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研究生:簡戊鑑
研究生(外文):Wu-Chien Chien
論文名稱:台灣地區燒燙傷流行病學特性及醫療照護服務分析
論文名稱(外文):Epidemiology of burns and analysis of burn care services in Taiwan
指導教授:白璐白璐引用關係
指導教授(外文):Lu Pai
學位類別:博士
校院名稱:國防醫學院
系所名稱:生命科學研究所
學門:生命科學學門
學類:生物學類
論文種類:學術論文
論文出版年:2004
畢業學年度:92
語文別:中文
論文頁數:209
中文關鍵詞:燒燙傷流行病學醫療照護體系燒傷中心工作團隊滿意度病患期望危險因子
外文關鍵詞:BurnsEpidemiologyMedical care systemBurn centerWork teamSatisfactionPatient''''s expectationsRisk factors
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為全面了解台灣地區燒燙傷的流行病學特性及醫療照護情形,並從中找出問題,提出建議供衛生主管單位參考,本研究運用了生命統計、全民健保資料及燙傷登錄系統資料進行流行病學分析,並以觀察、訪談及問卷調查對燒燙傷醫療照護體系做深入探討。藉由各種資料檔的分析,可以瞭解台灣地區燒燙傷(照護設施及防制成效)的長期趨勢,以及住院病患各項流行病學特性與住院死亡的影響因子;經由觀察訪談的記錄來探討照護組織(工作團隊)運作現況;藉由自擬式問卷調查資料來瞭解工作團隊滿意度及住院病患對服務品質期望的情況。資料檔及問卷調查資料的分析以Chi-square、Student’s t-test、ANVOA及Multiple logistic regression等統計方法處理;而觀察訪談的資料採歸納法,並以文字陳述為主。主要的研究結果及結論如下:
台灣地區燒燙傷照護設施主要集中於台北市及高雄縣市,自1996年至2001年,燒燙傷中心的佔床率及平均住院天數均呈現下降趨勢。
整體而言,燒燙傷的死亡率、重大燒燙傷率及住院率逐年下降,而門診率則呈現上升趨勢,燒燙傷的分布(死亡:重大燒燙傷:住院:門診=1: 1.7: 21.3: 174.7)呈金字塔型,且其形狀由瘦型趨向胖型發展,輕度燒燙傷的比例相對增加,嚴重燒燙傷的比例相對減少,燒燙傷防制已有一定成效。往後重點在為數眾多的輕度燒燙傷之預防。
台灣地區燒燙傷住院病患以男性居多(67%),兩個高危險年齡層是5歲以下兒童及35-44歲成人,燒燙傷發生的高峰時間是在準備正餐的10-12時及16-18時,發生地點以居家廚房的比例最高,熱液體(如熱水、熱湯等)是造成燙傷的主要原因,預防計畫應針對與烹煮及熱食有關的燒燙傷為重點,尤其是有兒童的父母。
有五個因素(年齡、燒傷面積、吸入性傷害、入院前沖水及實施手術)與燒燙傷住院病患死亡有關,年齡越大、燒傷面積越大、有吸入性傷害,病患死亡的危險性越高,但是,入院前沖水、實施手術,病患死亡的危險性越低;有吸入性傷害病患死亡的危險性是無吸入性傷害者的2.57倍,入院前沖水可以降低51.8%的死亡危險性,因此,興建房屋時使用防火及無煙建材是當務之急,而燒燙傷發生後立即沖水更值得鼓勵。
台灣地區燒燙傷照護組織(工作團隊)的運作模式可以區分為病患導向、醫護導向及院方導向。病患導向型較重視服務上的考量,提供「整體服務」,院方導向型較重視成本上的考量,提供「基本服務」,而醫護導向型則介於兩者之間,必須在院方成本壓力及病患服務滿足兩方面取得一個平衡點,以醫師及護理服務為主體。而組織運作的良窳會影響燒燙傷住院病患的預後。
目前台灣地區從事燒燙傷工作的人員(醫師、護理及其他)中,以護理人員的工作滿意度最低,但是,工作壓力及離職傾向的比例都是三類人員中最高,因此,醫院管理階層應找出實際原因,協助解決。
燒燙傷中心住院的病患本身對服務品質的期望程度高於實際感受程度,工作人員對住院病患服務品質的期望程度普遍低估,尤其以醫師低估的情況最明顯,因此,醫院管理階層應依據住院病患期望與感受有落差之項目,以及工作人員與住院病患對服務品質期望有差距的部份改善服務品質。
In order to have a comprehensive understanding of burn injuries in Taiwan, this project (1) provided epidemiological information by analyzing vital statistical data, National Health Insurance data and burn registry data, (2) studied medical care system for burns in depth through observation, interview and questionnaire survey. The subjects of burn epidemiological information including the temporal trend and distribution of burns, and the characteristic of hospitalized burn patients were generated from vital statistics and insurance data with ICD-9 E codes that defineding causes of burns. The risk factors of mortality were analyzed by using registry data. The analysis of medical care for burns targeted on facilities, working teams’ satisfaction, and patients’ expectations. Statistical analyses on questionnaire data included Chi-square test, Student’s t-test, ANVOA and Multiple logistic regression. Observation and interview records were presented in words. The main results and conclusions are as follows:
In Taiwan, the burn care facilities located mostly in Taipei and Kaohsiung. Both hospital bed occupation rate and length of stay of burn patients were decreasing during the 6 year period from 1996 to 2001.
