ICU护理上海护理学会课件

1、ICU护理上海护理学会1临床重症监护新进展临床重症监护新进展徐丽华徐丽华上海交通大学护理学院上海交通大学护理学院世界健康基金会世界健康基金会 （Project HOPEProject HOPE）ICU护理上海护理学会2The Development of Critical Care Nursing 重症监护发展重症监护发展1950 年照顾脊髓灰白质炎病人1960 年开始麻醉恢复室1960 开始Johns Hopkins Hospital 3-bed 神经外科手术后重症护理床开始，而后有CCU及在芝加哥建立早产儿单位1970年发展共性重症监护室 ICU护理上海护理学会3适当的适当的ICU环境能促

2、进病人安全环境能促进病人安全ICU护理上海护理学会4NICU Progress in 90s (3)Surfactant therapy 肺表面张力素治疗Antenatal Steroids 产前激素治疗Folate to prevent NTDs 叶酸预防神经管道缺损Improved survival of micropremies 微小早产儿提升存活率Nitric Oxide therapy 一氧化氮治疗Fetal Therapy 胎儿治疗“Back to Sleep” reduced SIDS “平躺”预防婴儿悴死症发生by Dr. Avroy Fanaroff, 2001ICU护理上海

3、护理学会5AACN Defines Role of Critical Care Nurses 定义重症护理角色重症护理是一个专业，处理人们面临危及生命的问题及反应 工作范畴 包括病危者、家属、重症护理同事、及重症护理工作环境目标：确保有效的互动及最佳的患者照顾结果ICU护理上海护理学会6The Development of Critical Care Nursing 重症护理发展重症护理发展认可护理人员在重症护理 贡献及角色，促进与医师间 的合作医疗技术与仪器发展促进特别的重症护理单位建立ICU护理上海护理学会7Contemporary Critical Care 现代的重症护理多医疗梯队的照

4、顾 ： physician intensives, specialty physicians, nurse, advanced practice nurses, and other nurse clinicians, pharmacists, RT, PT, OT, social workers, clergy, child life specialist 照顾的连续性 Continuum of care from one setting to another （连接医院到家庭、社区)ICU护理上海护理学会8ICU相关人员ICU病人病人微生物学家微生物学家临床心理治疗师临床心理治疗师深切治疗专

5、家深切治疗专家专科医师专科医师职业治疗师职业治疗师物理治疗师物理治疗师医学社工医学社工营养师营养师 院感护士院感护士 伤口护士伤口护士ICU 护士护士ICU护理上海护理学会9ICU Patient and Family ICU护理上海护理学会10引导重症护理发展的理念引导重症护理发展的理念 Synergy Model (Villaire, 1996):Synergy Model (Villaire, 1996): 叙述护士与病人间的相互关系叙述护士与病人间的相互关系 病人的特质促使护理能力的发展，以便能病人的特质促使护理能力的发展，以便能提供整体的、修复的照顾，促使病人达到提供整体的、修复的照

6、顾，促使病人达到最佳的护理结果最佳的护理结果ICU护理上海护理学会11Synergy Model: 护理胜任能力理胜任能力Clinical judgment Clinical judgment 临床判断临床判断Advocacy Advocacy 建言建言Caring practices Caring practices 关怀的实践关怀的实践Collaboration Collaboration 协和性协和性Systems thinking Systems thinking 系统思维系统思维Response to diversity Response to diversity 多元性的反应多元性

7、的反应Clinical inquiry Clinical inquiry 临床的质疑临床的质疑Facilitation of patient and family Facilitation of patient and family learning learning 是病人及家属学习的促进者是病人及家属学习的促进者 ICU护理上海护理学会12Synergy Model: 环境 Environment Value 价值官Respect 尊重Knowledge 知识Ethical 道德Collaboration 协作Diversity 多元化Leadership 领导Life-long lear

8、ning 终身学习Optimized talent and resources 扩展能力及资源Innovation and creativity创新及创造Nurses create a healing, humane, and caring environmentICU护理上海护理学会13ICU护理上海护理学会14 AACN AACN 重症护理专业标准重症护理专业标准Quality of Care Quality of Care 照顾品质照顾品质Individual Practice Evaluation Individual Practice Evaluation 个别实践个别实践评价评价E

