臺灣博碩士論文加值系統

背景：減少住院病人跌倒及因跌倒導致的傷害，不但是醫院照護品質的重要指標之一，也是健康照護者的重要挑戰。
研究目的：本研究目的為修訂住院病人實證跌倒預防照護方案，並建置跌倒預防護理決策輔助系統及易致跌倒藥物提示系統，以促進實證知識轉譯，並評估其成效。
研究方法：本研究採用Graham等人(2006) 提出「知識至行動的概念架構」(knowledge-to-action conceptual framework) 進行之知識轉譯研究 (knowledge translation research)。研究包括兩階段，分別為：(1) 知識創造 (knowledge creation) 階段：以系統性文獻回顧找出臨床實踐的最佳作法 (systematic review of fall prevention guidelines)，探索知識與臨床照護之間的差異，修訂住院病人實證跌倒預防照護方案。(2) 行動循環-應用 (the action cycle - application) 階段：採單機構、介入措施(intervention)、前後測研究 (before-after study) 設計，評估知識轉譯之成效。研究期間為2015年1至12月。結果指標包括：住院病人跌倒發生率、因跌倒致中度 (含) 以上傷害率，及健康照護者執行病人跌倒防範措施的完整率。主要統計方式包括：卜瓦松迴歸模型 (poisson regression model) 及獨立樣本t檢定等，p < .05 為統計上顯著差異。
結果：介入措施後，跌倒事件發生率明顯降至0.07% (β ̂= -0.37, p = .02)，但跌倒致中度(含)以上傷害率無顯著改善 (β ̂= 0.25, p = .64)。此外，健康照護者執行病人跌倒防範措施完整率明顯提升至95.0% (mean difference = -8.52, 95% CI -10.29~ -6.75, t = -9.48, p < .001)。
結論：運用知識轉譯架構及資訊策略能有效降低住院病人跌倒發生率，並可提升健康照護者執行病人跌倒防範措施的完整率。然而，此處置並不會改善因跌倒所致之傷害。後續的研究值得進一步探討更有效的策略。

Background: Reducing falls and associated injuries is one of the imperative quality indicators in hospital. It is also an important challenge for health professionals.
Aims: The aims of this study were to revise the falls prevention guidelines for inpatients, as well as to establish "fall prevention nursing decision aids" and "prone to fall medication reminder system" to promote knowledge translation.
Methods: This is a knowledge translation research which based on "knowledge-to-action conceptual framework" (Graham et al., 2006). There are two stages including: (1) Knowledge creation: Fall prevention guidelines were reviewed systematically to explore the gap between best evidence and clinical practice. Moreover, the inpatients' falls prevention guideline of the target hospital was revised. (2) The action cycle: A single center, intervention, before-after study design was conducted in a medical center between Jan. 2015 and Dec. 2015. The main outcomes were falls rate (%), fall-related injuries (%), and compliance rate of fall prevention guidelines among health professionals. The main statistical methods were Poisson regression model and independent t-test. All reported p < .05 is considered statistically significant.
Results: After the intervention, the falls rate were significantly reduced to 0.07% (β ̂= -0.37, p = .02), but the fall-related injuries were not improved (β ̂= 0.25, p = .64). In addition, the compliance rate of fall prevention guidelines among health professionals was significantly improved up to 95.0% (mean difference = -8.52, 95% CI -10.29~ -6.75, t = -9.48, p < .001).
Conclusions: The use of the "knowledge-to-action conceptual framework" and information strategies in study hospital significantly reduced the falls rate, and increased the compliance rate of fall prevention guideline among health professionals. However, the fall-related injuries were not improved. Further researches are needed on the fall prevention strategies.

