跳到主要內容

臺灣博碩士論文加值系統

(44.192.20.240) 您好!臺灣時間:2024/02/24 01:50
字體大小: 字級放大   字級縮小   預設字形  
回查詢結果 :::

詳目顯示

: 
twitterline
研究生:孫春轉
研究生(外文):Sun Chun-Chuan
論文名稱:加護病房呼吸器管路更換頻率與其肺炎相關感染率之比較
論文名稱(外文):Different frequency of ventilator circuit changes in intensive care units associated with pneumonia infection
指導教授:張上淳張上淳引用關係
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:流行病學研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2001
畢業學年度:89
語文別:中文
中文關鍵詞:呼吸器相關肺炎呼吸器管路更換院內感染肺炎加護病房
外文關鍵詞:ventilator-associated pneumoniaventilator circuit changenosocomial pneumoniaintensive care units
相關次數:
  • 被引用被引用:2
  • 點閱點閱:828
  • 評分評分:
  • 下載下載:109
  • 收藏至我的研究室書目清單書目收藏:3
隨著時代的改變,醫院經營模式面臨著相當大的衝擊,加上
現今資源與經濟困乏與拮据下,如何保持醫療品質並兼顧成本,又要
符合健保制度之要求是目前醫院經營者所面臨的一大挑戰。感染率是
醫院品質保證的指標之一,降低院內感染率也可以減少醫療浪費和控
制成本,各種侵入性醫療器材之更換頻率,是否可重覆使用,安全期
限如何等?也是成本考量之一環。國外一些文獻報導:呼吸器管路延
長更換時間,不會影響病人之肺炎感染率,但是是否可推論至國內各
類型之醫院值得深思。由於考量到國內醫院型態,病人疾病特性及醫
療品質情況下,不敢貿然更改呼吸器管路更換時間。因此希望藉由研
究證明在不影響醫療品質之前題下,評估呼吸器管路每週更換2次與
每週更換1次其呼吸器相關肺炎感染率(ventilator-associated
pneumonia,VAP)之差異,分別收集了外科加護病房於民國88年12
月1日至89年4月30日之病人作為對照組(即每週更換2次)及民
國89年12月1日至90年4月30日之病人作為研究組(即每週更換
1次)之人口學資料及使用呼吸器之相關危險因子後,比較兩組在各
變項之分佈情形。對照組有561人次之個案,男性有322人次,女性
有239人次,平均年齡為58.9±8.2歲,總共使用呼吸器人日數為
3562,呼吸器相關肺炎感染人次為21,感染率為5.9/1000使用呼吸
器人日數,平均使用呼吸器之天數為6.3±11.9,平均停留在加護病房
之天數為9.1±13.0,研究組有623人次之個案,男性有402人次,女
性有221人次,平均年齡為61.5±5.9歲,總共使用呼吸器人日數為
3290,呼吸器相關肺炎感染人次為11,感染率為3.3/1000使用呼吸器
人日數,平均使用呼吸器之天數為5.3±9.9,平均停留在加護病房之天
數為8.0±10.4。兩組感染率之RR為0.57,95% CI:0.251-1.078,P
值=0.079,無統計上之差異。而兩組分佈有差異之變項( P<0.05)有性
別、年齡、入加護病房時肺部狀況、開刀術式、使用呼吸器至發生感
染之天數、氣管插管及使用呼吸器期間噴霧治療情形。對照組中,感
染個案之分佈與未感染個案有統計差異之變項為性別、疾病診斷、入
加護病房時肺部狀況、開刀術式,使用呼吸器天數、氣管切開情形及
重新插管之有無,而研究組中,則只有使用呼吸器天數及移除呼吸器
之理由上有統計上之差異。經Poisson regression model調整各變項
後,兩組之RR為0.945,95 % CI:0.438-2.040,P值為0.886,經
多變項分析後,病患入加護病房時肺部狀況(RR=0.152,95 % CI:
0.065-0.357,P=0.0001) 、使用呼吸器天數(RR=8.885,95 % CI:
1.953-40.434,P=0.005)與肺炎之發生,具有統計上之差異。兩組在
使用呼吸器天數與呼吸器相關肺炎感染之關係上,經存活分析,P值為
0.239。結論是呼吸器管路一週更換2次與一週更換一次其呼吸器相關
肺炎感染率無統計上之差異。

