臺灣博碩士論文加值系統

本研究是回溯性研究，對台灣地區2003年曾有收治SARS病患的50家醫院，將各項感染控制措施，以問卷調查(100個觀察變項)，合併使用結構方程模式(Structural Equation Modeling, SEM)分析，驗證各種感染控制措施對院內感染控制的影響及其因果關係。研究結果發現，在配置最佳的模型中，A模型（R2=81.8％, CFI=0.583）與B模型（R2=67.0％,CFI=0.976），雖然無法同時兼顧達到兩個指標的標準(R2>90%，CFI>0.9)，但是藉由醫院執行「急診的動線規劃」以避免醫護人員發生SARS感染，重要性分別佔A模型的83.4％和B模型的67.0％。A模型中，其他減少醫護人員感染SARS的重要原因，包括個人保護裝備(PPE)（佔重要性9.2％），簡易隔離病房（佔重要性4.2％），急診室到隔離病房的隔板建立（佔重要性2.8％）。在B模型中，急診的動線規劃（佔重要性69.0％），群突發處理原則（佔重要性12.2％），全院內所有訪客病人量體溫（佔重要性9.4％），轉診流程制定（佔重要性5.2％），全院洗手節點設置時間（佔重要性3.2％），運送疑似病患自急診室到隔離病房後有漂白水消毒（佔重要性1.0％）。其中，急診動線管制中的發燒篩檢站，佔整體的重要性為50.05％。 此外，負壓隔離病房在本研究中，無法加入SEM模型中(P-value=0.586)；而簡易隔離病房，是一個重要的感控措施，可以保護醫護人員免於罹患重急性呼吸道症候群。本研究建立了模型，並考驗模型，評估證明這些感染控制措施，對於院內醫護人員免於罹患重急性呼吸道症候群，具有因果關係的影響性。尤其以急診室與動線管制更是能對SARS疫情有效控制的原因。本研究結果將來可在面對未知傳染病，如人類禽流感等相似的傳染途徑的傳染病防治上，對於醫護人員提供經濟有效的感染控制措施。

Health-care workers (HCWs) are at risk in acquiring SARS infection while caring for SARS patients. Personal protective equipment (PPE) and negative pressure isolation rooms (NPIR) have not been completely successful to halt the nosocomial transmission of SARS. Many infection control measures were implemented to protect HCWs during the panic of SARS epidemic. However, there is no control evaluation to determine the effectiveness and the causation of each control measure. Thus, we conducted a retrospective controlled analysis to determine the effectiveness of infection control measure for SARS using a causation modeling algorithm-structural equation modeling (SEM). Fifty hospitals that had cared for SARS patients were included, in which incidence of HCWs acquiring nosocomial SARS infection occurred in 36% (18/50) of the hospitals. The questionnaire on infection control measures (100 variables) were completed by infection control personnel in each hospital. SPSS 13.0 and Amos 5.0 software were used for data and SEM analysis. Two models were constructed based on optimal coefficient of determination (R2) (Model A) and optimal comparative-fit index (CFI) (Model B). In Model A, four major categories were contributed to minimizing HCWs acquiring SARS and the cause-relation model was established by SEM: 83.4% contribution from traffic control in emergency department (ED) (4 variables), 9.2% contribution from installation of simplified isolation room (2 variables), 4.6% contribution from personal protective equipment (2 variables), and 2.8% contribution from installation of physical barriers from entrance in ED to isolation room. In Model B, 8 factors were contributed to minimizing HCWs acquiring SARS and the cause-relation model was established by SEM: 50.5% contribution from fever screen station out of ED, 17.2% contribution from traffic control in ED (3 variables), 12.2% contribution from outbreak standard operation procedure, 9.4% contribution from body temperature measure for all people in hospital, 5.2% patients transfer procedure, 3.2% contribution from time for handwashing setup at each checkpoint in whole hospital, 1.73% contribution from triage on fever patients with unknown etiology in ED, and 1.0% contribution from bleach disinfection performed after crossing with clean zones and during cross contact in patient routing. The time of outbreak standard operation procedure and HCWs acquiring SARS in hospital are cause-relation to each other. In addition, not every infection control measure has significant contribution to the minimization of HCWs acquiring SARS infection. For example, negative pressure isolation room and the amount of capital investment have no significant protective effect in protecting HCWs. Traffic control is the major factor in preventing HCWs from SARS infection by SEM analysis, especially fever screen station outside of ED. The same concept and analysis may be applied to prevention of HCWs in caring patients with emerging infectious diseases, such as avian flu in human, with the same transmission route.