9、ducation Education 教育教育Collegiality Collegiality 同事间合作同事间合作Ethics Ethics 道德道德Collaboration Collaboration 共同合作共同合作Research Research 科研科研Resource UtilizationResource Utilization 资源应用ICU护理上海护理学会15ICU 护理重视议题ICU护理上海护理学会16重症医疗与护理趋势重症病人复杂性增加老年病人有慢性疾病及多器官问题、留院时间长、费用增加、增加重症护理的负荷。重症医疗费用昂贵，占据大部分的医疗预算重症护理护理人力不足

10、，病人住院时间缩短、评价护理成效与结果ICU护理上海护理学会17重症医疗与护理趋势-(2)重视病人安全、临床护理指引、以循证为基础医疗梯队合作适应高科技的发展与应用，及高科技所带来的道德冲突临终关怀与护理远距医疗与护理ICU护理上海护理学会18重症护理中所重视的护理议题降低ICU院内感染发生率（管道、呼吸机、抗生素降低自身免疫力)ICU 陪客与家属看护问题ICU 护理成效及指标入住 ICU指标及病情严重度评价ICU管理：财务、仪器、费用平衡、新技术与材料可及性ICU病人出院后的随访与康复，如何降低ICU出院病人的再入院或急诊再使用率？ ICU护理上海护理学会19重症疾病照顾与家属压力重症单位家

11、属需求：1。 需要离重病家属近（Keske，1992），病室要有足够空间容纳家属2。家属需要舒适感：情绪与生理舒适，等候室空间、医疗进程报告护理人员工作在重症单位的压力（符合、单位设计、休息时间与场所，环境舒适感）ICU护理上海护理学会20重症单位病人的经验沟通困难沟通困难疼痛疼痛口渴口渴吞咽困难吞咽困难焦虑焦虑失去控制失去控制忧郁忧郁害怕害怕缺少朋友及家属缺少朋友及家属被约束觉得被拖累无法活动舒适睡眠困难寂寞思想死亡或有滨死感觉ICU护理上海护理学会21Concern pt comfortICU护理上海护理学会22ICU环境与患者问题环境与患者问题 Sensory overload Sens

12、ory overload 感官刺激过渡感官刺激过渡 Sensory deprivation Sensory deprivation 感官刺激不足感官刺激不足 Sleep deprivation Sleep deprivation 睡眠不足睡眠不足 Lack of privacy Lack of privacy 缺乏隐私缺乏隐私 Technology dependent Technology dependent 仰赖科技仰赖科技 Separation from familiar setting and Separation from familiar setting and people peo

13、ple 与家属分离与家属分离Uncomfortable sensation associated with Uncomfortable sensation associated with Treatment Treatment 与治疗相关的不舒适ICU护理上海护理学会23ICU 精神心理健康ICU病人曾经历焦虑、烦躁、及幻觉1964年发现ICU病人的心理问题：ICU Psychosis, Intensive care delirium, .许多ICU的疾病进展也可能导致病人产生幻觉ICU病人需要实际的讯息护理目标：确保病人的安全，使病人有安全感、降低环境刺激、提供环境定向感建立、促进病人休息I

14、CU护理上海护理学会24影响ICU病人心理健康因素年龄发展阶段过去疾病经验家庭关系及社会支持个人对生命与死亡看法文化因素（不同种族对空间与接触的看法不同）ICU护理上海护理学会25重症病人家属一个重症病人可以影响全家人精神心理压力及医疗财务压力照顾家属照顾病人，协助家庭（病人与家属）度过危机压力期ICU护理上海护理学会26ICU 的睡眠问题patients in critical care units may spend 40% to 50% of their sleep time awake（清醒）（清醒）, and of the remaining sleep time only 3% t

15、o 4% in REM sleep （快速动眼期）（快速动眼期）not being able to sleep was ranked as the second most important stressor, second only to pain. 无法入睡是无法入睡是ICU病人最大的压力病人最大的压力ICU护理上海护理学会27ICU病人的睡眠混乱问题镇静剂催眠影响: 在幼儿中睡眠混乱导致儿童日间行为减少, 因睡眠不佳而累积的疲惫增加, 依赖, 耐受, 快速动眼期受抑止或反弹. ICU护理上海护理学会28ICU 病人的睡眠问题正常睡眠降低心血管系统的生理负荷如睡眠不足可导致生理与精神的消耗