The overall mortality rate of burn injuries and incidence rate of catastrophic and hospitalized burns have a decreasing trend, whereas, the incidence rate of ambulatory burns has an increasing trend. The proportions of different severity levels of burns (dead: catastrophic: hospitalized: ambulatory= 1: 1.7: 21.3: 174.7)consisted different shapes of pyramids. The shape changes from slim to fat across the time. The percentage of minor burn injury increased, but massive burn injury decreased. The overall prevention and medical care for burns has shown some effect. In the future, attention should be paid to prevention of minor burns which will cause a great deal of ambulatory care.
The majority of hospitalized patients (67%) were male. The age distribution of burns patients showed peaks occurring at the age groups of 0-5 and 35-44 years. Over the time course of a day, burn injuries occurred more frequently from 10:00 to 12:00 hours and from 16:00 to 18:00 hours. Most burn accidents took place in the home, particularly in the kitchen.The leading type of burn injury was scalds. Corresponding to meal preparation time, hot substances such as boiling water, hot soup, etc. are the most common agents responsible for scalds. Prevention programs for reducing the risk of burn injuries during cooking and eating are required, especially for parents with young children.
Five factors(age, burn size, inhalation injury, flushing with cold water as a pre-hospital first aid treatment, and surgical treatments) were found to be correlated with burn mortality. Old age, large burn size and inhalation injury had a higher associated risk of death, whereas flushing the wound area with cold water and surgical treatments had a protective effect against burn-related deaths. The odds of death from burn injuries is 2.57 times higher for patients suffering from inhalation injury than for patients without similar injury. Treating burn wounds by flushing with cold water prior to reaching hospital can reduce the risk of death by 51.8%. It is important to encourage people to flush burn wounds using copious amount of cold water after such an injury has occurred, as well as to push government authorities to legislate for the use of non-inflammable material in housing construction.
There were three types of burn care working teams. The patient centered teams emphasize the quality of services; the hospital centered teams focus on medical cost; and the doctor and nurse centered teams attempt to balance the service cost and patient’s satisfaction. How well the team functioned was a significant factor that affects the prognosis of hospitalized burn patients.
Among the team workers, nurses have the lowest work satisfaction, but encounter the greatest work stress and more likely to leave their job. The manager of the hospital must to figure out a way to resolve the problem.
