第五章 結論與建議
第三節 研究限制
研究者從題目擬定、文獻資料收集、研究設計、資料收集至資料分析與 結論撰寫過程中,發現有以下三項限制:
一、基本資料收集之限制
由於榮院護家院內感染收案流程及基本資料表未統一,資訊系統未建置 完全,所以研究變項資料取得不易而影響研究設計,例如:無法查到住民住 院中不同時間的 ADLs 指數;各榮院護家對菌株所做的化學藥劑敏感性測試 不同,以致於本研究無法完整呈現菌株抗藥性情形。
二、醫療資源耗用情形外推性之限制
研究設計因無法排除醫療資源耗用情形與健保支付制度下,每家醫院的 因應方案不同,及每位醫師對健保支付制度下所受的影響程度,難度較高,
也難以量化。
三、研究資源之限制
文獻指出長照機構院內感染肺炎老人的臨床症狀是非典型的,如不發燒 或很少痰(李聰明,1994)。另葉宏明(2000 )也指出老人病毒性肺炎包含有流行 性及副流行性感冒病毒、呼吸道融合性病毒及腺病毒。然而在本研究結果中 發現並無病毒性的流行性感冒收案件數,因為CDC 院內感染收案定義以檢驗 證據為主,而一般流行性感冒並不會特地培養病毒的,若想取得相關的研究 數據,恐將有特定的研究經費支持,方能了解台灣長照機構院內病毒性呼吸 道感染的盛行率及感染密度。
參考文獻
(Bibliographies)
英文部分
Arun, S. & Bradley, S.F.(2003). Clostridium difficile in Older Adults and Residents of Long-Term Care Facilities. Annals of Long-Term Care,11 : 43-7.
Centers for Disease Control and Prevention.(1992). Public health focus: surveillance, prevention, and control of nosocomial infections. MMWR, 41:783.
Centers for Disease Control and Prevention.(1996). Prevention and control of influenza-recommenddations of the Advisory Committee on Immunization Practices. MMWR, 45: 1-24.
Centers for Disease Control and Prevention.(2002). Staphylococcus aureus resistant to vancomycin – United States, 2002. MMWR , 51: 565-7.
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. J Chronic Dis, 40: 373-83.
Cross, J.T., Jr. & Campbell, G.D., Jr.(1999). Drug-resistant pathogens in community- and hospital-acquired pneumonia. Clin Chest Med, 20: 499-506.
Edmond, M.B., Wallace, S.E. & McClish, D.K.(1999). Nosocomial bloodstream infections in united states hospitals: a three-year analysis. Clin Infect
Dis,29:239-240.
Friedman, C., Baker, C.A., Mowry-Hanley, J.L., Hyde, K.V., Stites, M.S. & Hanson, R.J.(1993). Use of the total quality process in an infection control program: a
Garner, J.S., Jarvis, W.R., Emori, T.G., Horan, T.C. & Hughes, J.M.(1988). CDC definitions for nosocomial infections. AJIC, 16:128-140.
Girou, E., Stephan, F., Novara , A.N.A., Safar, M.& Fagon, J.Y. (1998). Infections Results of a Matched Case-control Study of ICU Patients. Am. J. Respir. Crit.
Care Med., 157(4):1151-1158.
Golden, G.S.(1979). The Alice in Wonderland Syndrome in Juvenile Migraine.
Pediatrics, 63:517-519.
Goldrick, B.A.(1999). Infection control programs in skilled nursing long-term care facilities: An assessment, 1995. AJIC, 27(1):4-9.
Gross, P.A., Hermogenes, A.W., Sacks, H.S., et al.(1995). The efficacy of influenza vaccine in elderly persons-a meta-analysis and review of the literature. Ann Intern
Med,123:518-27.
Harkness, G.A., Bentley, D.W. & Mottley, M., et al.(1992). Streptococcus pyogenes outbreak in a long-term care facility. Am J Infect Cont, 20:142-148.
Herwaldt, L.A.(1999). Control of methicillin-resistant Staphylococcus aureus in the hospital setting. Am J Med, 106:12S.
