臺灣博碩士論文加值系統

摘 要
研究目的
呼吸器相關肺炎(Ventilator-associated pneumonia,VAP)造成住院日數延長及死亡率增加,欲藉由服務醫院收集相關病例找出重要影響因子，改善臨床工作，增進臨床品質。本研究目的在於探討呼吸器相關肺炎之趨勢，及影響醫療資源耗用和醫療療效之重要因子。
研究方法
本研究針對南部某區域教學醫院之成人加護病房住院患者，其罹患呼吸器相關肺炎為對象，以收集西元2005年1月至2012年12月期間病歷資料登錄表，作回溯性資料研究分析。共收錄276位病例。以醫院感控室的蒐集相關病例，由專人依研究變項一一抄錄相關數據資料進行研究。業已通過高雄醫學大學附設中和紀念醫院人體試驗審查委員會，同意進行臨床試驗，IRB編號：KMUH-IRB-20120429。P值小於0.05定義為統計學上顯著意義。
研究結果
呼吸器相關肺炎病人中使用呼吸器原因為外傷者(OR 3.80)及神經科病人(OR 2.30)比率，隨時間傾向有增加之趨勢；感染菌種ORSA(OR 0.17)及使用呼吸器日數超過22天者(OR 0.43)，隨時間傾向有減少之趨勢；住院日數≦30天(OR 1.76)有增加之趨勢，住院日數>30天(OR 0.44)有減少之趨勢。接受手術(P=0.041)、白血球異常(P=0.006)、使用呼吸器日數(P<0.001)、從住院至感染日(P<0.001)及從使用呼吸器至感染日(P<0.001)皆顯著影響住院日數。罹患心臟病者(P=0.012)、接受手術(P<0.001)、抗生素使用(P=0.045)、使用呼吸器日數(P<0.001)、從住院至感染日(P<0.001)，從使用呼吸器至感染日(P<0.001)及外科患者(P=0.044)皆顯著影響住院總費用。罹患腎臟病(P=0.004)、上消化道出血(P=0.003)及人工氣道選擇插管再加氣切(P=0.001)皆顯著影響住院期間死亡。罹患腎臟病(P=0.011)、接受輸血(P<0.001)、人工氣道選擇插管再加氣切(P<0.001)及使用呼吸器至感染日(P<0.001)皆顯著影響呼吸器依賴。人工氣道選擇插管再加氣切(P=0.025)及外科病人(P=0.047)皆顯著影響轉至呼吸照護病房(RCW)之比率。
結論與建議
本研究蒐集台灣南部某區域教學醫院之加護病房住院患者，罹患呼吸器相關肺炎住院資料進行統計分析，找出八年期間之趨勢以及影醫療資源耗用及醫療療效的重要因子，期望能提供醫療單位制訂更精準的政策及專業人員訓練方向，以增進醫療品質。

Abstract
Objectives
Ventilator-associated pneumonia (VAP) causes prolonged lengths of stay (LOS) and increases mortality. In this study, cases were collected by providing services at a regional hospital in order to identify the important factors that contribute to the development of VAP . The aims of this study were to analyze the trend of VAP and to explore the key factors affecting medical resource utilization and medical efficiency.
Methods
Adult ICU patients admitted to a regional teaching hospital in southern Taiwan. The 276 subjects'' medical records between January 2005 and December 2012 were retrospective collected. Relevant cases obtained from the Office of Infection Control were copied in detail according to the variables specified in this study.It was approved by the IRB of Kaohsiung Medical University Chung-Ho Memorial Hospital. A p-value <0.05 was defined as statistically significant.
Results
The ratios of patients with VAP due to trauma(OR 3.80) and who were from the Department of Neurology(OR 2.30) increased .The ratios decreased with bacterial infections of ORSA(OR 0.17) and who used mechanical ventilator for more than 22 days(OR 0.43).The LOS have reduced as well≦30days(OR 1.76) >30days(OR 0.44). Surgery(P=0.041), abnormal leukocytes(P=0.006), durations of mechanical ventilation(P<0.001), durations from the admission date to the infection date(P<0.001) durations from the start date of mechanical ventilation to the infection date(P<0.001) had significant impacts on LOS.Heart diseases(P=0.012), surgery(P<0.001), use of antibiotics(P=0.045), durations of mechanical ventilation(P<0.001), durations from the admission date to the infection date(P<0.001), durations from the start date of mechanical ventilation to the infection date(P<0.001) and being a surgical patient(P=0.044) all had an effect on the total hospital costs.Kidney diseases(P=0.004), bleeding of the upper gastrointestinal tract(P=0.003), and artificial airways with intubation and tracheostomy(P=0.001) all significantly increased mortality rates during hospitalizations.Kidney diseases(P=0.011), blood transfusions(P<0.001), artificial airways with intubation and tracheostomy (P<0.001)as well as durations from the start date of mechanical ventilation to the infection date(P<0.001) were found to greatly affect ventilator dependence as well. Artificial airways with intubation and tracheostomy(P=0.025) and being a surgical patient(P=0.047) are both highly associated with the rates of patients transferred to respiratory care ward (RCW).
