환자사례관리모형 개발 및 적용 효과 : 척추후궁절제술 환자 중심으로

다국어 초록 (Multilingual Abstract)

As a result of the recent problems of increased medical expenses and
ineffective utilization of medical resources, related to an increase in the
people's medical needs, the medical reform has made by the government.
Medical facilities have therefore been searching for a medical delivery system,
one that could make a quality improvement and one that is at the same time
cost effective. In order to meet these demands, it was also seen necessary to
develop a new nursing delivery system, that is able to improve nursing
productivity.
The purpose of this study was to develop a case management model for
patients who have undergone laminectomy, then to analyze the outcomes after
the clinical application of the developed case management model. In order to develop a case management model, the case management team
was constituted with the members of a neurosurgeon, rehabilitation doctor,
nurse manager, and nurses, who were involved in the care of laminectomy
patients and a staff member of the QA team, department of the medical
records and the billing and finance. Pre-admission program, CP to be used
during hospitalization and the form to be used to record variances, were
developed by reviewing various domestic and international literature,
bench-marking of leading hospitals with successful programs and also by
reviewing medical records and case manager's role was defined.
Subjects of this study were consisted of patients who have admitted and
received laminectomy during 13 months period, from May 1998 to May 1999.
Those patients who agreed to be managed under a case management model
was used for the experimental group, previously used nursing care methods
were used for the control group.
The results are as follows
1. Development of case management model
Once the patient was selected as an experimental group patient, he(or she)
is admitted through the pre-admission program. The pre-admission program
included visiting the neuro-surgical outpatient department twice prior to the
admission. The outpatient case manager then performed pre-operative tests and
reviewed the results of the tests, did any measurements necessary for the
operation, filled out the patient information form, performed procedures and specific instructions regarding the operation. The patient was admitted to the
inpatient unit directly on the day of surgery, and was received preparations
and instructions on the day of surgery, then got transferred to the operating
room.
The standardized CP, to be applied from the moment the patient is
admitted to the ward after the operation, until he(or she) was discharged. The
standardized CP was developed through 4 phases. During the first phase, the
conceptual framework was constructed by putting assessment and observation,
activity, diet, treatment, drainage, consultation, tests, medications, patient
teaching, emotional support and remarks to evaluate daily treatment and
nursing care on the vertical axis, and by putting the time frame which has
operational date as a center on the horizontal axis. During the second phase,
the preliminary CP was developed after analysis of the medical record of 27
patients , who were discharged after receiving laminectomy from February to
April 1998, based on the developed conceptual framework. The third phase
consisted of correction of the preliminary CP by the professional groups
consisting of neurosurgeons, nurses working in the neurosurgical nursing unit.
and the final form of CP was confirmed by the case management team. In
this model, instead of assigning a full time case manager, the unit nurse
manager, the nurses in the neurosurgical inpatient unit and the outpatient
department, were all taught to assume this role. Variance sheets were then
developed to record all variance. 2. Outcomes of the case management model
1) Outcomes from the patient's perspective
⑴ Nursing Quality Evaluation Score(NQES)
The mean NQES for the experimental group(1.96) was higher than that for
the control group(1.81).
⑵ Hours of direct nursing care provided to each patient in one day
The average direct nursing care hour for a patient in one day for the
experimental group(82.71 min) was higher than that for the control group(73.71
min).
⑶ Surgical outcomes
① The degree of lower back pain postoperatively
The mean score of lower back pain of the experimental group(2.61) was
lower than that of the control group, but no significant difference was noted
between the two groups when compared pre and post operatively.
② The degree of lower extremities pain postoperatively
The mean score of lower extremities pain of the experimental group(1.67)
was lower than that of the control group(3.12), and statistically significant
difference was noted between the experimental group(6.21) and the control
group(4.15) when compared the lower extremities pain pre and post operatively.
③ Post-operative complications
The experimental group was seen to have one wound problem, and one
minor problem related to impairment of elimination and urination
postoperatively. However these problems were minimal and rather insignificant.
The degree of decreased ambulatory discomfort after the surgery for the experimental group(4.42) was higher than that for the control group(3.65).
⑷ Medical expense per patient
The mean medical expense for the experimental group(1,833,163￦) was
lower than for that of the control group(2,589,065￦).
⑸ Level of patient satisfaction
No significant difference was seen between the experimental group(4.35)
and the control group(4.17), in terms of patient satisfaction.
2) Outcomes from the perspective of hospital management
⑴ Length of stay(LOS)
The mean LOS for the experimental group(6.06 day) was shorter than that
for the control group(10.04 day).
⑵ Nursing cost
The mean cost of nursing for the experimental group(262,387￦) was lower
than that for the control group(418,070￦).
3) Outcomes from the medical care providers' perspective
No statistically significant difference was found between the experimental
group(3.26) and the control group(3.18) in terms of nurses' job satisfaction.
3. Analysis of variances
There were 125 variances with 43 cases(35.25%) in patients/family factor,
79 cases(63.2%) in medical care providers factor and 3 cases(2.4%) in hospital
factor. When the variance were classified by 3 grades, grade 1 was seen with
no change or minimal variances from CP, grade 2 was seen with some
variances from CP, but still able to apply CP, grade 3 was seen to be unable to apply CP. There were 111 cases(88.8%) of grade 1, 14 cases(11.2%) of
grade 2, and no case of grade 3.
In conclusion, through effective activation activities by the case management
team, as a result of active participation of medical doctors, the outpatient
management program, CP during hospitalization, and forms to record the
variances were all developed successfully, and the standard of evaluations
which could systematically and comprehensively test the outcomes of case
management was also selected. This research has shown that it may be
necessary to consider a full time case manager in developing future patient
case management model, since there was no positive outcomes from the
medical care providers' perspective, by giving dual assignments to the staff
nurses in this study.
The case management model has been seen to be a cost-effective nursing
delivery system, that could improve the level of nursing care quality and
reduce the patient's burden for medical expense from the patient's perspective,
and that could reduce the length of stay and the nursing cost from the
perspective of hospital management.