The expectations of hospitalized burn patients for the quality of medical care service were higher than their perceptions. The burn care workers significantly underestimated patients’ expectations. It is the administrators’ responsibility to reduce the gaps between patient’s expectations and perceptions, and between the burn care worker’s and patient’s expectations by improving the quality of burn care services.
正文目錄
誌謝……………………………………………………………………Ⅰ
正文目錄………………………………………………………………Ⅲ
附表目錄………………………………………………………………Ⅶ
附圖目錄………………………………………………………………Ⅸ
附錄目錄………………………………………………………………Ⅹ
中文摘要……………………………………………………………ⅩⅠ
英文摘要……………………………………………………………ⅩⅢ
第一章 緒論……………………………………………………….1
第一節、問題背景及重要性……………………………………….1
壹、燒燙傷是重要的公共衛生問題…………………………….1
貳、台灣地區燒燙傷照護設施及能力有必要加以瞭解……….1
參、台灣地區燒燙傷的防制成效應加以評估………………….2
肆、台灣地區缺乏完整的燒燙傷流行病學資料……………….3
伍、台灣地區燒燙傷照護體系運作現況有待瞭解…………….3
陸、台灣地區燒燙傷照護工作團隊的情緒應予關切………….4
柒、燒燙傷照護服務品質已成為關心重點…………………….4
第二節、研究動機與目的………………………………………….6
第三節、論文寫作方式…………………………………………….7
第二章 研究設計與方法………………………………………….8
第一節、名詞界定………………………………………………….8
壹、燒燙傷……………………………………………………….8
貳、流行病學特性……………………………………………….8
參、醫療照護體系……………………………………………….8
肆、燒燙傷中心或燒燙傷病房………………………………….9
伍、工作團隊…………………………………………………….9
陸、工作滿意度…………………………………………………10
柒、服務品質……………………………………………………10
第二節、研究架構、內容與面向…………………………………11
壹、研究架構……………………………………………………11
貳、研究內容……………………………………………………11
參、研究面向……………………………………………………12
第三節、研究假設…………………………………………………13
壹、長期趨勢部份………………………………………………13
貳、流行病學特性部份…………………………………………13
參、運作模式部份………………………………………………14
肆、工作滿意度部份……………………………………………14
伍、服務品質期望部份…………………………………………14
第四節、研究材料與方法…………………………………………16
壹、資料檔………………………………………………………16
貳、觀察訪談……………………………………………………18
參、問卷調查……………………………………………………19
第五節、研究步驟與時間及統計分析……………………………22
壹、研究步驟與時間……………………………………………22
貳、統計分析……………………………………………………22
第三章 台灣地區燒燙傷的長期趨勢……………………………28
第一節、燒燙傷照護設施及照護能力評估指標…………………28
壹、前言…………………………………………………………28
貳、材料與方法…………………………………………………28
參、結果…………………………………………………………29
肆、討論…………………………………………………………33
伍、結論…………………………………………………………36
第二節、不同程度的燒燙傷及分布………………………………37
壹、前言…………………………………………………………37
貳、材料與方法…………………………………………………37
參、結果…………………………………………………………39
肆、討論…………………………………………………………42
伍、結論…………………………………………………………46
第四章 台灣地區燒燙傷的流行病學特性………………………55
第一節、燒燙傷住院病患的流病特性……………………………55
