Kirton O C, Civetta J M, Hudson-Civetta J
Department of Surgery, University of Miami School of Medicine, FL, USA.
Surg Clin North Am. 1996 Feb;76(1):175-200. doi: 10.1016/s0039-6109(05)70430-8.
Effective policies to reduce true costs will require integrated information systems and demand behavioral changes from providers. A congenial environment must be created among medical educators, providers, vendors, and consumers if cost reduction is to be accomplished without compromising quality or access to critical care services. Physicians should do everything they believe may be of benefit for their patients, but we have an obligation to educate the public about the limitations of our art and the fact that "doing everything" is not always best for the patient or the grieving family. A significant method of controlling ICU costs is closely monitoring which patients are admitted and when they are discharged. Laboratory tests represent a source of cost reduction, and physicians must learn to order specific tests and not simply a battery of tests which includes the actual test desired. Limits should be placed on the tests that are ordered in terms of number and frequency. Improved efficiency of the utilization of resources should improve the care of our patients. The largest budget item of any or most critical care units is nursing; it is paramount that this essential and invaluable resource be utilized in a cost-effective manner. Diminishing unnecessary activity will both decrease complications and have salutary effects. Having more time to be with patients and their families will decrease our sense of failure and fulfill the important goal of caring. Physicians and nurses can return to thinking, assessing, and decision making instead of frenetically ordering, reacting, and intervening, which, we believe, accurately describes informational overload created by undue emphasis on high technology. In this way, we can respond to Fuch's exhortation that "physicians consider the possibility of contributing more by doing less." In responding, however, we must never forget that the societal, not merely the economic impact of medical care, is our principal consideration. We must first contribute more by achieving a greater understanding of the medical care process. Only then can we know how to do less at the bedside. We can and must distinguish between costly and high-quality care--they are not necessarily synonymous.
降低实际成本的有效政策需要综合信息系统，并要求提供者改变行为。如果要在不影响质量或重症护理服务可及性的前提下实现成本降低，就必须在医学教育工作者、提供者、供应商和消费者之间营造一个融洽的环境。医生应该做他们认为可能对患者有益的一切事情，但我们有义务向公众说明我们医术的局限性，以及“竭尽所能”并不总是对患者或悲痛的家属最有利这一事实。控制重症监护病房成本的一个重要方法是密切监测哪些患者被收治以及何时出院。实验室检查是成本降低的一个来源，医生必须学会开具特定的检查项目，而不是简单地开具一系列检查项目，其中包括所需的实际检查。应在检查的数量和频率方面设定限制。提高资源利用效率应能改善我们对患者的护理。任何或大多数重症监护病房最大的预算项目是护理；以具有成本效益的方式利用这一至关重要且不可替代的资源至关重要。减少不必要的活动既能减少并发症，又会产生有益的效果。有更多时间陪伴患者及其家属将减少我们的失败感，并实现护理这一重要目标。医生和护士可以回归思考、评估和决策，而不是疯狂地开医嘱、做出反应和进行干预，我们认为，这准确地描述了过度强调高科技所造成的信息过载。通过这种方式，我们可以回应富克斯的劝诫：“医生应考虑通过少做多得的可能性。”然而，在回应时，我们绝不能忘记，医疗保健的社会影响，而不仅仅是经济影响，才是我们的主要考虑因素。我们必须首先通过更深入地了解医疗保健过程来做出更多贡献。只有这样，我们才能知道在床边如何少做一些事情。我们能够而且必须区分昂贵的护理和高质量的护理——它们不一定是同义词。