TABLE OF CONTENTS
Page
AKNOWLEDGEMENT..............................................................................................Ⅰ
ABSTRACT.................................................................................................................Ⅲ
CHINESE ABSTRACT……………………….…………………………………......Ⅵ
TABLE OF CONTECTS …………………………………………………………….Ⅷ
1.0 INTRODUCTION………………………………………………………………....1
1.1 Background………………………………………………………..………...1
1.2 Hypothesis……………………………………………………………...……2
2.0 LITERATURE REVIEW………………………………………………………….3
2.1 SARS: emerging infection…………………………………….…..………….3
2.2 Symptoms of SARS………………………………………….………………3
2.3 Infection control………………………………………………………...…....3
2.4 Personal protective equipment (PPE)………………………………………...4
2.5 Integrated infection control strategy …………………………………………4
2.6 Protection of healthcare workers (HCWs) …………………………………..4
2.7 Structural equipment modeling (SEM) ……………………………………...5
3.0 Materials and methods………………………………………………………….…7
3.1 Data acquisition………………………………………………………………7
3.2 Variable definition……………………………………………………………7
3.2.1 Infection control measures as variables………………………….……7
3.2.2 Date of hospital infection control implementation……………………7
3.2.3 Zero-one variables…………………………………………………….8
3.2.4 SARS risk…………………………………………………………..…8
3.3 Data analysis…………………………………………………………..…….9
3.3.1 Single variable and multi variables analysis…………………...…….9
3.3.2 Time dependent analysis………………………………………….….9
3.3.3 Structural equation modeling (SEM) …………………………….….9
3.4 Data reduction………………………………………………………………10
3.4.1 Co-linearity……………………………………………………......…10
4.0 Result…………………………………………………………………………..…12
4.1 Single variable and multi variables analysis…………………………..……12
4.2 Time dependent analysis……………………………………………………15
4.3 Structural Equation Modeling (SEM)………………………………………18
4.3.1 Model A: SEM model with highest R2………………………..……..18
4.3.2 Model B: SEM model with highest CFI……………………………..20
5.0 Discussion..............................................................................................................22
6.0 Conclusion………………………………………………………………………..26
7.0 Reference……………………………………………………………...………….27
Appendix I:
Part I………………….………………………………………………………………31
醫療機構SARS政策與動線規劃研究問卷調查表
Part II…………………………………………………………………………………56
醫院感染管制組織與政策實況訪查暨紀錄
Appendix Ⅱ
各院動線管制問卷原始資料數據檔案譯碼簿(Codebook)……………………...…60

LIST OF TABLES
Table 1. Single variable and multi variables analysis in category 1…………………12
Table 2. Single variable and multi variables analysis in category 2 …………...……13
Table 3. Single variable and multi variables analysis in category 3 ………...………13
Table 4. Single variable and multi variables analysis in category 4 ………..……….14
Table 5. Whether nosocomial infection was terminated after implementation of
handwashing in ED …………………………………………………….....15
Table 6. Whether nosocomial infection was terminated after implementation of traffic
and routing into ED ………………………………………………….……15
Table 7. Whether nosocomial infection was terminated after implementation of screen
station in ED ………………………………………………………………15
Table 8. Whether nosocomial infection was terminated after implementation of
handwashing, traffic control, and screen station in ED ………………..….15
Table 9. Statistic in Model A………………………..………………………..………19
Table 10. Statistic in Model B………………………..………………………………21

LIST OF FIGURES
Fig 1. Time dependent analysis in HCWs acquiring SARS in hospitals……….…….17
Fig 2. SEM model with highest R2 （Model A）…………………………………..…18
Fig 3. SEM model with highest CFI （Model B）……………………………………20
Fig 4. Model A from Amos……...……………………………………………………29
Fig 5. Model B from Amos…………………………………………………..………30

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