Ho, M., McDonald, L.C., Lauderdale, T.L., Yeh, L.L., Chen, P.C., & Shiau, Y.R.(1999).
Surveillance of antibiotic resistance in Taiwan, 1998. Journal of Microbiology
Immunology & Infection,2:239- 249.
Jasny, B.R & Floom, F.E.(1998). It's not rocket science—but it can save lives [editorial]. Science, 280:1507.
Kauffman, C.A., Hedderwick, S.A &Bradley, S.F.(1999). Antibiotic resistance: Issues
in long-term care. Infections in Medicine, 16:122-128.
Kunin, C.M.(1997). Care of the urinary catheter. In: Urinary Tract Infections:
Detection, Prevention and Management. Baltimore, Md:
Williams & Wilkins,
5:227-79.Lee, Y.L., Cesario, T., Tran, C., Stone, G & Thrupp, L.(2000). Nasal colonization by methicillin-resistant coagulase-negative Staphylococcus in community skilled nursing facility patients. AJIC , 28(3):269-72.
Loeb, M., McGeer, A., McArthur, M., Peeling, R.W., Petric, M.& Simor, A.E.(2000) Surveillance for outbreaks of respiratory tract infections in nursing homes. CMAJ, 162(8):1133-7.
Makris, A.T., Morgan, L., Gaber, D.J., Richter, A.& Rubino, J.R.(2000). Effect of a comprehensive infection control program on the incidence of infections in long-term care facilities. AJIC, 28 (1): 3-7.
Marshall, L.L., Jolley, M.R.& Elwell, D.S.(1999) Evaluation of Antibiotic Usage in a Long-Term Care Facility. Consult Pharm ,9:982-996.
McGeer, A., Campbell, B., Emori, T.G., Hierholzer, W.J., Jackson, M.M.& Nicolle, L.E., et al.(1991). Definitions of infection for surveillance in long-term care facilities. AJIC, 19:1-7.
Meehan, T.P., Chua-Reyes, J.M., Tate, J., Prestwood, K.M., Scinto, J.D., Petrillo,
M.K.& Metersky, L.(2000).Process of Care Performance, Patient Characteristics, and Outcomes in Elderly Patients Hospitalized With Community-Acquired or Nursing Home-Acquired Pneumonia. CHEST, 117:1378-1385.
Muder, R.R., Brennen, C., Swenson, D.L.& Wagener, M.(1996). Pneumonia in a
long-term care facility. A prospective study of outcome. Arch Intern Med, 156(20):2365-2370.
Muder R.(1998). Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention. Am J Med, 105(4):319-330.
Mylotte, J.M.(1999). Antimicrobial prescribing in long-term care facilities:
Prospective evaluation of potential antimicrobial use and cost indicators. AJIC, 27(1):10-9.
Nicolle, L.E., Bentley, D., Garibaldi, R., Neuhaus, E., Smith, P.(1996). SHEA
Long-Term Care Committee. Antimicrobial use in long-term-care facilities. Infect
Control Hosp Epidemiol,17:119-28.
Nicolle, L.E.(1993). Urinary tract infections in long-term care facilities. Infect Control
Hosp Epidemiol, 14: 220-225.
Oxman,M.N.(1995) Immunization to reduce the frequency and severity of herpes zoster and its complications. Neurol , 45:41-45.
Patient Safety in American Hospitals, Health Grades 2004.
Perl TM. The threat of vancomycin resistance. Am J Med. 1999; 106: 28S, 32S.
Richards, C., Emori, G., Edwards, J., Fridkin, S., Tolson, J. & Gaynes, R.(1999).
Characteristics of hospitals and infection control professionals participating in the National Nosocomial Infections Surveillance System. AJIC, 29(6):400-403.
Sedor, J. & Mulholland, S.G.(1999). Hospital-acquired urinary tract infections associated with the indwelling catheter. Urol Clin North Am,26:821.
Smith, P.W., Black, J.M. & Black, S.B.(1999). Infected pressure ulcers in the long-term care. Infect Control Hosp Epidemiol, 20:358-361.