16、与延迟恢复精神心理情况改变，重症监护相关的精神病及强化疼痛ICU护理上海护理学会29重症监护室的噪音监护室噪音应低于 35 to 40 dB 以利有效休息， 在白天低于 180 mm Hg (or increase of 20% or more) or diastolic BP 100 mm HgHeart rate 120 beats/minute (or increase of 20% or more)Respiratory rate 30 breaths/minute (or changing 50% or more)SpO2 90%Signs of increased work of

17、breathing-dyspnea, accessory muscles useDiaphoresisFatigue or painICU护理上海护理学会41Hemodynamic monitoringBP: 6070/40-50 mmHgLA 12-14mmHgRA 15-18mmHgMaintain HCT above 35%，ICU护理上海护理学会42Hemodynamic monitoring动脉导管动脉导管: Transducer position不能有空气不能有空气淡肝素持续淡肝素持续 绝对无菌绝对无菌ICU护理上海护理学会43Hemodynamic monitoringDrugs

18、 Used to Improve CO and BP多巴安多巴安5-10ug/kg/minMilrione 米力农米力农0.5ug/kg/minICU护理上海护理学会44Hemodynamic monitoring小剂量及单位小剂量及单位剂量剂量IV给药给药Label meds.Set the rate。 ICU护理上海护理学会45动脉导管波形代表在QRS后收缩压的锋值: cardiac systolic pressure wave to reach the peripheral catheter and sensor双锋代表动脉瓣的关闭Dichotic notch indicates the

19、 closure of the aortic valveICU护理上海护理学会46ICU护理上海护理学会47ICU护理上海护理学会48ICU护理上海护理学会49Cardiac Output 心输出量主要与心跳及心排（stroke volume) 有关， 心跳增加时， 心输出量可能增加。但心跳过速影响心室灌注，并减少心输出量导致系统的循环失常。因此心跳过慢或心跳过速 （180200/min)均应仔细评估。Cardiac output=HR X Stroke VolumePreload, Afterload, ContractilityICU护理上海护理学会50The Pulmonary Arte

20、ry catheter (PAC)The purpose of this catheter is to:Indirectly measure the left ventricular end-diastolic pressure. Evaluate the hemodynamic treatments and measure the patients hemodynamic status. Draw mixed venous blood samples. Obtain central vascular pressures measurements. Measure cardiac output

21、. ICU护理上海护理学会51PA Catheter IndicatorConditions of shock such as septic and hypovolemic shock. Evaluation of fluid volume status. Evaluation of cardiac output in complex medical situations. Prophylactic insertion for high-risk surgeries. ICU护理上海护理学会52ICU护理上海护理学会53ICU护理上海护理学会54ICU护理上海护理学会55Parameter N

22、ormal ValueBlood PressureSystolic (SBP)90-140 mmHgDiastolic (DBP)60-90mmHgMean Arterial Pressure (MAP) 70 - 100 mm HgCardiac Index (CI)2.5-4 L/min/m2Cardiac Output (CO)4-8 L/minCentral Venous Pressure (CVP) (also known as Right Atrial Pressure (RA) 2-6mmHgICU护理上海护理学会56Parameter Normal ValuePulmonary

23、 Artery Pressure (PA)Systolic 20-30 mmHg (PAS)，Diastolic 8-12 mmHg (PAD)Mean 25 mmHg (PAM)Pulmonary Capillary Wedge Pressure (PWCP)4-12 mmHgPulmonary Vascular Resistance (PVR)37-250 dynes/sec/cm5Right Ventricular Pressure (RV)Systolic-20-30 mmHg，Diastolic 0-5 mmHgStroke Index (SI) 25 - 45 ml/m2Strok

24、e Volume (SV) 50 - 100 mlSystemic Vascular Resistance (SVR)800-1200 dynes/sec/cm5ICU护理上海护理学会57心脏指标计算方式Body Surface Area (BSA) = ( Height (cm) x Weight (kg) / 3600 )1/2Cardiac Index (CI) = Cardiac Output (CO) / Body Surface Area (BSA)Mean Arterial Pressure (MAP) = (2 x DBP) + SBP / 3Pulmonary Vasular

