背景: 住院期間留置尿管常被不當使用且易導致許多其他併發症。目前，針對住院高齡病人不當使用留置尿管相關危險因子與結果之研究極為有限。
目的: 針對住院高齡病人於尿管放置當時、持續使用階段與重置三個時期，分別探討不當使用留置尿管之發生率、原因、相關影響因子與可能之臨床結果。
方法: 採縱貫性研究設計，以方便取樣調查65歲以上且入院後24小時內放置尿管之病人。資料收集前，發展留置尿管醫療適應症之檢核表並由研究者使用檢核表辨識留置尿管之適當性。再者，經由病歷與會談收集資料，包含病人與留置尿管特性、過去排泄功能、健康狀態、尿管放置當時的照護情境、重置尿管的情境與尿管留置的主觀知覺。最後，出院時經由病歷與會談收集結果資料，包含死亡率、住院天數、第一次尿管移除的時間、出院時仍留置尿管、尿管導致泌尿道感染、尿管相關併發症、日常生活活動功能衰退與入住機構。
結果: 321位住院高齡病人入院當時不當放置尿管發生率為38.3%，最常見不當放置原因為「方便照護」 (49.6%)。住院高齡病人有慢性便秘、泌尿道感染病史、此次住院接受內科治療、認知障礙、憂鬱症狀與日常生活活動功能較佳為不當放置尿管的高危險族群。夜班與缺乏護理紀錄呈現尿管放置原因亦與不當放置尿管顯著相關。此外，不當放置尿管將導致高齡病人日常生活活動功能衰退。321位住院高齡病人尿管留置總天數為1958天；其中，67%為不當使用留置尿管。最常見不當使用留置尿管的原因亦為「方便照護」。女性、此次住院接受手術、入院當時不當放置尿管、缺乏尿管留置醫療紀錄顯著與不當使用留置尿管相關。住院高齡者增加不當使用留置尿管天數將導致延長住院天數、延遲尿管移除時間、增加出院時仍留置尿管比率、增加尿管導致泌尿道感染與尿管相關併發症發生率、導致日常生活活動功能衰退。在所有住院高齡者中，尿管重置發生率為20.6%；然而，亦高達49.5%為不當重置尿管。
結論: 衰弱高齡病人為不當使用留置尿管的高危險族群，而不當使用尿管又易引發負向的臨床結果。健康照護人員、病人與家屬因對尿管正確使用的忽視，可由不當放置尿管開始，延續至不當使用尿管的時間延長，至移除尿管後又不當重置，導致一連串的惡性循環。欲解決不當使用留置尿管的問題，醫院宜制定相關尿管使用的政策，包含詳細尿管醫療紀錄的規範及病人與照護者(健康專業照護人員與非正式照護者)尿管相關教育課程；以全面提升尿管使用之照護品質。

Background: Urinary catheterization may lead to substantial complications and is often used in hospitals without an appropriate indication. Studies of factors and clinical outcomes associated with inappropriate use of urinary catheters in the elderly population are rare.
Purpose: To explore the incidence, rationales, associated factors and clinical outcomes of inappropriate urinary catheter use in hospitalized elderly patients among three phases: initial urinary catheter placement, urinary catheter remaining, and urinary catheter re-insertion.
Methods: A longitudinal study enrolling patients aged 65 years and older with urinary catheters placed within 24 hours of hospitalization was conducted. Criteria for urinary catheter use were developed to identify inappropriate catheter use. Characteristics of patients and catheter use, voiding function history, health conditions, care conditions related to catheter placement, conditions for urinary catheter re-insertion, and subjective perceptions of urinary catheter use were collected through reviewing medical records and by interviewing patients or their primary caregivers. Mortality, length of hospital stay, time to first removal of catheter, catheter remaining in place at discharge, catheter-associated urinary tract infections (CAUTIs), catheter-related complications, change of activities of daily living (ADLs), and new admission to nursing home after discharge determined as clinical outcomes.