국문 초록 (Abstract)

현재 의료계는 국민의 의료수요의 증가, 인구의 노령화 및 질병구조의 만성화에 따른 의료비 상승문제, 의료자원의 비효율적인 활용의 문제를 안고 있어, 정부차원의 의료개혁이 시도되고 있다. 1997년 포괄수가제 도입을 위시하여 여러 가지 의료정책의 변화는 의료서비스의 질을 향상시키면서도 비용효과를 가져올 수 있는 혁신적인 의료전달체계를 모색하게 되었고, 이에 따라 간호계에서도 간호생산성을 향상시킬 수 있는 새로운 간호전달체계의 개발을 필요로 하게 되었다.
본 연구의 목적은 일개 종합병원의 척추후궁절제술 환자를 대상으로 사례관리모형을 개발하고 이를 임상에 적용하여 환자 측면의 효과로는 진료와 간호의 질 수준, 진료비 부담수준 및 만족도를, 병원운영 측면의 효과는 재원일수와 간호원가를, 의료제공자 측면의 효과로는 직무만족도를 분석하는데 있으며, 이를 바탕으로 효율적인 간호전달체계를 수립하고 진료 및 간호의 생산성을 향상시키기 위한 기초자료를 제공하는데 있다.
관련 의료진과 환자사례관리팀에게 환자사례관리에 대한 교육을 시행한 후, 1998년 5월부터 1999년 5월까지 13개월동안 환자사례관리모형을 적용한 실험군 33명과 기존의 진료 및 간호를 받은 대조군 26명을 대상으로 환자사례관리의 효과를 평가하였다.

목차 (Table of Contents)

• I. 서론 1
• 1. 연구의 필요성 1
• 2. 연구의 목적과 범위 3
• 3. 용어정의 4
• 1) 환자사례관리모형(case management model) 4
• 2) 환자사례관리 효과 6
• Ⅱ. 문헌고찰 7
• 1. 환자사례관리모형 개발 7
• 1) 환자사례관리모형 개발단계 8
• 2) 주진료경로(Critical Pathway) 9
• 3) 환자사례관리자(Case Manager) 11
• 4) 변이분석(Variance Analysis) 13
• 2. 환자사례관리의 효과 14
• Ⅲ. 연구방법 21
• 1. 연구의 개념틀 21
• 2. 연구의 체계 22
• 3. 연구방법 24
• Ⅳ. 연구결과 35
• 1. 환자사례관리모형 개발 35
• 1) 환자사례관리모형 35
• 2) 입원전 프로그램 37
• 3) 주진료경로(Critical Pathway) 39
• 4) 환자사례관리자의 역할 및 업무 46
• 5) 평가지표 46
• 2. 환자사례관리 효과 47
• 1) 연구대상환자의 일반적 특성 47
• 2) 효과분석 48
• 3) 변이분석 54
• V. 논의 58
• 1. 환자사례관리모형 개발 58
• 2. 환자사례관리 효과 61
• 3. 변이분석 67
• Ⅵ. 결론 및 제언 69
• 참고문헌 73
• ABSTRACT 102