長期呼吸器使用者之壓瘡發生率、相關因子及預後研究

長期依賴呼吸器的病患(使用呼吸器≥42天)是醫院壓瘡事件的高風險群，如何預防病人產生壓瘡為護理人員的重要任務。然而，壓瘡的產生被認為較不會威脅到生命及預後，因此壓瘡在加護單位是最常被低估的問題之一。目前長期依賴呼吸器的重症病患之壓瘡危險因子相關文獻不足，而壓瘡對呼吸器患者預後的影響更是闕如，故本研究的目的旨在探討(1)呼吸器使用者的壓瘡發生率及長期趨勢；(2)探討呼吸器使用者發生壓瘡之內在及外在危險因子分布情形及其相關性；(3)探討呼吸器使用者之人口學特質、疾病特性、對預後之影響；(4)分析呼吸器使用者不良後果之危險因子。本研究設計以回溯式世代追蹤研究法，以「衛生福利部健康加值應用協作中心」之全民健康保險資料2000年至2013年之兩百萬人承保抽樣歸人檔進行資料分析，篩選出20歲以上曾在呼吸照護中心或呼吸照護病房住院之呼吸器使用者進行研究；研究數據以SAS 9.4進行資料分析並以描述性分析、獨立樣本t檢定、卡方檢定進行單變項分析、再以邏輯斯迴歸、多元線性迴歸進行多變項分析預測相關因子。本研究重要結果如下，全國抽樣檔中，符合健康保險給付之呼吸器使用者佔8,278人，19.5%在使用呼吸器之後曾發生一處以上的壓瘡，須接受治療。2003-2004年兩年長期呼吸器使用者為1177人為研究世代，這些長期呼吸器使用者之壓瘡發生率0.57‰，6年內死亡率為89.55%，平均住院天數大於6個月者佔21.41%；壓瘡之盛行率為15.38%，其中在呼吸照護中心之壓瘡盛行率為15.6%，住在呼吸照護病房的使用者之壓瘡盛行率為16.29%，2001年至2012年之壓瘡發生密度未有減少之趨勢。長期呼吸器使用者之腦血管疾病與壓瘡發生有顯著相關，在多變項分析中，長期呼吸器使用者發生壓瘡之預測因子包含腦血管疾病(AOR:1.78，95 CI: 1.25-2.53)、營養不良(AOR:1.91，95 CI: 1.07-3.41)。發生壓瘡之長期呼吸器使用者的預後較差、死亡率較沒有壓瘡者高，在多變項分析結果顯示，有壓瘡者死亡勝算比是沒有壓瘡者的2.51倍(95 ％CI:1.19-5.30)。本研究結果有助於確立長期呼吸器使用者的壓瘡之危險因子及預後，壓瘡者的死亡風險較無壓瘡者高，且需耗費更多的醫療資源和疾病負擔，尤其是患有腦血管疾病和營養不良者是發生壓瘡的高危險群。臨床醫療人員在照護長期依賴呼吸器病患時應盡可能讓病患免於壓瘡風險之情境，在維持重症病患生命的同時，也需重視壓瘡問題，進而減少可避免的死亡。

關鍵字

呼吸器使用者；壓瘡；預後；壓瘡發生率；死亡率

並列摘要

Patients who are dependent on mechanical ventilation (MV) in the long-term (receiving mechanical ventilation ≥42 day) are at high risk of developing pressure ulcers (PU). Prevention of PU in these patients has become a major priority in nursing. PU are one of the most underrated problems in the intensive care unit (ICU), because they are not considered a life-threatening disease. Health professionals also tend to pay little attention to PU prevention in patients at risk. Several risk factors related to PU have been proposed, but definitive factors remain inconclusive within the international community. Few studies have investigated the effect of PU on the prognosis of mechanical ventilation users. Aim: The study purposes were (1) to investigate the incidence and trends of PU; (2) to identify internal and external factors related to PU in MV patients; (3) to explore the characteristics of patients who receive long-term MV and their prognosis; (4) to analysis the prognostic factors of PU in patients receiving long-term mechanical ventilation. Methods: A fixed-cohort retrospective study was designed, which used data of national health insurance enrollees from the Taiwan National Health Insurance Research Database. We obtained data for patients aged ≥20 years who had been admitted to a respiratory care center (RCC) or respiratory care ward (RCW) and received long-term mechanical ventilation during 2003–2004. Data were analyzed by descriptive statistics, independent-sample t-tests, the Chi-square test, and multiple regression analysis using SAS 9.4 software. Results: According to claims data obtained from the two million people sampled, 8,278 patients every year who were resident in ICUs, RCCs or RCWs were mechanical ventilation users, of whom 19.5% developed at least one pressure ulcer that required treatment. In total, 1177 patients received long-term mechanical ventilation from 2003 to 2004, with an incidence of 0.57 per 1,000. Mortality at 6 years was 89.55%. 21.41% of patients had an average length of stay of more than 6 months. (2) The prevalence of patients who received long-term mechanical ventilation was 15.38%; that of patients who had been admitted to an RCC or an RCW was 15.6% and 16.29%, respectively. A downward trend in the PU incidence density was not observed between 2001 and 2012. (3) There was a significant difference in the incidence of cerebrovascular disease between subjects with and without PU. Multivariate analysis identified cerebrovascular disease, malnutrition as significant predictors of PU. (4) Development of PU is an indicator of a poor prognosis (mortality). In multivariate analysis, cerebrovascular disease and malnutrition were found to be strongly related to the occurrence of PU. After adjustment for comorbidities, patients with a previous CVA diagnosis had a higher risk of developing PU (AOR: 1.78, 95%CI 1.24-2.53); the adjusted odds ratio of malnutrition was 1.91-fold (95%CI: 1.07-3.41) as compared with MV patients without a diagnosis of malnutrition. PU are also associated with a 2.51-fold (95% CI: 1.19–5.30) risk of death as compared with MV patients without PU. Conclusions:This study demonstrated that PU affected patients' prognosis and mortality and led to higher medical utilization and a greater disease burden. We identified co-existing CVA disease and malnutrition as being strongly related to the development of PU among MV patients. Clinicians and nurses caring for these patients should avoid development of these risks related to PU, which are in turn a risk factor for a poor prognosis and mortality.