Results: The incidence of initial inappropriate placement of urinary catheters (IIPC) in hospitalized elderly patients was 38.3%. The rationale most often reported for IIPC was “convenience of care.” Factors associated with IIPC were, chronic constipation, a history of urinary tract infection, medical treatment diagnosis, cognitive impairment, depressive symptoms, independence in ADLs, insertion of catheter during evening and night shifts, and lack of nursing documentation of the rationale for catheterization. Patients with IIPC showed greater decline in ADLs. Among 321 patients, a total of 1958 urinary catheter-days were observed, 67% catheter-days were inappropriate. Inappropriate use of urinary catheters occurred mostly in females and surgical patients and was associated with IIPC and lack of medical documentation. “Convenience of care” was the most common rationale for inappropriate use. Increasing inappropriate catheter-days was a significant predictor of longer hospital stay, delayed time to removal of catheters, increased rate of urinary catheterization at discharge, development of CAUTIs and catheter-related complications, and a decline in ADLs. The incidence of catheter re-insertion was 20.6%, of which 49.5% of them were improperly re-inserted.
Conclusions: Older patients are at greater risk of inappropriate use of urinary catheters. Inappropriate use may lead to substantial complications in older patients. The health care professions, patients and their caregivers do not pay attention to appropriate use of urinary catheters, which induces a vicious cycle of inappropriate catheter use. To eliminate inappropriate catheter use, formulating hospital-level clinical policies related to the use of urinary catheters is extremely important and should include concrete regulations for documentation and a specific education protocol for health care professionals, patients and their caregivers.

中文摘要.............................................Ⅰ
Abstract............................................Ⅲ
誌謝................................................Ⅴ
Table of contents...................................Ⅵ
List of figures.....................................Ⅷ
List of tables......................................Ⅸ
Chapter 1: Introduction.............................1
1.1 Background......................................1
1.2 Purpose.........................................4
1.3 Research question...............................5
Chapter 2: Literature Review........................6
2.1 Indications for urinary catheter use............6
2.2 Incidence and rationales for inappropriate urinary
catheter use....................................10
2.3 Associated factors of inappropriate urinary catheter
use.............................................14
2.4 Clinical outcomes of inappropriate urinary catheter
use.............................................21
Chapter 3: Methods..................................25
3.1 Definition of terms.............................25
3.2 Research framework..............................27
3.3 Study design and sampling.......................32
3.4 Instruments and measurements....................33
3.5 Data collection and procedure...................37
3.6 Statistical analysis............................41
3.7 Ethic considerations............................44
Chapter 4: Results..................................45
4.1 Characteristics of hospitalized elderly patients and
catheter use....................................45
4.2 Initial inappropriate urinary catheter
placement.......................................47
4.3 Remaining inappropriate use of urinary
catheters.......................................54
4.4 Inappropriate urinary catheter
re-insertion....................................61
Chapter 5: Discussion...............................68
5.1 Initial inappropriate urinary catheter
placement.......................................68
5.2 Remaining inappropriate use of urinary
catheters.......................................72
5.3 Inappropriate urinary catheter re-insertion.....75
Chapter 6: Conclusion...............................78
6.1 Conclusions.....................................78
6.2 Limitations of the research.....................79
6.3 Applications and recommendations for the
research........................................80
Acknowledgments.....................................82
References..........................................83

Abrams, P., Cardozo, L., Fall, M., Griffiths, D., Rosier,
P., Ulmsten, U.,… Wein, A. (2003). The standardisation
of terminology in lower urinary tract function: report
from the standardisation sub-committee of the
International Continence Society. Urology, 61(1), 37–
49.
Apisarnthanarak, A., Rutjanawech, S., Wichansawakun, S.,
Ratanabunjerdkul, H., Patthranitima, P., Thongphubeth,
K.,… Fraser, V. J. (2007). Initial inappropriate
urinary catheters use in a tertiary-care center:
incidence, risk factors, and outcomes. American Journal
of Infection Control, 35(9), 594–599.
doi:10.1016/j.ajic.2006.11.007
Bootsma, A. M., Buurman, B. M., Geerlings, S. E., ＆
Rooij, S. E. (2013). Urinary incontinence and
indwelling urinary catheters in acutely admitted
elderly patients: relationship with mortality,
institutionalization, and functional decline. Journal
of the American Medical Directors Association, 14(2),
147.e7–147.e12. doi:10.1016/j.jamda.2012.11.002
Centers for Disease Control and Prevention. (2012, May,
17). Catheter-associated urinary tract infections
(CAUTI). Retrieved from
http://www.cdc.gov/HAI/ca_uti/uti.html
Charlson, M. E., Pompei, P., Ales, K. L., ＆ MacKenzie, C.