Smith, P.W.& Rusnak, P.G..(1997). Infection prevention and control in the long-term-care facility. AJIC, 25(6):488-512.
Smith PW, Seip CW, Schaefer SC, Bell-Dixon C. Microbiologic survey of long-term care facilities. AJIC 2000; 28(1): 8-13.
Standfast, S.J., Michelsen, P.B.& Baltch, A.L(1984). A prevalence survey of
infections in a combined acute and long-term care hospital. Infect Control ,5(4):
177-184.
Starfield.(2000). Death and mortality statistics for Nosocomial infection. JAMA, 284(4):483-5
Steed, C.J.(1999). Common infections acquired in the hospital: the nurse's role in prevention. Nurs Clin North Am, 34:443.
Steinmiller, A.M., Robb, S.S., Muder, R.R.(1991). Prevalence of nosocomial infection in long-term-careVeterans Administration medical centers. AJIC, 19:143-146.
Stevenson, K.B.(1999). Regional data set of infection rates for long-term care facilities: Description of a valuable benchmarking tool. AJIC, 27(1):20-26.
Strausbaugh, L.J.(1999). Infection control in long-term care:New from the front.
AJIC, 27(1):1-3.
Strausbaugh, L.J. & Joseph, C.L.(2000). The burden of infection in long-term care.
Infect Control Hosp Epidemiol, 21(10):674-679.
Tambyah, P.A. & Maki, D.G..(2000). Catheter-Associated Urinary Tract Infection Is Rarely Symptomatic: A Prospective Study of 1497 Catheterized Patients. Archives of Internal Med ,160(5):678-682.
Thompson, R.S., Hall, N.K., Szpiech, M.(1999). Hospitalization and Mortality Rates for Nursing Home -Acquired Pneumonia. J Family Practice, 48(4): 291-293.
Yoshikawa, T.T., Nicolle, L.E., Norman, D.C.(1996). Management of complicated urinary tract infection in older patients. J Am Geriatr Soc, 44:1235-1241.
中文部分
內政部(1994)。中華民國內政部社會司 93 年社政年報-老人福利與政策。台北:
內政部。
行政院主計處(1996)。中華民國台灣地區老人健康狀況調查報告。台北:行政會
主計處。
退輔會(2006)。行政院國軍退除役官兵輔導委員會
95
年1
月統計資料。台北:行政院退輔會。
李聰明(1994)。護理之家老人的院內感染性肺炎。感控雜誌,4:202-204。
林依亭、陳亮恭、黃信彰(2005)。機構住民的泌尿道感染。基層醫學,20(12):
328-332。
張上淳﹙2001﹚。醫學中心及區域醫院清潔手術預防性抗生素使用之分析。感控雜誌
2001; 11: 341- 54。
張上淳﹙2003﹚。台灣近年來抗生素使用改善措施及其影響。感控雜誌,13:33-42。
張上淳、謝維銓(1996)。目前台灣地區抗藥性菌株流行概況。中華感染醫誌,7:
83-88。
黃高彬、黃樹樺、曾糸秀婷、白秀華(2005)。發生在社區之 Methicillin 抗藥性金 黃色葡萄球菌菌血症之流行病學分析。感控雜誌,15:352-364.
許清曉、王立信、王任賢、楊祖光(2001)。臺灣住院病患抗生素使用適當性及相 關問題的調查結果。感控雜誌,11:273-288。
許智強、蔡明芳、鍾瑞容(2005)。機構式照護的老年人肺炎。基層醫學,20(4):
100-103。
陳長安(1997)。第一篇 化學治療劑。常用藥物治療手冊,全國藥品年鑑雜誌社,9-185。
葉宏明(2000)。護理之家的院內感染性肺炎。長期照護雜誌,4(1):31-34。
葉宏明、蔡季君(2000)。護理之家的院內感染管制。院內感染控制雜誌,10(5):
338-341。
葉宏明、蔡季君(2002)。長期照護機構的抗生素抗藥性問題。院內感染控制雜誌,
12(6):382-384。
臧麗琳(1998)。台灣地區護理之家院內感染管制現況及相關危險因子探討,國防
醫學院護理研究所未發表碩士論文。
網頁部分
李至恭(2005)。院內感染及社區感染菌種分布性的差異。感染控制雜誌,第 15 卷第 4 期電子期刊。2006 年 11 月 1 日。網址:
http://www.nics.org.tw/magazine/15/04/15-4-6.htm.