To keep good quality is the most important thing and goal in medical care. However, cost-benefit is another important issue in modern medicine.It’s always a hot topic about the conflict of reducing costs and keeping high quality of medical care. How to keep balance between costs and quality is always under discussion. Nosocomial infection rate is an important indication for hospital care quality. Invasive procedures such as endotracheal tube insertion and ventilator usage are common risk factors for noscomial infection. Although there have been some studies in U.S. or Europe demonstrated that reducing the frequency of ventilator circuit change will not increase the chance of nosocomial pneumonia. However,in Taiwan we have very rare such data to prove that changing ventilator circuit less frequently will no influence the chance of nosocomial infection.
To evaluate the effect of changing frequency from twice per week to once per week on the ventilator-associated pneumonia, we performed a prospective study with historical control in surgical intensive care units(SICU) of National Taiwan University Hospital during the peroid of 1999/12/01~2000/04/30(as control group) and 2000/12/01~2001/04/30(as study group). All patients stayed at SICU and using ventilator were included. There were no significant difference about the demographic data and risk factors between the control group(1999/12/01~2000/04/30,changing ventilator circuit twice per week) and study group(2000/12/01~2001/04/30,changing ventilator circuit once per week). There were 561 cases(male:female=322:239) in the control group with a mean age of 58.9±8.2 years. Total ventilatordays were 3562 and the infection rate of ventilator-associated pneumonia was 5.9/1000 ventilator days.The mean ventilator-using day was 6.3±11.9 and the mean ICU day was 9.1±13.0. In the study group , there were 623 cases(male:female=402:221) with a mean age of 61.5±5.9 years. The total ventilator days were 3290 and the infection rate of ventilator-associated pneumonia was 3.3/1000 ventilator days. The mean ventilator-using day was 5.3±9.9 and the mean ICU day was 8.0±10.4. The RR of ventilator-associated pneumonia rate was 0.57(95% CI:0.251~1.078,P=0.079). The factors with significant difference between two group were sex,age,lung condition when entering SICU,operation type,days between ventilator using and getting infection,using aerosol therapy or not. By Poisson regression model, the RR was 0.945(95% CI:0.438~2.040,P=0.886). By multivariate analysis, only two factors were significant related to ventilator-associated pneumonia:lung condition when patient entering SICU(RR=0.152, 95% CI:0.065~0.357,P=0.0001);ventilator using day(RR=8.885,95% CI:1.953~40.434,P=0.005). Survival analysis about the probability of acquired ventilator-associated pneumonia byventilator-using days demonstrated there was no significant difference between the control group and study group.
From this study, we concluded that there was no significant difference for risk of getting ventilator-associated pneumonia either the ventilator circuit was changed twice per week or once per week.