R. (1987). A new method of classifying prognostic
comorbidity in longitudinal studies: Development and
validation. Journal of Chronic disease, 40(5), 373-383.
Chen, A. C. (1996). Clinical validation of the Geriatric
Depression Scale (GDS): Chinese version. Journal of
Aging and Health, 8(2), 238-253.
doi: 10.1177/089826439600800205
Chou, K. L. (2002). Hong Kong Chinese everyday competence
scale: a validation study. Clinical Gerontologist,
26(1), 43-51. doi:10.1300/J018v26n01_05
Crowe, H., Clift, R., Duggan, G., Bolton, D., ＆ Costello,
A. (1994). Randomized study of the effect of midnight
removal of urinary catheters. Urologic Nursing, 14(1),
18–20.
Curtis, L. A., Dolan, T. S., ＆ Cespedes, R. D. (2001).
Acute urinary retention and urinary incontinence.
Emergency Medicine Clinics of North America, 19(3),
591–619. doi: 10.1016/S0733-8627(05)70205-4
Davoodian, P., Nematee, M., ＆ Sheikhvatan, M. (2012).
Inappropriate use of urinary catheters and its common
complications in different hospital wards. Saudi
Journal of Kidney Diseases and Transplantation, 23(1),
63−67. doi: 10.1016/j.eimc.2013.02.013
Fakih, M. G., Shemes, S. P., Pena, M. E., Dyc, N., Rey,
J. E., Szpunar, S. M., ＆ Saravolatz, L. D. (2010).
Urinary catheters in the emergency department: very
elderly women are at high risk for unnecessary
utilization. American Journal of Infection Control 38,
683–688. doi: 10.1016/j.ajic.2010.04.219
Fernández-Ruiz, M., Calvo, B., Vara, R., Villar, R. N., ＆
Aguado, J. M. (2013). Inappropriate use of urinary
catheters in patients admitted to medical wards in a
university hospital. Enfermedades Infecciosas y
Microbiología Clínica, 31(8), 523−525.
doi: 10.1016/j.eimc.2013.02.013
Fillenbaum, G. G., ＆ Smyer, M. A. (1981). The
development, validity, and reliability of the OARS
multidimensional functional assessment questionnaire.
Journal of Gerontology, 36(4), 428-434.
doi: 10.1093/geronj/36.4.428
Garner, J. S., Jarvis, W. R., Emori, T. G., Horan, T. C.
＆ Hughes, J. M. (1988). CDC definitions for nosocomial
infections, 1988. American Journal of Infection
Control,16(3), 128–140. doi: 10.1016/0196
6553(88)90053-3
Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G.,
＆ Pegues, D. A. (2010). Guideline for prevention of
catheter-associated urinary tract infections 2009.
Infection Control and Hospital Epidemiology, 31(4),
319–326. doi: 10.1086/651091
Gokula, R. R., Hickner, J. A., ＆ Smith, M. A. (2004).
Inappropriate use of urinary catheters in elderly
patients at a midwestern community teaching hospital.
American Journal of Infection Control, 32(4), 196–199.
doi: 10.1016/j.ajic.2003.08.007
Greene, M. T., Kiyoshi-Teo, H., Reichert, H., Krein, S.,
＆ Saint, S. (2014). Urinary catheter indications in the
United States: results from a national survey of acute
care hospitals. Infection Control and Hospital
Epidemiology, 35(3), S96-98. doi: 10.1086/677823
Haglund, R. M. J., ＆ Schuckid, M. A. (1976). A clinical
comparison of tests of organicity in elderly patients.
Journal of Gerontology, 31(6), 645-459.
doi: 10.1093/geronj/31.6.654
Halekoh, U., Højsgaard, S., ＆ Yan, J. (2006). The R
package geepack for generalized estimating equations.
Journal of Statistic Software, 15(2), 1-11.
Hazelett, S. E., Tsai, M., Gareri, M., ＆ Allen, K.(2006).
The association between indwelling urinary catheter use
in the elderly and urinary tract infection in acute
care. BMC Geriatrics, 6(15), 1–7.
doi: 10.1186/1471-2318-6-15
Ho, D. E., Imai, K., King, G., ＆ Stuart, E. A. (2011).