Conclusions and Suggestions
We identified the key factors that affect medical resource utilization and medical efficiency. It is hoped that the results obtained may help to improve the quality of medical care by providing healthcare providers with the information to implement precise policies as well as to provide guidance on the training of healthcare professionals.

目 錄
頁次
第一章 緒論-1
第一節 背景和動機 1
第二節 研究目的 4
第三節 預期貢獻 5
第二章 文獻探討 6
第一節 呼吸器相關肺炎(VAP)簡介 6
第二節 呼吸器相關肺炎危險因子與高危險群 12
第三節 呼吸器相關肺炎醫療耗用的影響 15
第四節 呼吸器相關肺炎預防與醫院管理策略 19
第三章 研究方法 23
第一節 研究假說和研究架構 23
第二節 研究設計與樣本 25
第三節 研究變項 28
第四節 分析方法 35
第四章 研究結果 38
第一節 研究族群基本特質描述 38
第二節 影響呼吸器相關肺炎人口學臨床科別之趨勢分析 42
第三節 影響呼吸器相關肺炎病患醫療資源耗用的重要因素 43
第四節 影響呼吸器相關肺炎病患醫療療效之重要因素 45
第伍章 討論與結論 47
第一節 呼吸器相關肺炎之趨勢分析 47
第二節 呼吸器相關肺炎與醫療資源耗用之關係 51
第三節呼吸器相關肺炎與醫療療效之關係 59
第四節 研究限制及未來研究方向 62
第五節 結論與建議 64
參考文獻 66
附錄一 呼吸器相關肺炎病歷審查資料表 93
附錄二 APACHE Ⅱ SCORE 95
附錄三 人體試驗/研究同意證明書 96

表 目 錄
頁次
表一 呼吸器相關肺炎病人之描述性分析(N=276)-病人特性 72
表二 呼吸器相關肺炎病人之描述性分析(N=276)-臨床特性 73
表三 呼吸器相關肺炎病人之描述性分析(N=276)-科別特性 74
表四 呼吸器相關肺炎病人之描述性分析(N=276)-時間特性 75
表五 呼吸器相關肺炎病人醫療耗用及療效-結果變項 76
表六 呼吸器相關肺炎病人人口學之時間傾向 77
表七 呼吸器相關肺炎病人臨床特徵之時間傾向 78
表八 呼吸器相關肺炎病人臨床特徵之時間傾向(續) 79
表九 呼吸器相關肺炎病人科別特性之時間傾向 80
表十 呼吸器相關肺炎病人臨床成效之時間傾向 81
表十一 影響呼吸器相關肺炎病人住院日數之危險因子 82
表十二 呼吸器相關肺炎病人住院總費用之危險因子 83
表十三 影響呼吸器相關肺炎病人住院期間死亡之危險因子 84
表十四 影響呼吸器相關肺炎病人呼吸器依賴之危險因子 85
表十五 影響呼吸器相關肺炎病人轉入呼吸照護病房(RCW)
之危險因子 86

圖 目 錄
頁次
圖一 呼吸器相關肺炎病患-使用原因之趨勢分析 87
圖二 呼吸器相關肺炎病患-感染菌種之趨勢分析 88
圖三 呼吸器相關肺炎病患-科別特性之趨勢分析 89
圖四 呼吸器相關肺炎病患-呼吸器日數之趨勢分析 90
圖五 呼吸器相關肺炎病患-住院日數(低)之趨勢分析 91
圖六 呼吸器相關肺炎病患-住院日數(高)之趨勢分析 92

參考文獻
1.姜伯穎 and 謝文斌, 內科-呼吸器相關之肺炎（Ventilator-associated pneumonia, VAP）. 200111. 337: p. 909-917.