25、 Resistance (PVR) = PAM - PCWP / CO X 80Stroke Index (SI) = Stroke Volume (SV) / Body Surface Area (BSA)ICU护理上海护理学会58心脏指标计算方式Stroke Volume (SV) = is the amount of blood ejected by the left ventricle into the vasculature in one heart beat.Systemic Vascular Resistance (SVR) = (MAP - CVP) / CO X 80ICU护

26、理上海护理学会59系统重症患者的监护ICU护理上海护理学会60休克症状评估原理-1焦炉，混乱，失去方向感乃因早期休克交感神经反应及缺氧及休克晚期脑部灌注不良所导致深而快的呼吸：因循环氧量减少，乳酸及二氧化碳聚集所导致, Sao2 95%, Pao2 5 sec)尿量降低每小时少于30西西(UO 10 mmHg within 30 minutes, tolerance depends on pt condition) 促使分泌物及压力的放松ICU护理上海护理学会67Position and VAPSemi-recumbent head-of-bed positioning (45 degree)

27、 to decrease VAP 抬高床头ICU pt 抬高头部减少胃液反流及细菌游走到呼吸道 (Helman et.al., 2003)ICU护理上海护理学会68Prevention of VAP呼吸机相关性肺炎预防 1. 好的口腔护理. 2. 在ICU执行口腔卫生评估 3. 适当的处理与呼吸道接触的医疗用物 4. Eliminating the routine changing of disposable equipment. 减少不必要的更换 5. Use a sterile single-use catheter with each procedure 使用一次性的抽吸管 ICU护理上

28、海护理学会69VAP and Hand washing 肺炎与洗手Importance of Hand Hygient for all patient care activity 强调洗手重要性The CDC recommends using alcohol-based hand rubs to increase hand hygiene compliance and decrease the incidence of hand-transmitted infections 使用含酒精的免洗手液ICU护理上海护理学会70预防吸入及呼吸机相关性肺炎Remove endotracheal and

29、tracheostomy tubes as soon as possible早拔管 Avoid Reintubation 避免重复插管Elevate the head of the bed for all patients with enteral feedings to an angle of 30 to 45 degrees. 喂食时抬高床头 3040度ICU护理上海护理学会71预防吸入与呼吸机相关性肺炎 (con.)regulation of enteral feeding rate and volume to prevent gastric regurgitation 挑整肠胃喂食率与

30、量以预防胃反流 Practice deep breathing, coughing, and frequent turning. 促进肺扩张运动及体位Encourage to increase patient mobility by ambulating or placing the patient upright in a chair 鼓励病人活动及坐起ICU护理上海护理学会72AACN “Ventilator Bundle”Elevation of the head of the bed to 30-45 degree if no contraindicationContinuous re

31、moval subglottic secretionsChange of ventilator circuit no more often than every 48 hoursWashing of hands before and after contact with each patient Tolentino-DelosReyes, 2007ICU护理上海护理学会73重症护理基本概念 Nutritional Support 营养支持Mechanical ventilation 机械通气Homodynamic monitoring 血液动力监测Sedating and pain contr

32、ol 镇静与疼痛控制Alternations in consciousness 意识改变Wound and skin care 伤口与皮肤护理Prolonged immobility 长期卧床Psychosocial Support pt and family 心理支持Ethical consideration in critical care practice 道德观ICU护理上海护理学会74ICU 护士的职业疲惫（burn out）及哀伤失落疲惫感及无力感是ICU护士离职的主因护 理 人 员 应 检 视自 己 对 死 亡 的 看 法 及 观 念， 了 解 自 己 如 何 因 应 死 亡 及

33、 哀 伤， 及 所 需 要 的 回 馈 与 支 持。ICU护理上海护理学会75影响病危期医疗品质因素医护人员著重在治疗疾病,治愈病童病危期的舒适及支持往往在急着救治生命时被忽略家属们认为选择临终治疗就等于放弃治疗,不愿意做此决定医护人员对个案病情及放弃治疗的矛盾反应ICU护理上海护理学会76ICU 的高科技挑战与管理呼吸机：种类与模式输液泵监视器除颤仪心内、心外起搏器腹透ICU护理上海护理学会77From the ManufacturersSmart Breath DeliveryInteractive ModeConfigurableSafetyUpgradabilityHK QMH 黎自强