MatchIt: nonparametric preprocessing for parametric
causal inference. Available at:
http://r.iq.harvard.edu/docs/matchit/2.4-20/matchit.pdf
(accessed 12 January 2013).
Holroyd-Leduc, J. M., Sands, L. P., Counsell, S. R.,
Palmer, R. M., Kresevic, D. M., ＆ Landefeld, S. (2005).
Risk factors for indwelling urinary catheterization
among older hospitalized patients without a specific
medical indication for catheterization. Journal of
Patient Safety, 1(4), 201–207.
doi: 10.1097/01.jps.0000205737.68588.d5
Holroyd-Leduc, J. M., Sen, S., Bertenthal, D., Sands, L.
P., Palmer, R. M., Kresevic, D. M.,… Landefeld, C. S.
(2007). The relationship of indwelling urinary
catheters to death, length of hospital stay, functional
decline, and nursing home admission in hospitalized
older medical patients. Journal of American Geriatrics
Society, 55(2), 227–233.
doi: 10.1111/i.1532-5415.2007.01064.x
Hooton, T. M., Bradley, S. F., Cardenas, D. D., Colgan,
R., Geerlings, S. E., Rice, J. G…Nicolle, L. E. (2010).
Diagnosis, prevention, and treatment of catheter-
associated urinary tract infections in adults: 2009
international clinical practice guidelines from the
Infectious Diseases Society of America. Clinical
Infectious Disease, 50(1), 625–663. doi: 10.1086/650482
Ihaka, R., ＆ Gentleman, R. (1996). R: a language for data
analysis and graphics. Journal of Computational and
Graphical Statistics, 5, 299–314.
doi: 10.1080/10618600.1996.10474713
Igawa, Y., Wyndaele, J. J., ＆ Nishizawa, O. (2008).
Catheterization: possible complications and their
prevention and treatment. International Journal of
Urology, 15(6), 481–485.
doi: 10.1111/j.1442-2042.2008.02075.x
Jansen, I. A. V., Hopmans, T. E. M., Wille, J. C., van
den Broek, P. J., van der Kooi, T. I. I., ＆ van
Benthem, B. H. B. (2012). Appropriate use of indwelling
urethra catheters in hospitalized patients: results of
a multicenter prevalence study. BMC Urology, 12(1), 12–
25. doi: 10.1186/1471-2490-12-25
Katz, S., Ford, A. B., ＆ Moskowitz, R. S. (1963). Studies
of illness in the aged. The index of ADL: a
standardized measure of biological and psychosocial
function. Journal of the American Medical Association,
185(12), 914–919. doi:10.1001/jama.1963.03060120024016
Kunin, C. M., Douthitt, S., Dancing, J., Anderson, J., ＆
Moeschberger, M. (1992). The association between the
use of urinary catheters and morbidity and mortality
among elderly patients in nursing homes. America
Journal of Epidemiology, 135(3), 291–301.
Lee, H. C. B., Chiu, H. F. K., Kwok, W. Y., Leung, C. M.,
Kwong, P. K., ＆ Chung, D. W. S. (1993). Chinese elderly
and the GDS short form: a preliminary study. Clinical
Gerontologist, 14(2), 37–42.
Leuck, A. M., Wright, D., Ellingson, L., Kraemer, L.,
Kuskowski, M. A., ＆ Johnson, J. R. (2012).
Complications of foley catheters-is infection the
greatest risk? Jornal of Urology, 187(5): 1662-1666.
doi: 10.1016/j.juro.2011.12.113
Leuck, A. M., Wright, D., Ellingson, L. A., Kraemer, L.,
Kuskowski, M. A., ＆ Johnson,
J. R. (2012). Complications of foley catheters: is
infection the greatest risk? The Journal of Urology,
187(5), 1662–1666. doi: 10.1016/j.juro.2011.12.113
Maki, D. G., ＆ Tambyah, P. A. (2001). Engineering out the
risk for infection with urinary catheters. Energing
Infectious Disease, 7(2), 342–347.
doi:10.3201/eid0702.700342
Meddings, J., ＆ Saint, S. (2011). Disrupting the life
cycle of the urinary catheter. Clinical Infection
Disease, 52(11), 1291–1293. doi: 10.1093/cid/cir195
Mezey, M.D., Rauckhorst, L. H., ＆ Stokes, S. A. (1993).