指導教授推薦書
口試委員會審定書
致謝 …………………………………………………………………… iii
中文摘要 …………………………………………………………………… v
英文摘要 …………………………………………………………………… vii
目錄 …………………………………………………………………… ix
圖目錄 …………………………………………………………………… xiii
表目錄 …………………………………………………………………… xv
第一章 緒論 …………………………………………………………………… 1
第一節 研究動機及重要性 …………………………………………………………………… 1
第二節 研究目的 …………………………………………………………………… 3
第二章 文獻查證 …………………………………………………………………… 5
第一節 住院病人跌倒之概述 …………………………………………………………………… 5
一、跌倒的定義、發生率及其對照護品質的衝擊 …………………………………………………………………… 5
二、跌倒預防策略的系統性文獻回顧、及實證防跌指引 …………………………………………………………………… 6
三、知識缺口 (knowledge gap) …………………………………………………………………… 8
第二節 實證知識轉譯的概念架構、障礙及促進策略 …………………………………………………………………… 11
一、知識轉譯的概念架構 …………………………………………………………………… 11
二、知識轉譯的障礙及促進策略 …………………………………………………………………… 13
第三章 研究方法 …………………………………………………………………… 16
第一節 研究設計 …………………………………………………………………… 16
第二節 研究架構 …………………………………………………………………… 17
第三節 研究假說 …………………………………………………………………… 21
第四節 研究步驟 …………………………………………………………………… 22
第一階段：知識創造 …………………………………………………………………… 22
一、知識查詢 …………………………………………………………………… 23
二、知識合成 …………………………………………………………………… 25
三、知識工具 …………………………………………………………………… 29
第二階段：行動循環 - 應用-研究步驟 …………………………………………………………………… 30
一、找出知識與行動的差異 …………………………………………………………………… 30
二、轉化知識到當地環境 …………………………………………………………………… 30
三、評估應用知識時的阻力或助力 …………………………………………………………………… 31
四、選擇、修正、實施介入方式 …………………………………………………………………… 36
五、監督知識應用 …………………………………………………………………… 37
六、評估結果 …………………………………………………………………… 37
七、持續應用知識 …………………………………………………………………… 41
第四節 資料分析方法 …………………………………………………………………… 42
第五節 倫理考量 …………………………………………………………………… 47
第四章 研究結果 …………………………………………………………………… 48
第一階段：知識創造 …………………………………………………………………… 48
一、知識查詢 …………………………………………………………………… 48
二、知識合成 …………………………………………………………………… 52
三、知識工具 …………………………………………………………………… 84
第二階段：行動循環 - 應用-研究步驟 …………………………………………………………………… 87
一、找出知識與行動的差異 …………………………………………………………………… 87
二、轉化知識到當地環境 …………………………………………………………………… 96
三、評估應用知識時的阻力或助力 …………………………………………………………………… 101
四、選擇、修正、實施介入方式 …………………………………………………………………… 120
五、監督知識應用 …………………………………………………………………… 134
六、評值結果 …………………………………………………………………… 136
七、持續應用知識 …………………………………………………………………… 145
第五章 討論 …………………………………………………………………… 146
第一節 知識轉譯架構的臨床適用性 …………………………………………………………………… 146
第二節 知識轉譯架構對降低病人跌倒之成效探討 …………………………………………………………………… 154
第三節 資訊策略對促進知識轉譯的成效 …………………………………………………………………… 160
第六章 結論與建議 …………………………………………………………………… 162
第一節 結論 …………………………………………………………………… 162
第二節 護理與臨床應用 …………………………………………………………………… 163
第三節 研究限制及對後續研究的建議 …………………………………………………………………… 164
參考文獻 …………………………………………………………………… 168 

附錄目錄
附錄一 「運用研究於臨床作業之障礙及促成因子」問卷 (BARRIERS Scale) 原作者授權翻譯及同意使用證明 ……190
附錄二 各資料庫文獻搜尋歷程 …………………………………………………………………… 192
 