目 錄
第一章緒論
一、研究動機
二、研究目的
三、研究假說
第二章文獻查證
一、肺炎之診斷
二、呼吸器相關肺炎感染之致病機轉及危險因子
三、病人嚴重度指標
四、加護病房呼吸器相關肺炎感染率國內外之文獻
五、預防院內肺炎感染措施
六、不同呼吸器管路更換頻率與其肺炎感染率之國外研究
第三章研究方法
一、研究設計
二、研究對象和場所
三、收案條件
四、肺炎之定義與呼吸器相關肺炎感染率之計算
五、呼吸器類型
六、樣本數之估計
七、資料之收集內容
八、呼吸器管路更換標準
九、院內肺炎判定之可信度
十、統計方法
第四章研究結果
一、對照組與研究組之基本資料
二、對照組與研究組與其肺炎相關感染個案之分佈
三、對照組與研究組於各變項中肺炎相關感染之存活分析
四、對照組與研究組之多變項分析
第五章討論
一、本研究結果與國外呼吸器管路不同更換頻率之肺炎相關感
染率比較
二、研究設計之探討
三、肺炎診斷工具之可信度
四、呼吸器相關肺炎感染率
五、呼吸器管路由一週更換兩次改為一週更換一次所節省
之直接成本
第六章結論與建議
一、結論
二、研究限制與建議
參考文獻
一、中文部份
二、英文部份
附錄一:APACHE II Scoring System
附錄二:Therapeutic Intervention Scoring System
附錄三:Glasgow Coma Score
附錄四:呼吸器管路更換技術標準表
附錄五:呼吸器管路更換過程技術標準表