Health assessment of the older individual. New York:
Springer Publishing Company.
Nasr, A. (2010). State of the globe: catheterisations
continue to cultivate urinary infections. Journal of
Global Infectious Disease, 2(2), 81–82.
doi: 10.4103/0974-777X.62869
Nicolle, L. E. (2005). Catheter-related urinary tract
infection. Drugs Aging, 22(8), 627–639.
doi: 10.2165/00002512-200522080-00001
Nicolle, L. E. (2010). Catheter-acquired urinary tract
infection: the once and future guidelines. Infection
Control and Hospital Epidemiology, 31(4), 327-329.
doi: 10.1086/651092
Patton, J. P., Nash, D. B., ＆ Abrutyn, E. (1991). Urinary
tract infection: economic considerations. The Medical
Clinics North America, 75(2), 495–513.
Pfeiffer, E. (1975). A short portable mental status
questionnaire for the assessment of organic brain
deficit in elderly patients. Journal of the American
Geriatrics Society, 23(10), 433-441.
Raffaele, G., Bianco, A., Aiello, M., ＆ Pavia, M. (2008).
Appropriateness of use of indwelling urinary tract
catheters in hospitalized patients in Italy. Infection
Control and Hospital Epidemiology, 29 (3), 279–281.
doi:10.1086/528814
Rosenbaum, P. R., ＆ Rubin, D. B. (1983). The central role
of the propensity score in observational studies for
causal effects. Biometrika, 70(1), 41–55.
doi: 10.1093/biomet/70.1.41
Reijneveld, S. A., Spijker, J., ＆ Dijkshoorn, H. (2007).
Katz' ADL index assessed unctional performance of
Turkish, Moroccan, and Dutch elderly. Journal of
Clinical Epidemiology, 60(4), 382-388.
doi:10.1016/j.jclinepi.2006.02.022
Saint, S. (2000). Clinical and economic consequences of
nosocomial catheter-related
bacteriuria. American Journal of Infection Control, 28,
68–75.
Saint, S., Wiese, J., Amory, J. K., Bernstein, M. L.,
Patel, U. D., Zemencuk, J. K.,… Hofer, T. P. (2000).
Are physicians aware of which of their patients have
indwelling urinary catheters? American Journal of
Medicine, 109(6), 476–480.
doi: 10.1016/S0002-9343(00)00531-3
Saint, S., Lipsky, B. A., ＆ Goold, S. D. (2002).
Indwelling urinary catheters: a one-point
restraint? Annals of Internal Medicine, 137(2), 125–
126. doi: 10.7326/0003-4819-137-2-200207160-00012
Sheikh, J. I., ＆ Yesavage, J. A. (1986). Geriatric
depression scale (GDS): Recent evidence
and development of a shorter version. The Journal of
Aging and Mental Health, 5(1-2), 165-173.
doi:10.1300/J018v05n01_09
Tambyah, P. A., ＆ Maki, D. G. (2000). Catheter-associated
urinary tract infection is rarely symptomatic: a
prospective study of 1497 catheterized patients.
Journal of the American Medical Association Internal
Medicine, 160(5), 678–82.
doi:10.1001/archinte.160.5.678.
Tiwari, M. M., Charlton, M. E., Anderson, J. R., Hermsen,
E. D., ＆ Rupp, M. E. (2012). Inappropriate use of
urinary catheters: a prospective observational study.
American Journal of Infection Control, 40(1), 51–54.
doi: 10.1016/j.ajic.2011.03.032
Wald, H. L., Ma, A., Bratzler, D. W., ＆ Kramer, A. M.
(2008). Indwelling urinary catheter use in the
postoperative period: analysis of the national surgical
infection prevent project data. Journal of the American
Medical Association Surgery ,143(6), 551-557.
doi: 10.1001/archsurg.143.6.551
Warren, J. W. (1997). Catheter- associated urinary tract
infections. Infectious Disease Clinics North
America,11(3), 609–622.
Wong, E. S. (1983). Guideline for prevention of catheter-
associated urinary tract infections. American Journal
of Infection Control, 11(1), 28–36.
Wyman, A. (1987). What time of day should a uretheral
catheter be removed? Journal of the Royal Society of
Medicine, 80 (12), 755–756.