，同時參考個案醫院平衡計分卡成果發表會書面資料，而國內外醫學中心的資料，均由搜尋文件檔案、已發表論文和平衡計分卡成果發表會書面資料得來。個案醫院實行平衡計分卡之效果，乃以全院財務構面、顧客構面、內部流程構面和學習與成長構面為主要評比依據，而在其他國內醫學中心之比較方面，亦同樣以四大構面為主要評比方式。 主要發現為個案醫院自2003年實施平衡計分卡後，在財務構面上營收均逐年增加，顧客滿意度方面也是逐年上升，內部作業流程均有改進，學習與成長方面論文發表數目也逐年增多，更是全台灣第一名。在結合績效獎勵金方面，僅有非醫師人員實行過，而且才第一年，無法真正反應平衡計分卡與績效獎勵金結合之成效。在和其他國內外醫療院所比較方面，每家醫院在施行平衡計分卡後，在四大構面上均有程度不一的進步。 個案醫院目前仍朝願景目標在努力，是否在平衡計分卡之管理方式協助下得以實現願景仍有待日後查證。但個案醫院在四大構面方面均有改善，而且比較國內外醫療院所實行平衡計分卡之結果，初步發現平衡計分卡之目標管理方式適合於大形醫療院所，但其衡量指標之擬定仍需檢討改進。This study is a case study of one national medical center to evaluate the effect of the execution of balanced scorecard program and to compare the performance of other domestic medical center applying the balanced scorecard program. This case study used retrospective longitudinal method. The data most came from this national medical center and his abstract of balanced scorecard performance conference. Those data of the other domestic and foreign medical centers was obtained from the web site, published paper and their abstract of balanced scorecard performance conferences. The interdepartmental performance in this medical canter is compared using the individual key performance indicator. However, the inter-hospital differences are compared with their financial, customer, internal process, and growth and development scope. Our study showed that this national medical center has improved his performance in financial, customer, internal process, and growth and development scope after the execution of balanced scorecard program from 2003. However, the effect of combined operative bonus with balanced scorecard program is unclear due to limited data. Both domestic and foreign hospitals showed improved operative performance when applying balanced scorecard program. Currently, this national medical center is eager to reach its hospital vision. Whether it can be upgraded to his vision is warranted for further study. However, this national medical center and other medical center, either domestic or foreign, all showed improved operative performance after the set up of balanced scorecard program. We considered that balanced scorecard program is a useful modality to improve hospital operative performance.目錄 中文摘要----------------------------------------------------V 英文摘要----------------------------------------------------VI 目錄------------------------------------------------------- VII 表目錄------------------------------------------------------IX 圖目錄------------------------------------------------------XI 第一章 緒論------------------------------------------------1 第一節 研究背景----------------------------------------1 第二節 研究動機----------------------------------------4 第三節 研究目的----------------------------------------7 第四節 研究範圍----------------------------------------7 第二章 文獻探討--------------------------------------------9 第一節 組織績效----------------------------------------9 第二節 醫院績效評估-----------------------------------11 第三節 平衡計分卡理論與衡量指標-----------------------16 第四節 醫療院所推行平衡計分卡之相關研究---------------24 第三章 研究材料與方法------------------------------------41 第一節 研究方法---------------------------------------41 第二節 研究設計---------------------------------------41 第三節 資料來源與分析---------------------------------42 第四節 研究限制---------------------------------------42 第四章 個案研究與發現-------------------------------------45 第一節 個案醫院歷史背景-------------------------------45 第二節 實施平衡計分卡緣由與過程-----------------------46 第三節 個案醫院全院性平衡計分卡績效衡量指標-----------57 第四節 個案醫院導入平衡計分卡的初期直接及間接效果-----70 第五節 三軍總醫院實施平衡計分卡成果-------------------80 第六節 馬偕紀念醫院實施平衡計分卡成果-----------------87 第七節 個案醫院與三軍總醫院、馬偕紀念醫院實施結果比較-96 第五章 結論與建議----------------------------------------103 