今後の結核病床のあり方 [in Japanese] HOW BEDS FOR TUBERCULOSIS BE PROVIDED AND UTILIZED? [in Japanese]
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結核病床は, 昭和20年代にはまず自然療法の場, 次いで外科療法を含む積極的な治療の場として積極的に整備が進められ, 昭和33年には26万床強に達した。その後は, 対策の推進による結核患者数の急速な減少の影響を受け, 病床数が削減されてきたが, 治療の進歩による治療期間短縮の影響を受け, 入院期間も短縮されたため, 一部の地域を除いて空床が目立つようになってきている。結核病床の問題点としては, 近代化が行われず, 病棟単位で運営されてきたため, 整理統合が進むと, かなり離れた施設への入院を余儀なくされ, 病院職員に対する感染防止の配慮もされていない点が指摘される。<BR>今後の結核病床のあり方としては, 運営を病棟単位から病室単位に切り替え, 一般病院内にも隔離できる換気設備を持った急性期用結核病室を整備し, 都道府県内に適切に配置し, 従来の国立療養所には慢性化した患者のための病床も残す。新たに発見された患者に対する入院期間を短縮し, 入院中から確実な服薬を行う指導を始め, 外来治療に円滑なバトンタッチを行う。換気設備を持つ急性期用病室の整備に補助を行い, 急性期の診療に対しては適切な医療費を設定するべきである。
In 1951 when TB Control Law was legislated, and the government of Japan started intensive TB programme mainly consisting of mass health examination, BCG vaccination and distribution of appropriate treatment for TB cases, there were about 100, 000 beds for TB, similar to the number of then TB deaths, and many TB patients died before admission to sanatoria. Urgent measures were taken to increase beds for TB with a target of 250, 000, 2.5 times of then TB death. The target was achieved in 1957.<BR>Thereafter, the number of beds for TB as well as the occupancy rate had decreased with the decline of TB, and then policy on beds for TB could be summarized as follows: (1) top priority was given to increase the number of beds for TB, (2) general hospitals were improved with the progress of medical science and economic development, while no improvement was done on TB beds with the assumption that the need for TB beds will soon disappear, (3) minimum unit of TB beds was a TB ward with generally 40 to 50 beds, (4) an idea to provide TB bed in a general hospital came out only since 1992 as a small model project, (5) it was intended to segregate infectious TB patients from the community, however, no consideration was made about super-infection among patients themselves and the infection to health care workers, (6) admission of TB cases to a general bed and admission of non-TB cases to a TB ward was not legally permitted, (7) cost for TB treatment was set on a low level. Recent data indicate that the occupancy rate of TB beds was 43.5%, and the average stay in TB beds is still slightly over 100 days, and observing by prefectures, marked differences were seen.<BR>Taking into account changes in the pattern on TB patients such as aging and the increase of cases with serious complications and most health care workers in TB wards are not yet infected with TB, it is needed to divide TB beds into two types, one for new cases and the other for chronic cases. Beds for new cases should be provided in principle as a single room in a general hospital with good ventilation system, and DOT should be started in a hospital. Stay in this type of bed should not exceed 2 months, and higher medical fee should be provided. Beds for chronic cases could be provided in a TB ward. MDRTB cases are admitted in bed for chronic cases, however, preferably in a single room, and if active intervention such as chest surgery is tried in a few sophisticated hospital, medical fee for acute bed should be applied. Now, we have to change our mind from old concept of beds in TB ward to a TB bed in a single room with good ventilation.
Kekkaku(Tuberculosis) 77(1), 3-9, 2002-01-15
JAPANESE SOCIETY FOR TUBERCULOSIS