2.Estefa, M., R. Hernandez, and R. Berba, Compliance of UP-PGH Medicine Residents to the 1995 American Thoracic Society Consensus on Hospital-Acquired Pneumonia.
3.Eggimann, P., et al., Ventilator-associated pneumonia: caveats for benchmarking. Intensive care medicine, 2003. 29(11): p. 2086-2089.
4.Chastre, J. and J.Y. Fagon, Ventilator-associated pneumonia. American journal of respiratory and critical care medicine, 2002. 165(7): p. 867-903.
5.Heyland, D.K., et al., The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group. Am J Respir Crit Care Med, 1999. 159(4 Pt 1): p. 1249-56.
6.Rello, J., et al., Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest, 2002. 122(6): p. 2115-21.
7.Cook, D.J. and M.H. Kollef, Risk factors for ICU-acquired pneumonia. JAMA, 1998. 279(20): p. 1605-6.
8.羅永達, 影響呼吸器依賴病人三十日死亡率危險因子之探討; Identifying the risk factors of 30 days mortality for ventilator dependent patients. 1991.
9.Arabi, Y., et al., Ventilator-associated pneumonia in adults in developing countries: a systematic review. International Journal of Infectious Diseases, 2008. 12(5): p. 505-512.
10.Restrepo, M.I., et al., Economic Burden of Ventilator‐Associated Pneumonia Based on Total Resource Utilization. Infection Control and Hospital Epidemiology, 2010. 31(5): p. 509-515.
11.Warren, D.K., et al., Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center*. Critical care medicine, 2003. 31(5): p. 1312-1317.
12.Chelluri, L., et al., Hospital costs in patients receiving prolonged mechanical ventilation: Does age have an impact? Critical care medicine, 2003. 31(6): p. 1746-1751.
13.Dubose, J., et al., Measurable outcomes of quality improvement using a daily quality rounds checklist: one-year analysis in a trauma intensive care unit with sustained ventilator-associated pneumonia reduction. J Trauma, 2010. 69(4): p. 855-60.
14.Diaz, O., E. Diaz, and J. Rello, Risk factors for pneumonia in the intubated patient. Infect Dis Clin North Am, 2003. 17(4): p. 697-705.
15.Hu), 胡.S.-C. and 李.R.-P. Lee), 重症病患呼吸器相關肺炎的預防與照護. 201208. 59:4: p. 012-017.
16.Edwards, J.R., et al., National Healthcare Safety Network (NHSN) Report, data summary for 2006, issued June 2007. American Journal of Infection Control, 2007. 35(5): p. 290-301.
17.Cook, D.J., et al., Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med, 1998. 129(6): p. 433-40.
18.Chen, Y.-Y., et al., Surveillance on secular trends of incidence and mortality for device-associated infection in the intensive care unit setting at a tertiary medical center in Taiwan, 2000-2008: a retrospective observational study. BMC Infectious Diseases, 2012. 12: p. 209-209.
19.Bouza, E., et al., Ventilator-associated pneumonia due to meticillin-resistant Staphylococcus aureus: risk factors and outcome in a large general hospital. The Journal Of Hospital Infection, 2012. 80(2): p. 150-155.
20.Klompas, M., K.P. Kleinman, and A. Karcz, Variability in mean duration of mechanical ventilation among community hospitals. Infect Control Hosp Epidemiol, 2012. 33(6): p. 635-7.
21.Dimov, G.S., et al., Ventilator-associated pneumonia in patients with cerebral depression. Folia Med (Plovdiv), 2009. 51(1): p. 56-60.
22.Bird, D., et al., Adherence to ventilator-associated pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical intensive care unit. Arch Surg, 2010. 145(5): p. 465-70.
23.Hsu, C.L., et al., Timing of tracheostomy as a determinant of weaning success in critically ill patients: a retrospective study. Crit Care, 2005. 9(1): p. R46-52.
24.Huang, K.T., et al., An early predictor of the outcome of patients with ventilator-associated pneumonia. Chang Gung Med J, 2010. 33(3): p. 274-82.
25.Alp, E., et al., Economic burden of ventilator-associated pneumonia in a developing country. J Hosp Infect, 2012. 81(2): p. 128-30.