第一節 研究結論--------------------------------------103 第二節 研究建議--------------------------------------105 第三節 未來研究方向----------------------------------106 參考文獻--------------------------------------------------109 中文部份----------------------------------------------109 英文部份----------------------------------------------114 附件------------------------------------------------------118 作者簡歷--------------------------------------------------128 表目錄 表 1-1 國內醫院實施平衡計分卡時程表-------------------------4 表 1-2 評鑑合格醫院家數-------------------------------------6 表 2-1 傳統衡量指標系統與策略性衡量指標系統的比較----------11 表 2-2 品質類指標------------------------------------------13 表 2-3 投入、產出、經營效率指標----------------------------14 表 2-4 系統整合與教研指標----------------------------------16 表 2-5 衡量策略的財務主題----------------------------------20 表 2-6 Duke Children’s Hospital財務、顧客及內部流程構面指標--27 表 4-1 個案醫院SWOT分析---------------------------------55 表 4-2 個案醫院目標管理醫療單位主要衡量指標----------------63 表 4-3 個案醫院目標管理行政支援單位主要衡量指標------------64 表 4-4 個案醫院目標管理不同單位績效評估及主要衡量指標------66 表 4-5 個案醫院平衡計分卡策略目標評分----------------------67 表 4-6 個案醫院醫療支援單位平衡計分卡各構面配分------------71 表 4-7 個案醫院目標管理評核結果----------------------------74 表 4-8 個案醫院年營收與成長率---------------------------------------------77 表 4-9 個案醫院節約能源或抑低二氧化碳排放措施及成效------------79 表 4-10 三軍總醫院SWOT分析------------------------------82 表 4-11不同醫院性質比較------------------------------------97 表 4-12不同醫院使命與願景比較------------------------------98 表 4-13不同醫院年度SCI論文發表比較-----------------------104 圖目錄 圖 2-1 平衡計分卡四大構面---------------------------------19 圖 2-2 顧客構面五大核心量度-------------------------------21 圖 2-3 顧客價值一般模型-----------------------------------22 圖 2-4 企業內部流程構面-----------------------------------22 圖 2-5 學習與成長構面的衡量架構---------------------------23 圖 2-6 Duke Children’s Hospital策略地圖--------------------------------25 圖 2-7 Mayo Clinic策略地圖-------------------------------------------------29 圖 2-8 Ontario Hospital策略地圖-----------------------------33 圖 2-9 Rural Hospital Performance Improvement delta region------36 圖 2-10 Rural Hospital Performance Improvement使命、價值與願景 ---------------------------------------------------37 圖 2-11 Rural Hospital Performance Improvement策略地圖---------38 圖 4-1 個案醫院目標管理架構-------------------------------57 圖 4-2 個案醫院策略地圖-----------------------------------------------------60 圖 4-3 個案醫院目標與部室目標之連結-----------------------62 圖 4-4 個案醫院住院病人滿意度-----------------------------78 圖 4-5 個案醫院SCI論文發表篇數---------------------------80 圖 4-6 三軍總醫院策略地圖---------------------------------84 圖 4-7 三軍總醫院院內感染發生率---------------------------85 圖 4-8 三軍總醫院SCI及SSCI論文發表篇數-----------------86 圖 4-9 三軍總醫院自費佔醫療收入比率-----------------------87 圖 4-10 馬偕醫院平衡計分卡四大構面-------------------------92 圖 4-11 馬偕醫院平衡計分卡推行進度-------------------------93 圖 4-12 馬偕醫院策略地圖-----------------------------------94 圖 4-13 馬偕醫院不同單位的策略地圖比較---------------------95 圖 4-14 不同醫院平衡計分卡構面與策略地圖比較---------------99 圖 4-15 不同醫院年度營收比較------------------------------10

月經病史在鑑別診斷急性闌尾炎和骨盤腔發炎的 價值

From August 1992 to August 1993, 45 female patients with acute appendicitis and 48 patients with pelvic inflammatory disease, all between the ages of 15 and 45, were included for comparative study at the onset of symptoms between each phase od the menstrual cycle. There was no significant difference of onset of symptome between acute appendicitis and pelvic inflammatory disease in each phase of the menstrual cycle. Menstrual history was not a good indicator for differentiating the two conditions. To make a more precise differential diagnoses, more information, to include detailed history, physical examinations and laboratory findings, is necessary.#0771