許清曉(2005)。抗生素的使用如何管制。感控雜誌第 15 卷第 2 期電子期刊。2006 年 11 月 1 日。網址:http://www.nics.org.tw/magazine/15/02/15-2-2.htm.
新華網(2006)。就醫指南-“預後是啥意思”。2007 年 3 月 26 日。網址:
http://big5.xinhuanet.com/gate/big5/news.xinhuanet.com/health/2006-07/26/content_
4878955.htm.
張上淳、陳宜君、賴美淑、張鴻仁(2006)。台灣住院病人 2000─2004 年抗生素使用 之情形。第16 卷第 4 期電子期刊。搜尋日期:2006 年 11 月 1 日。網址:
http://www.nics.org.tw/magazine/16/04/16-4-1.htm
顏慕庸 (2006)。後煞時期對於院內感染與醫院評鑑之醒思。搜尋日期:2006 年 11 月 1 日。網址:http://std.health.gov.tw/td/UploadFiles/200671154718628.pdf.
lideki Koketsu, Yasuharu Yokuda & Gerald H.Stein.(2003), Risk factors for mortality from infectious diseases among elderly from Long-Term Care Facilities. The Internet Journal of Infectious Diseases,Vol. 2 No.2.. Search Day:2006/01/24. Web Set:
http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijid/front.xm
eMedicine. Klebsiella Infections. April 27, 2006。Search Day:2006/01/24. Web Set:
http://www.emedicine.com/med/topic1237.htm.
LookSmart (2006) Almeida ,Reqina Capanema. Nosocomial infection in long-term care facilities. 1999; A survey in a Brazilian psychiatric hospital. Search Day:2006/02/08 . Web Set:http://findarticles.com/p/articles/mi_qa3855/is_199911/ai_n8874183.
PowerPak C.E. Nosocomial Infections: A Multidisplinary Approach to Management.2005.
Search Day:2006/02/08. Web Set:
http://www.powerpak.com/index.asp?show=lesson&1sn_id=2826&page=courses/282 6/lesson.htm.
Terry Leiker (2006).Cephalosporins. Search Day:2006/02/08 . Web Set:
http://www.fhsu.edu/nursing/otitis/cephalosporins.html
Wikipedia (2006 ). Prognosis. Search Day:2006/02/08 . Web Set:http://enwikipedia.org/wiki/Prognosis.
Wikipedia (2006 )。抗生素。Search Day:2007/06/04 . Web Set:
http://zh.wikipedia.org/w/index.php?title=%E6%8A%97%E7%94%9F%E7%B4%A0
&variant=zh-tw#_note-0
WrongDiagnosis(2006). Diagnosis. Search Day:2006/02/08 .Web Set:
http://www.wrongdiagnosis.com/n/nosocomial_infections/intro.htm.
附錄一 2005 年榮院護家調查表(A B C)
醫 院 資 料
層級別: 1.地區醫院 2.區域醫院 教學醫院資格: 1.是 2.否
健保床位數: 床 護理之家床位數: 床 護家榮患收住情形:年入住人日 佔床率 %
住民平均年齡 歲
感 控 人 力
專任感染科醫師: 1.是 2.否 位 兼任感染科醫師: 1.是 2.否 位 專任感控護理師: 1.是 2.否 位 兼任感控護理師: 1.是 2.否 位
感 控 作 業
收案方式及狀況描述:
附錄二 榮院護家住民感染病例調查表
附錄三
ID:
CULTURE 結果及抗藥性情形資料表
採 集 日 期
檢 體 種 類
菌 株