壹、前言…………………………………………………………55
貳、材料與方法…………………………………………………55
參、結果…………………………………………………………55
肆、討論…………………………………………………………59
伍、結論…………………………………………………………62
第二節、影響住院病患死亡的因子………………………………63
壹、前言…………………………………………………………63
貳、材料與方法…………………………………………………63
參、結果…………………………………………………………64
肆、討論…………………………………………………………67
伍、結論…………………………………………………………70
第五章 台灣地區燒燙傷照護體系的運作現況…………………87
第一節、照護體系的基本特性……………………………………88
壹、組織型態及分布情形………………………………………88
貳、人力編制與素質……………………………………………89
參、床位及運用…………………………………………………91
第二節、照護組織運作模式及優缺點……………………………94
壹、運作模式類型及特性………………………………………94
貳、運作模式優缺點……………………………………………96
第三節、照護組織運作對燒燙傷住院病患預後的影響…………97
壹、醫學中心重大燒燙傷及住院病患死亡比例較高…………97
貳、組織運作良窳會影響住院病患的預後……………………97
第四節、醫病(家屬)間互動……………………………………99
壹、醫病間應是長期的伙伴或朋友關係嗎?…………………99
貳、病患必須由依賴合作進展至獨立自主……………………99
參、家屬參與病患照護工作………………………………….100
第五節、當前燒燙傷照護工作所面臨的問題………………….102
壹、政策層面………………………………………………….102
貳、經營層面………………………………………………….103
參、工作團隊層面…………………………………………….104
肆、服務層面………………………………………………….105
第六節、未來展望……………………………………………….108
壹、健保局應打破統一支付費用之作法…………………….108
貳、燒燙傷中心應依素質及能力評鑑分級………………….108
參、台灣地區應依地區設置責任燒傷中心………………….109
肆、消防救災體系與醫療體系應整合……………………….110
伍、醫療體系與社會福利體系應統合……………………….111
第六章 台灣地區燒燙傷工作團隊滿意度及相關問題看法….118
壹、前言……………………………………………………….118
貳、材料與方法……………………………………………….118
參、結果……………………………………………………….119
肆、討論……………………………………………………….125
伍、結論……………………………………………………….129
第七章 台灣地區燒燙傷住院病患服務品質期望與實際感受.141
壹、前言……………………………………………………….141
貳、材料與方法……………………………………………….141
參、結果……………………………………………………….142
肆、討論……………………………………………………….145
伍、結論……………………………………………………….147
第八章 總結…………………………………………………….156
第一節、研究結果與建議……………………………………….156
壹、台灣地區燒燙傷中心數量分布及照護能力評估……….156
貳、台灣地區燒燙傷的趨勢及照護成效…………………….156
參、台灣地區燒燙傷住院病患的流行病學特性…………….156
肆、台灣地區燒燙傷住院病患死亡的影響因子…………….157
伍、台灣地區燒燙傷照護體系運作現況…………………….157
陸、燒燙傷工作團隊工作滿意度、壓力情況及離職傾向….157
柒、燒燙傷住院病患對服務品質的期望與感受…………….158
第二節、研究限制……………………………………………….159
第三節、未來研究方向………………………………………….160
參考文獻…………………………………………………………….161
附表目錄
附表2-1:國際疾病傷害及死因分類標準,外因補充分類(E-codes)
屬於燒燙傷者…………………………………………………23
附表2-2:燒傷中心及燒傷病房設置標準表……………………………24
附表2-3:中華民國兒童燙傷基金會燒燙傷登錄系統合約醫院………25
附表3-1:台灣地區85-90年燒燙傷照護設施數量、分布及收療量….47
附表3-2:台灣地區85-90年燒燙傷設施住院、手術、重大燒燙傷
及住院死亡人數(%)……………………………………….48
附表3-3:台灣地區85-90年不同類別燒燙傷中心(病房)佔床率
及平均住院天數比較…………………………………………49
附表3-4:台灣地區85-90年各燒燙傷中心及病房之病患所使用之
醫療費用(百萬)……………………………………………50