<一> 中文部份:
楊志良、羅紀瓊、李玉春:「健康保險」,陳拱北預防醫學基金會主編,« 公共衛生學上冊修訂二版»。臺北:巨流圖書公司,1997
葉金川:「醫療體系」,陳拱北預防醫學基金會主編,« 公共衛生學上冊修訂二版»。臺北:巨流圖書公司,1997
韓揆:「醫院之功能、組織與管理」,陳拱北預防醫學基金會主編,« 公共衛生學上冊修訂二版»。臺北:巨流圖書公司,1997
行政院衛生署:「加強加護病房院內感染監測試辦計畫」訓練課程教材,民國83年4月11日
行政院衛生署:「加強加護病房院內感染監測」試辦計畫成果至84年6月。感控雜誌 85;6:146-52.
臺大醫院院內感染監視年報.1997-2000
李豫芸:以活動式超音波機評估膀胱尿量之成本效益探討.臺大護理研究所碩士論文 1998
<二>英文部份
Andrews CP, Coalson JJ, Smith JD, Johanson WG. Diagnosis of nosocomial bacterial pneumonia in acute, diffuse lung injury. Chest 1981;80:254-8.
Bonten MJ, Gaillard CA, Wouters EF, van Tiel FH, Stobberingh EE, van der Geest S. Problems in diagnosing nosocomial pneumonia in mechanically ventilated patients:a review 82 refs. Crit Care Med 1994;22:1683-91.
Celis R, Torres A, Gatell JM, Almela M, Rodriguez-Roisin R, Agusti-Vidal A. Nosocomial pneumonia. A multivariate analysis of risk and prognosis. Chest 1988;93:318-24.
Craven DE, Goularte TA, Make BJ. Contaminated condensate in mechanical ventilator circuits a risk factor for nosocomial pneumonia? Am Rev Respir Dis 1984;129:625-8.
Craven DE, Connoly MG, Lichtenberg DA, Primeau PJ, Mc Cale WR. Contamination of mechanical ventilator with tubing changes every 24 or 48 hours. N Engl J Med 1982;306:1505-9.
Craven DE, Steger KA. Epidemiology of nosocomial pneumonia new perspectives on an old disease. Chest 1995;108:1S-16S.
Craven DE, Kunches LM, Kilinsky V, Lichtenberg DA, Make BJ, McCabe WR. Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation. Am Rev Respir Dis 1986;133:792-6.
Dreyfuss D, Djedaini K, Weber P, Brun P, Lanore JJ, Rahmani J, Boussougant Y, Coste F. Prospective study of nosocomial pneumonia and of patient and circuit colonization during mechanical ventilation with circuit changes every 48 hours versus no change. Am Rev Respir Dis 1991;143:738-43.
Drummond MF, Stoddart GL, Torrance GW. Methods for the Economic Evaluation of Health Care Programmes, Oxford Med Publ, Oxford, 1987.
Drummond MF, O’Brien BJ, Stoddart GL, Torrance GW. Methods for the Economic evaluation of health care programs 2nd ed. Oxford:Oxford University Press,1997.
Emori TG, Culver DH, HoranTC, Jarvis WR, White JW, Olson DR, Banerjee S, Edwards JR, Martone WJ, Gaynes RP, Hughes JM. National Nosocomial Infections Surveillance system(NNIS):description of surveillance methods. Am J Infect Control 1991;19:19-35.
Fagon JY, Chastre J, Domart Y, Trouillet JL, Pierre J, Darne C. Gibert C. Nosocomial pneumonia in patients receiving continuous mechanical ventilation. Prospective analysis of 52 episodes with use of a protected specimen brush and quantitative culture techniques. Am Rev Respir Dis 1989;139:877-84.
Fagon JY, ChastreJ, Hance AJ, Montravers P, Novara A, Gibert C .Nosocomial pneumonia in ventilated patients:a cohort study evaluating attributable mortality and hospital stay. Am J Med 1993;94:281-8.
Fink JB, Krause SA, Barrett L, Schaaff D, Charles G. Extending ventilator circuit interval beyond 2 days reduces the likelihood of ventilator-associated pneumonia. Chest 1998;113:405-11.
Garner JS, Jarvis WR, Emori TG , Horan TC, Hughes JM.CDC definitions of nosocomial infections,1988. Am J Infect Control 1988;16:128-40.
George DL. Epidemiology of nosocomial ventilator-associated pneumonia. Infect Control Hosp Epidemiol 1993;14:163-9.
Garrard CS, A’Court CD. The diagnosis of pneumonia in the critically III. Chest 1995;108:17S-25S.
Grossman RF, Fein A. Evidence-based assessment of diagnostic tests for ventilator-associated pneumonia:Executive summary. Chest 2000;117:177S-181S.
Hess D, Bruns E, Romagnoli D, David MS, Kacmarek RM .Weekly ventilator circuit changes. A strategy to reduce costs without affecting pneumonia rates. Anesthesiology 1995;82:903-11.
Hixson S,Sole ML,King T.Nursing strategies to prevent ventilator-associated pneumonia.Advenced Practice in Acute & Critical Care 1998;9:76-90.
Kaye J, Ashine V, Erickson D, Zeiler K, Gavigan D, Gannon L, Wynne P, Cooper J, Kittle W, Sharma K, Morton J. Critical care bug team:a multidisciplinary team approach to reducing ventilator-associated pneumonia. Am J Infect Control 2000;28:197-201.
Kelleghan SI, Salemi C, Padilla S, McCord M, Mermilliod G, Canola T, Becker L. An effective continuous quality improvement approach to the prevention of ventilator-associated pneumonia. Am J Infect Control 1993;21:322-30.
Keene AR, Cullen DJ. Therapeutic Intervention Scoring System:update 1983.Crit Care 1983;11:1-3.
