臺灣博碩士論文加值系統

本研究探討不投予預防性抗生素對甲狀腺手術部位感染之影響，研究採世代研究設計，比較不投予預防性抗生素與甲狀腺手術部位感染徵象、術後服用抗生素治療、平均住院天數及平均醫療費用之間關聯性。研究對象來自於某醫學中心一般外科病房甲狀腺手術病人，第一階段以病歷回溯(retrospective)方法，收案手術前30分鐘有投予預防性抗生素160位、第二階段以前瞻性(prospective)方法，收案手術前30分鐘不投予預防性抗生素150位。結果顯示甲狀腺手術屬第一類清潔傷口，手術前不投予預防性抗生素與術後服用抗生素治療無顯著關聯性。其中手術部位感染危險因子以罹患糖尿病、手術時間超過2小時、手術部位引流管留置、引流管留置天數＞2天，為甲狀腺術後服用抗生素治療之主要影響因素。而手術前不投予預防性抗生素對縮短平均住院天數及藥費成本支出具顯著差異，但對醫療費用支出則無顯著相關，當住院天數超過4天以上，術後服用抗生素治療藥費增加5,850元、醫療費用支出也由32,436元增加到63,895元，但住院天數控制在4天內，術後有服用抗生素治療的處置，其藥費及醫療費用支出並無顯著差異。一旦術後使用抗生素治療，不但延長病人住院天數，也增加醫療費用支出，對醫院整體營運及醫療品質而言，勢必造成相當大震撼，所以手術前評估及手術後照護對手術品質就益發顯得重要。建議經由教育措施介入、醫院主管激勵和對抗生素劑量使用的管控，逐漸改變臨床抗生素用藥習慣，臨床醫護人員也應瞭解手術傷口分類型態，重視手術部位感染相關危險因子，確實執行手術前、中、後照護，以降低病人發生手術部位感染的風險。

This study investigates the non-utilization of prophylactic antibiotics on patients who underwent thyroid surgery in comparison with prophylactic antibiotic use. In order to know the difference between non-utilization and utilization of prophylactic antibiotics with regards to signs and symptoms of thyroidectomy infection, post-operative use of antibiotics, average length of stay in the hospital and average hospital expenses, cohort method was used.
Participants were from academic medical center’s general surgery ward patients who underwent thyroidectomy. The first phase of study used retrospective method by reviewing the hospital charts. 160 patients received prophylactic antibiotics 30 minutes prior to thyroidectomy. The second phase of the study enrolled 150 patients who were not given prophylactic antibiotics before thyroidectomy.
Results showed that non-utilization of prophylactic antibiotics prior to surgery and use of antibiotics after surgery for clean surgical wound showed no significant difference. However if there are risks like diabetic patients, more than 2 hours of surgery, insertion of draining tube and presence of drain for more than 2 days, use of antibiotics after thyroidectomy resulted in significant associations.
There is significant relationship between non-prophylactic antibiotic use prior to surgery with shortened hospital stay or lesser drug cost. Although hospital expenditures showed no significant findings, when hospital stay is longer than 4 days, drug cost increased to NT$5850 while using antibiotics after surgery, comparable figure for hospital expenses is from NT$ 32436 up to NT$ 63895. On the other hand, shorter hospital stay of less than 4 days did not show any significant findings for use of antibiotics after thyroidectomy in relation to drug cost or hospital expenses.
When antibiotics are used after thyroidectomy, the duration of hospital stay is prolonged, hospital bills are increased, and overall, the negative effect on hospital’s operational system is certain. Therefore, it is of paramount importance to assess patients before surgery and to care for them thoroughly after surgery.
The risk of infection on surgical sites can be decreased by interventions such as education, changing the habit of antibiotic use by senior health care staff. In addition, understanding types of surgical wound, evaluation of infection risks for surgical sites, and execution of proper care before, during or after surgery by clinical hospital staff can lower rate of infection.

第一章 前言………………………………………………………………………......................... ......1
第一節 .問題背景與研究動機 ………………………………........……………........................1
第二節 研究目的 ………………………………………………........……………….................2
第三節 研究問題 ………………………………………………...........………………..............3
第四節 研究假說 ………………………………………………..........………………...............3

第二章 文獻查證 ……………………………………………………...............………………...........4
第一節 手術傷口分類與感染……………...…………..................……...………………….......4
第二節 預防性抗生素在手術部位感染之應用….………….........................……..……...........7
第三節 預防手術部位感染實證策略……………………………....................………….........10
第四節 文獻查證總結….............................................................................................................17
第五節 操作性定義….................................................................................................................18
第六節 研究概念架構….............................................................................................................19

第三章 研究方法…..............................................................................................................................21
第一節 研究設計.........................................................................................................................21
第二節 研究對象….....................................................................................................................22
第三節 研究工具….....................................................................................................................22
第四節 資料收集過程….............................................................................................................23
第五節 資料分析與統計方法….................................................................................................24
第六節 研究對象的權益保護….................................................................................................25

第四章 研究結果…..............................................................................................................................26
第一節 甲狀腺手術病人基本屬性與特性….............................................................................26
第二節 兩階段投予預防性抗生素甲狀腺手術病人基本屬性與特性比.................................26
第三節 甲狀腺手術後服用抗生素治療病人基本屬性與特性.................................................28
第四節 兩階段投予預防性抗生素對甲狀腺手術病人住院天數及醫療費用影響….............28
第五節 甲狀腺手術後服用抗生素治療對住院天數及醫療成本影響….................................29
第六節 甲狀腺手術後服用抗生素治療相關之危險因子邏輯迴歸….....................................30

第五章 討論…......................................................................................................................................32
第一節 手術前不投予預防性抗生素對甲狀腺手術之影響….................................................32
第二節 不投予預防性抗生素對甲狀腺術後服用抗生素治療之影響….................................33
第三節 甲狀腺術後服用抗生素治療對住院天數及醫療費用影響…….................................34

第六章 結論與建議………………………………………………………………………………......36
第一節 結論…………………………………………………………………………………….36
第二節 建議…………………………………………………………………..……………........36
第三節 研究限制……………………………………………………………………..…….......38

參考文獻…............................................................................................................................................39
中文部分…...................................................................................................................................39
英文部分.......................................................................................................................................39

表目錄
表一 甲狀腺手術病人基本屬性與特性…...............................................................................44
表二 兩階段投予預防性抗生素甲狀腺手術病人基本屬性與特性比………..……….........46
表三 甲狀腺手術後服用抗生素治療病人基本屬性與特性…...............................................48
表四 兩階段投予預防性抗生素對甲狀腺手術病人住院天數及醫療費用影響……….......50
表五 甲狀腺手術後服用抗生素治療對住院天數及醫療成本影響…...................................51
表六 甲狀腺手術後服用抗生素治療相關之危險因子邏輯迴歸…………………...............51

附錄…………………………………………………………………....................................................52
附錄一 手術部位感染臨床評估紀錄表….................................................................................52
附錄二 專家效度評量表.............................................................................................................55
附錄三 受試者參與研究同意書….............................................................................................59

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