圖目錄
圖2-1 促進知識為照護行動概念架構 (knowledge-to-action conceptual framework) ……………………………… 13
圖3-1 研究架構：知識至行動的概念架構 …………………………………………………………………… 17
圖3-2 跌倒事件通報資料驗證程序 …………………………………………………………………… 40
圖4-1 文獻搜尋及納入/排除歷程流程圖 …………………………………………………………………… 49
圖4-2 本研究納入8篇指引建議之住院病人跌倒管理流程圖 …………………………………………………………………… 86
圖4-3 住院病人跌倒事件發生率(2010-2014年趨勢圖)…………………………………………………………………… 88
圖4-4 住院病人跌倒事件發生率(2010-2014年管制圖)…………………………………………………………………… 88
圖4-5 住院病人因跌倒所致中度 (含) 以上之傷害率 (2011-2014年趨勢)…………………………………………………………………… 89
圖4-6 住院病人因跌倒所致中度 (含) 以上之傷害率 (2011-2014年管制圖)…………………………………………………………………… 90
圖4-7 住院病人跌倒管理流程圖 (原有流程)…………………………………………………………………… 95
圖4-8 住院病人跌倒管理流程圖 (依實證指引建議修正後)…………………………………………………………………… 99
圖4-9 摩爾斯跌倒量表 (初始評估) (護理資訊系統畫面)…………………………………………………………………… 122
圖4-10 摩爾斯跌倒量表(由每日評估自動轉拋摩爾斯跌倒量表評分總表) (護理資訊系統畫面)…………………………………… 123
圖4-11 摩爾斯跌倒量表風險評估項目及其對應之實證跌倒預防措施(護理資訊系統畫面)………………………………………………… 124
圖4-12 護理診斷：「潛在危險性跌倒」之危險因子、護理目標及照護措施 (護理資訊系統畫面)………………………………… 125
圖4-13 跌倒後立即評估片語 (護理資訊系統畫面)…………………………………………………………………… 126
圖4-14 易致跌藥品衛教模組 (護理資訊系統畫面)…………………………………………………………………… 128
圖4-15 易致跌倒藥物註記 (給藥系統畫面)…………………………………………………………………… 131
圖4-16 易致跌倒藥物風險分級 ≥ 6分之「跌 (藥)」註記 (護理資訊系統畫面)…………………………………………………………………… 132
圖4-17 易致跌倒藥物風險分級自動計分功能 (醫療資訊系統畫面)…………………………………………………………………… 134
圖4-18 住院病歷跌倒預防措施落實度審查結果直條圖 …………………………………………………………………… 136
圖4-19 住院病人跌倒事件發生率趨勢圖及管制圖 …………………………………………………………………… 137
圖4-20 住院病人因跌倒所致中度 (含) 以上傷害率趨勢圖及管制圖 …………………………………………………………………… 140
 
表目錄
表3-1 文獻搜尋之關鍵字及策略 …………………………………………………………………… 24
表3-2 AGREE II (Appraisal of Guidelines for Research and Evaluation II) 工具評估領域及說明 …………………………………………………………………… 26
表3-3 AGREE II標準化領域分數計算方式說明：以四位評讀者針對「領域一」之標準化領域分數計算為例 ……………… 27
表3-4 評估應用知識時的阻力或助力：研究對象、估計樣本數及取樣/排除條件 …………………………………………………………………… 31
表3-5 用研究於臨床作業之障礙及促成因子問卷(BARRIERS Scale) 信度 …………………………………………………………………… 34
表3-6 資料分析方法一覽表 …………………………………………………………………… 46
表4-1 本研究納入實證跌倒預防指引之特徵 …………………………………………………………………… 51
表4-2 本研究納入8篇指引之AGREE II各領域標準化計分 …………………………………………………………………… 54
表4-3 本研究納入8篇指引之AGREE II各子題計分 …………………………………………………………………… 55
表4-4 本研究納入8篇指引之標的族群、場所、重要結果指標及指引發展方法學 …………………………………………………………… 60
表4-5 本研究納入8篇指引之跌倒風險評估 …………………………………………………………………… 66
表4-6 本研究納入8篇指引之易致跌倒藥品分析 …………………………………………………………………… 71
表4-7 本研究納入8篇指引之實證跌倒預防措施 …………………………………………………………………… 73
表4-8 床欄使用風險矩陣工具 …………………………………………………………………… 75
表4-9 本研究納入8篇指引之環境調整措施 …………………………………………………………………… 81
表4-10 本研究納入8篇指引之跌倒後照護措施 …………………………………………………………………… 83
表4-11 病人跌倒防範完整率：內部及外部稽核結果 …………………………………………………………………… 93
表4-12 摩爾斯跌倒量表之跌倒風險評估項目、及可選擇的實證跌倒預防措施對照表 ………………………………………………… 100
表4-13 研究對象：護理人員基本屬性 …………………………………………………………………… 101
表4-14 運用研究於臨床作業之障礙及促成因子問卷分析結果 …………………………………………………………………… 103
表4-15 研究對象：醫師及醫事人員基本屬性 …………………………………………………………………… 107
表4-16 易致跌倒藥物風險分級表 …………………………………………………………………… 130
表4-17 介入措施實施前後跌倒預防措施落實度住院病歷審查結果表…………………………………………………………………… 135
表4-18 介入措施實施後跌倒案件分析表 …………………………………………………………………… 138
表4-19 介入措施實施後跌倒致中度 (含) 以上傷害案件分析 …………………………………………………………………… 142
表4-20 介入措施實施前後病人跌倒防範措施執行完整率比較表 …………………………………………………………………… 144

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