Kleinbaum DG, Kupper LL, Muller KE, Nizam A. Applied regression analysis and other multivariable methods.3rd ed. Pacific Grove:Brooks/Cole publishing company, 1998.P 687-709.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II:a severity of disease classification system. Crit Care 1985;13:818-29.
Konrad F, Wiedeck H, Kilian J, Deller A. Risk factors in nosocomial pneumonia in intensive care patients. A prospective study to identify high-risk patients. Anaesthesist 1991;40:483-90.
Kotilainen HS, Keroack MA. Cost analysis and clinical impact of weekly ventilator circuit changes in patients in intensive care unit. Am J Infect Control 1997;25:117-20.
Kollef MH, Shapiro SD, Fraser VJ, Silver P, Murphy DM, Trovillion E, Hearns ML, Richards RD, Cracchilo L, Hossin L. Mechanical ventilation with or without 7-days circuit changes:a randomized controlled trial. Ann Intern Med 1995;123:168-74.
Kollef MH. Current concepts:The prevention of ventilator-associated pneumonia [review article].N Engl J Med 1999;340:627-34.
Kollef MH. Ventilator-associated pneumonia. JAMA 1993;270:1965-70.
Lefcoe MS, Fox GA, Leasa DJ, Sparrow RK, McCormack DG. Accuracy of portable chest radiography in the critical care setting:Diagnosis of pneumonia based on quantitative cultures obtained from protected brush catheter. Chest 1994;105:885-7.
Leu HS, Kaiser DL, Mori M, Woolson RF, Wenzel RP. Hospital-acquired pneumonia: attributable mortality and morbidity. Am J Epidemiol 1989;129:1258-67.
Long MN, Wickstrom G, Grimes A, Benton CF, Belcher B, Stamm AM Prospective randomized study of ventilator-associated pneumonia: in patients with one versus three ventilator circuit changes per week. Infect Control Hosp Epidemiol 1996;17:14-9.
Manangan L, Banerjee SN, Jarvis WR. Association between implementation of CDC recommendations and ventilator-associated pneumonia at selected US hospitals. Am J Infect Control 2000;28:222-7.
Polgar S, Thomas SA. Introduction to research in the health sciences 3rd ed. 1995. Churchill Livingstone: Melbourne; New York.
Rosner B. Fundamentals of biostatistics 4th ed. Belmont:Wadsworth Publishing Company,1995. P423-6.
Salata RA, Lederman MM, Shlaes DM, Eckstein E,Tweardy D, Toossi Z,Chmielewski R, Marino J, KingCH.Diagnosis of nosocomial pneumonia in intubated, intensive care unit patients. Am Rev Respir Dis 1987;135:426-32.
SAS/stat user’s guide:version 6,fourth ed. Cary, NC:SAS institute.
Schaberg DR, Culver DH, Gaynes RP. Major trends in the microbial etiology of nosocomial infections. AM J Med 1991;91:72S-75S.
Simmons BP, Wong ES.CDC guidelines for the prevention and control of nosocomial infections. Guideline for prevention of nosocomial infection. Am J Infect Control 1983;11:230-44.
Solé Violán J, Fernández JA, Benítez AB, Cardeñosa Cendrero JA, Rodríguez de Castro F. Impact of quantitative invasive diagnostic techniques in the management and outcome of mechanically ventilated patients with suspected pneumonia. Crit Care Med 2000 ;28:2737-41.
Tablan OC, Anderson LJ, Arden NH, Breiman RF, Butler JC, McNeil MM. Guideline for prevention of nosocomial infection. Am J Infect Control 1994;22:247-92.
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2:81-4.
Torres A, Gatell JM, el-Ebiary M, Puig de la Bellacasa, Gonzalez J, Ferrer M, Rodruguez-Roisin R. Re-intubation increase the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med 1995;152:137-41.
Torres A, Aznar R, Gatell JM, Jimenez P, Gonzalez J,Ferrer A, Celis R, Rodriguez-Roisin R. Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis 1990;142:523-8,
Vallés J, Artigas A, Rello J, Bonsoms N, Fontanals D, Blanch L, Fernández R, Baigorri F. Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Ann Intern Med 1995;122:179-86.
Winer-Muram HT, Rubin SA, Ellis JV, Jennings SG, Arheart kL, Wunderink RG, Leeper KV, Meduri GU. Pneumonia and ARDS in patients receiving mechanical ventilation:diagnostic accuracy of chest radiography. Radiology 1993;188:479-85.
Wunderink RG. Radiologic diagnosis of ventilator associated pneumonia. Chest 2000;117:188S-190S.
Wunderink RG, Woldenberg LS, Zeiss J, Day CM, Ciemins J, Lacher DA. The radiologic diagnosis of autopsy-proven ventilator-associated pneumonia. Chest 1992;101:458-63.

QRCODE
 
 
 
 
 
                                                                                                                                                                                                                                                                                                                                                                                                               
第一頁 上一頁 下一頁 最後一頁 top
無相關期刊