26.Moreira, M.R., et al., Antimicrobial use, incidence, etiology and resistance patterns in bacteria causing ventilator-associated pneumonia in a clinical-surgical intensive care unit. Revista da Sociedade Brasileira de Medicina Tropical, 2013. 46(1): p. 39-44.
27.Karaoglan, H., et al., Cost analysis of ventilator-associated pneumonia in Turkish medical-surgical intensive care units. Infez Med, 2010. 18(4): p. 248-55.
28.Wahl, W.L., C. Zalewski, and M.R. Hemmila, Pneumonia in the surgical intensive care unit: is every one preventable? Surgery, 2011. 150(4): p. 665-72.
29.Hortal, J., et al., Incidence and risk factors for ventilator-associated pneumonia after major heart surgery. Intensive Care Med, 2009. 35(9): p. 1518-25.
30.Gungor, G., et al., [The influence of community-acquired pneumonia to the clinical course in COPD cases admitted to intensive care unit with acute respiratory failure]. Tuberk Toraks, 2010. 58(4): p. 408-17.
31.Kollef, M.H., C.W. Hamilton, and F.R. Ernst, Economic impact of ventilator-associated pneumonia in a large matched cohort. Infect Control Hosp Epidemiol, 2012. 33(3): p. 250-6.
32.Teixeira, P.J., et al., Inadequate treatment of ventilator-associated pneumonia: risk factors and impact on outcomes. J Hosp Infect, 2007. 65(4): p. 361-7.
33.Sood, M.M., et al., Acute kidney injury in critically ill patients infected with 2009 pandemic influenza A(H1N1): report from a Canadian Province. Am J Kidney Dis, 2010. 55(5): p. 848-55.
34.Coca, S.G., et al., Long-term risk of mortality and other adverse outcomes after acute kidney injury: a systematic review and meta-analysis. Am J Kidney Dis, 2009. 53(6): p. 961-73.
35.Kute, V.B., et al., High mortality in critically ill patients infected with 2009 pandemic influenza A (H1N1) with pneumonia and acute kidney injury. Saudi J Kidney Dis Transpl, 2011. 22(1): p. 83-9.
36.Kollef, M.H., et al., The effect of late-onset ventilator-associated pneumonia in determining patient mortality. Chest, 1995. 108(6): p. 1655-62.
37.Kahn, J.M., J.N. Doctor, and G.D. Rubenfeld, Stress ulcer prophylaxis in mechanically ventilated patients: integrating evidence and judgment using a decision analysis. Intensive Care Med, 2006. 32(8): p. 1151-8.
38.Tong, C.C., et al., Tracheotomy Timing and Outcomes in the Critically Ill. Otolaryngology--Head and Neck Surgery, 2012. 147(1): p. 44-51.
39.Bickenbach, J., et al., Impact of early vs. late tracheostomy on weaning: a retrospective analysis. Minerva Anestesiol, 2011. 77(12): p. 1176-83.
40.Lisboa, T., et al., The ventilator-associated pneumonia PIRO score: a tool for predicting ICU mortality and health-care resources use in ventilator-associated pneumonia. Chest, 2008. 134(6): p. 1208-16.
41.Bochicchio, G.V., et al., Blood product transfusion and ventilator-associated pneumonia in trauma patients. Surg Infect (Larchmt), 2008. 9(4): p. 415-22.
42.Sarani, B., et al., Transfusion of fresh frozen plasma in critically ill surgical patients is associated with an increased risk of infection. Crit Care Med, 2008. 36(4): p. 1114-8.
43.Vidotto, M.C., et al., Implications of extubation failure and prolonged mechanical ventilation in the postoperative period following elective intracranial surgery. Braz J Med Biol Res, 2011. 44(12): p. 1291-8.
44.Cortinas Saenz, M., et al., [Incidences of early- and late-onset ventilator-associated pneumonia in a postanesthesia and critical care unit]. Rev Esp Anestesiol Reanim, 2007. 54(3): p. 147-54.
45.Kobashi, Y. and T. Matsushima, Clinical analysis of patients requiring long-term mechanical ventilation of over three months: ventilator-associated pneumonia as a primary complication. Intern Med, 2003. 42(1): p. 25-32.
46.Richardson, C.J. and J.L. Rodriguez, Identification of patients at highest risk for ventilator-associated pneumonia in the surgical intensive care unit. Am J Surg, 2000. 179(2A Suppl): p. 8S-11S.