附表3-5:台灣地區各類燒燙傷死亡人數及死亡率……………………51
附表3-6:台灣地區81-90年各年齡層燒燙傷死亡人數及死亡率…….52
附表3-7:台灣地區85-90年發生重大燒燙傷人數及發生率………….53
附表4-1:燒燙傷發生地點………………………………………………71
附表4-2:燒燙傷類型……………………………………………………72
附表4-3:不同性別及年齡層(兒童與成人)病患之燒燙傷面積……73
附表4-4:身體受傷部位…………………………………………………74
附表4-5:住院天數………………………………………………………75
附表4-6:各項人口學等因子與燒燙傷死亡的單變項分析……………76
附表4-7:不同年齡層、燒燙傷面積及Baux分數與死亡的關連………77
附表4-8:各項因子與燒燙傷死亡多變項分析結果……………………78
附表4-9:不同燒傷面積(TBSA%)情況下沖水的效果……………….79
附表5-1:台灣地區設置燒燙傷中心或病房的醫院及病床數…………113
附表5-2:燒燙傷照護組織運作模式類型、特性及優缺點……………114
附表5-3:燒燙傷組織運作對住院病患預後的影響之迴歸分析………115
附表5-4:台灣地區85-90年不同類別醫院燒燙傷住院病患醫療
費用比較………………………………………………………116
附表5-5:台灣地區85-90年燒燙傷住院病患各項費用比較………….117
附表6-1:不同機構工作人員基本特性…………………………………130
附表6-2:醫院內不同類別工作人員基本特性…………………………131
附表6-3:六個因素特質的內容及對工作滿意度的解釋量(%)…….132
附表6-4:不同機構工作人員滿意度比較(t-test檢定)……………133
附表6-5:醫院內不同類別工作人員滿意度比較(ANOVA檢定)…….134
附表6-6:燒燙傷工作人員的「普遍」及「首要」工作壓力源………135
附表6-7:燒燙傷工作人員考慮離職的「普遍」及「首要」原因……136
附表6-8:燒燙傷工作人員目前仍持續為燒燙傷照護工作貢獻心
力的原因………………………….………………………….137
附表6-9:燒燙傷工作人員最常協助燒燙傷住院病患的服務項目……138
附表6-10:燒燙傷工作人員對燒燙傷工作團隊最佳運作模式看法….139
附表6-11:燒燙傷工作人員對燒燙傷照護工作面臨的最大問題之
看法………………………………………………………….140
附表7-1:受訪的燒燙傷住院病患基本特性……………………………148
附表7-2:三個因素特質的內容及對服務品質期望的解釋量(%)…….149
附表7-3:燒燙傷住院病患對服務品質「期望」的看法………………150
附表7-4:燒燙傷住院病患對服務品質「感受」的看法………………151
附表7-5:燒燙傷住院病患對服務品質「期望」與「實際感受」
的比較…………………………………………………………152
附表7-6:不同類別工作人員對燒燙傷住院病患服務品質「期望」
看法比較………………………………………………………153
附表7-7:工作人員與燒燙傷住院病患對服務品質「期望」看法
比較……………………………………………………………154
附表7-8:不同類別工作人員與燒燙傷住院病患對服務品質「期
望」看法比較…………………………………………………155
附圖目錄
附圖2-1:服務品質期望與實際感受評估架構圖………………………26
附圖2-2:本研究架構圖…………………………………………………27
附圖3-1:台灣地區燒燙傷相對死亡數比值的金字塔型分布圖………54
附圖4-1:燒燙傷住院病患年齡及性別分布……………………………80
附圖4-2:18歲以上成人及7歲以下兒童父母的教育程度…………….81
附圖4-3:燒燙傷發生時間點……………………………………………82
附圖4-4:燒燙傷事件起因………………………………………………83
附圖4-5:不同燒燙傷面積情況下有無手術治療病患的死亡比例……84
附圖4-6:不同Baux分數情況下有無吸入性傷害病患的死亡比例……85
附圖4-7:不同Baux分數情況下入院前有無沖水病患的死亡比例……86
附錄目錄
附錄一:博士學位候選人資格考試記錄……………………………173
附錄二:博士論文研究進度報告審查記錄…………………………175
附錄三:工作人員調查問卷…………………………………………177
附錄四:住院病患調查問卷…………………………………………184
附錄五:投稿登載於Burns(SCI)的文章…………………………187
附錄六:投稿登載於J.P.S.A.R.O.C的文章……………………….194
附錄七:獲獎獎狀一…………………………………………………207
附錄八:獲獎獎狀二…………………………………………………208
附錄九:獲獎獎狀三…………………………………………………209
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