34、ICU护理上海护理学会78From the UsersManaging the Patient/Ventilator system is less difficult with an understanding of the fundamentals of operation, alarms, and capabilities.HK QMH 黎自强ICU护理上海护理学会79Mechanical VentilatorsNegativepressure ventilator Positivepressure ventilator Pressure ventilator High-frequency

35、 ventilator ICU护理上海护理学会80 Where to Start ?从何开始？IPPVSIMVMMVBIPAPSPONTPCVVCVAPRVPSASBILVPRVCVAPSPAVHK QMH 黎自强ICU护理上海护理学会81Methods-Inhaled Nitric Oxide Therapy 一氧化氮吸入治疗Concentration: (5-40) ppmMonitor NO2、MetHBIndications : - reactive PH/PHC - hypoxemia after Glenn or Fontan procedureICU护理上海护理学会82Pulse

36、 Oximetry Reflects the arterial oxygen saturation of hemoglobinSaturations of 93% to 99% are normal ICU护理上海护理学会83Arterial Blood GasespH: 7.357.45PaO2: 80100 mm HgPaCO2: 3545 mm HgHCO3: 2226 mm HgSaO2: 9399%ICU护理上海护理学会84Other Diagnostic TestsChest X-ray Ventilation-perfusion scanPulmonary angiogramPu

37、lmonary function test (PFT)Bronchoscopy Thoracentesis Sputum culture ICU护理上海护理学会85Artificial AirwaysNasopharyngeal / Oropharyngeal Size by placing device from ear lobe to corner of mouthEndotracheal tubeUncuffed tubes for children younger than 10 years of ageLaryngomask airway (LMA) Sizes 1,2,3,4, a

38、nd 5 Sizes 3 and 4 for most of the populationTracheostomiesICU护理上海护理学会86气管插管发展以减少呼吸机相关肺炎为目的，减少会咽处分泌物聚集ICU护理上海护理学会87Chest PT for Intubated Chest PT for Intubated Infants Infants 插管婴儿胸部理疗插管婴儿胸部理疗ICU护理上海护理学会88Issues in Ventilation management for children 儿童呼吸管理议题Extracorporeal Membrane Oxygenation ECMO

39、: Therapeutic effect very Controversial, case decreasing from 1200 in 1990 to 700 per year in 2000. 体外膜体外膜肺使用肺使用Apply Multimode therapy to treat adults and children with Acute hypoxia resp. 针针对呼吸衰竭者使用多重呼吸模式对呼吸衰竭者使用多重呼吸模式Bohn, 2001 Ped. Clinic N. Am, P. 565ICU护理上海护理学会89ECMO Support in the Pediatric C

40、ardiac PatientICU护理上海护理学会90降温处理减少耗氧Cooling Cooling blanketCore temperature: 34 36Prevent shivering (mechanical ventilation, sedatives, muscle relaxants, nitroprusside)Indications: - tachycardia (SVT, JET) - mild-to-moderate hypotensionICU护理上海护理学会91Pacemaker Treatment for AV BlockSingle-chamber Lead

41、in the ventricleDual chamber Lead in the atriumLead in the ventricleICU护理上海护理学会92ICD LeadProximal CoilDistal CoilICU护理上海护理学会93CRT/CHF device todayCRT ICD Fully programmableCHF monitoring ICU护理上海护理学会94Chronic Care and Rehabilitation(SOP) 心脏ICU后康复ILong-term Follow-upGeneral cardiac care 一般护理Patient/Fa

42、mily EducationCHF patients 心衰病人Adjustment of decongestive medsMonitoring weight/NYHA class/VO2Assess for cardiac transplantationDevice therapy 介入治疗护理Evaluation of deviceAssess intervention with device therapyPsychosocial support ICU护理上海护理学会95 Chronic Care and Rehabilitation(SOP) 心脏病人康复IICardiac Reha

43、bilitation 心脏康复Early mobilization of patient after acute event 早期下床Psychosocial Management- depression/anxiety 缓解焦虑忧郁Pharmacotherapy 药物辅助Lipid loweringBP controlAntiplatelet therapyBeta-blockersAngiotensin-converting enzyme inhibitorsICU护理上海护理学会96Kolbs Experiential Learning CycleExperienceReflection

44、ConceptualizationExperimentationICU护理上海护理学会97Simulation ScenariosInfection control: lines and dressingsAirway managementArrhythmia interpretation and managementHemodynamics / Cardiac OutputNeuromonitoringIntubationPost-op AdmissionRoles in a code and emergency equipmentMega CodeICU护理上海护理学会98心脏重症病人康复

45、与随访 IIIMonitor long-term outcomes 测量长期效果Maintenance of smoking cessationLipid profilesBody Mass IndexICU护理上海护理学会99ICU护理上海护理学会100ICU护理上海护理学会101HemodialysisRemoves urea, creatinine, and uric acidRemoves excess waterRestores the body buffer systemMaintains appropriate levels of electrolytesICU护理上海护理学会1

46、02重症护理发展关键 (1) 1. Prevention, detection and treatmetn of infection: Avoid nosocomial infection from various catheters or ventilator, gut decontamination and prevention of oral pharyngeal colonization 预防院内感染ICU护理上海护理学会103重症护理发展关键 (2)New approach “Inflammation control”: by using “immunotherapy or anti

47、body therapy”to lessen the development of SIRS 使用免疫治疗及抗体治疗处理炎症反应ICU护理上海护理学会104重症护理发展关键(3)2. Maintenance of tissue oxygenation to avoid Hypoperfusion and organ hypoxemia 促进组织关注Lactate （乳酸值）level indicate the severity of impaired perfusion and lactic acidosis Decrease oxygen demands: by sedation, pain

48、 control, mechanical ventilation, temp. control, and rest 减少病人耗氧情况ICU护理上海护理学会105重症护理发展关键 (4)3. Nutritional/metabolic support 营养及代谢上的支持: hypermetabolism results profound weight loss, and loss of organ function高代谢引发严重体重下降，丧失器官功能Enteral feedings may limit bacterial translocation 肠道进食避免细菌移位ICU护理上海护理学会10

49、6重症护理质量指标管道及管道及IV静脉护理静脉护理皮肤护理、褥疮皮肤护理、褥疮以家庭为中心的护理（家属与护理人员间的认以家庭为中心的护理（家属与护理人员间的认知差距）知差距）意外拔意外拔ET管率、失败撤机率、气管切开率管率、失败撤机率、气管切开率跌倒与使用约束带限制病人跌倒与使用约束带限制病人家属参与率、病人满意率（睡眠、协助、满足家属参与率、病人满意率（睡眠、协助、满足需求、环境）需求、环境）ICU院内感染率院内感染率ICU 再入室率再入室率 （出（出ICU 后后2448 小时）与小时）与住院天数住院天数ICU护理上海护理学会107ICU 的核心指标测量呼吸机相关性肺炎病人体位头抬高呼吸机相

50、关性肺炎病人体位头抬高30度度/呼呼吸机上机天数吸机上机天数呼吸机与胃压力性溃疡预防：预防天数呼吸机与胃压力性溃疡预防：预防天数/呼吸呼吸机使用天数机使用天数深部静脉栓塞预防与呼吸机上机天数深部静脉栓塞预防与呼吸机上机天数中央静脉血源感染种类中央静脉血源感染种类/CVP 种类天数种类天数ICU病人住院天数病人住院天数医院病人曾入院医院病人曾入院ICU死亡率死亡率JCAHO，2003ICU护理上海护理学会108Interdisciplinary Planning for CareInterdisciplinary Planning for Care医疗梯队间计划照顾医疗梯队间计划照顾采取统筹的过

51、程以支持及协调病人整个、连续性的健康照顾。以病人为中心、连续性导向、以结果为目的的团队方式 ICU护理上海护理学会109ICUCase Management Tool 重症个案管理工具Clinical Pathway 临床路径Algorithm 临床指引Practice guideline 实践指导Protocol 方案Order set 医嘱群ICU护理上海护理学会110ICU Outcomes-HOTSPUDHead of bed elevated 30 degreeOral care every 2 hoursTurn pt from side to back and to side e

52、very 2 hoursSedation vacation-allow pt to awake at least once per 24 hoursPeptic Ulcer prophylaxis within 24 hours of start mechanical ventilationDeep Vein thrombosis prophylaxis within 24 hours of start mechanical ventilationHatler,et al., 2006,AJCCICU护理上海护理学会111Challenges faced in Critical Care 重症护理挑战（重症护理挑战（1）Manpower shortage in critical care settings 重症护理单位人力短缺重症护理单位人力短缺 2004 年QMH ICU 护理人力 1 bed:4.5 nurses