高感染風險經皮穿刺傷後對醫療人員生理與心理之影響

Physical and psychological impacts from high infection risk percutaneous injuries on healthcare workers

吳雪菁(Hsueh-Ching Wu)

指導教授 ： 蕭淑銖

國立臺灣大學/醫學院/護理學研究所/博士(2015年)

https://doi.org/10.6342/NTU.2015.02934

摘要

研究背景
經皮穿刺傷是醫療人員最常見的職業傷害，尤其是病人源為陽性可經血液傳播性病原體之高感染風險經皮穿刺傷，其威脅包括被感染的機率、陽轉的風險、預防性投藥所帶來的身體作用、甚至可能死亡的威脅，更可能有心理上的傷害及對工作環境的不安全感等，皆會造成醫療人員及醫療職場重要的衝擊。
目的
本研究包含三個部分，第一部分為推估國內經皮穿刺傷的發生率，提供對醫療人員經皮穿刺傷更深入了解發生的趨勢，並可作為在全面提供安全針具前的基線資料；第二部分為進一步分析各職類醫療人員高感染風險經皮穿刺傷之流行病學，並推估可能陽轉的風險；第三部分即針對曾發生高感染風險經皮穿刺傷的醫療人員進行質性訪談，深入了解其對高感染風險經皮穿刺傷的心理影響與衝擊，以提供醫療執業環境更精確的參考與建議。
方法
第一、二部份研究皆是採用回溯性次級資料分析，利用醫療人員安全衛生中心之「中文版EPINet針扎通報系統」中之通報資料庫取得經皮穿刺傷通報及其追蹤資料，運用統計軟體JMP 及SAS進行分析與推估。第三部分研究質性研究法，以深度訪談、立意取樣方式收案，並採用質性內容分析法及嚴謹度考量。
結果
第一部分研究結果顯示以醫院病床數、全職醫療人員數、及住院日數推估全國醫療人員經皮穿刺傷之發生次數在6,710到8,319次間；仍與2004年的資料相近，但在醫師的通報次數及HIV的高感染風險經皮穿刺傷有增加的趨勢。
第二部分研究結果顯示，發生高感染風險經皮穿刺傷的地點中，醫師以「產房」、「檢查室」、「開刀房」較高；護理人員以「血液透析室」、「加護病房」、「病房」較高；醫療技術人員在「加護病房」、「抽血中心」較易發生；而支援人員則以「病房」發生的比例最高。另在2012年的通報資料中，所有醫療人員任一陽性高感染風險經皮穿刺傷發生率為0.87件/100位全職醫療人員，並推估每年可能因高感染風險經皮穿刺傷而感染HBV的醫療人員有52~133人、HCV者41~82人、HIV為<1~5人。
第三部分針對經歷高感染風險經皮穿刺傷之醫療人員的心理影響之質性研究結果，共歸納出五大主題，分別為情緒困擾、對疾病威脅的感受、缺乏心理支持、改變職業熱忱及正向調適。
結論與建議
本研究建議醫療職場應:依已辨識出之高感染風險經皮穿刺傷的發生地點與情境提供不同職類醫療人員進行防治教育訓練及提供相關防護措施；設立經皮穿刺傷單一通報窗口及標準化處理步驟；針對當事者提供最新知識、維護其權益，如工傷假的申請與心理諮商輔導轉介等。同時亦建議主管機關能善盡監督與稽核之責包括:針扎是否確實通報及安全針具之替代率是否依法規要求；此外，未來亦可針對安全針具使用是否可減少經皮穿刺傷發生而降低經濟耗損進行成本效益分析，以做為政策制定之依據。

關鍵字

經皮穿刺傷 ； 高感染風險 ； 針扎通報系統 ； 陽轉 ； 心理影響

並列摘要

Background
Percutaneous injury (PI) is the most common occupational hazard for healthcare workers (HCWs), especially the high infection risk PI from source patients who are positive blood-borne pathogens (BBP). These include risk of infection and seroconversion, impacts to physical health due to post-exposure prophylaxis and even threat of death. Even more crucial are feeling psychological harm and unsafe working environment. All of these risks have great impacts to HCWs and healthcare settings.
Objectives
This study includes three parts. First is to estimate the incidence of PI in Taiwan so as to understand PI occurring trend and to provide baseline data before mandatory usage of safety needles; Second is to further analyze high infection risk PI to different job category of HCWs and estimate risk of seroconversion; The final part is to conduct qualitative in-depth interviews with HCWs experiencing high infection risk PI to understand their psychological impacts. Through these three parts, the study aims to provide more precise references and suggestions to medical practice environment.
Methods
The first and second parts of the study adopted a retrospective secondary data analysis approach, with reporting and tracking data from Chinese Exposure Prevention Information Network (EPINet) of the Center for Medical Employees’ Safety and Health being analyzed and estimated by using statistical software JMP and SAS. The third of the study was designed using qualitative methods and purposive sampling approach. In-depth interviews were conducted for data collection, qualitative content analysis was performed and also the stringency rigor of the research was taken into account.
Results
The results of the first part revealed a national estimate of PI between 6710 and 8319 in 2011 by using estimated number of hospital beds, full-time HCWs, and days of inpatient care, which are similar to a previous study using 2004 data. There are increasing trend in reporting numbers of physicians and high infection risk PI of HIV.
The second part’s results showed that high infection risk PI for physicians often occur in delivery room, examination room and operation room; for nurses in dialysis room, ICU, and ward; and for medical technologists in ICU, blood collection counter; while for support personnel in ward. In addition, the notification data in 2012 revealed the incidence of any positive high infection risk PI for HCWs is 0.87 cases/100 full-time HCWs. The estimated annual number of high infection risk PI is 52~133 persons due to HBV, 41~82 to HCV and <1~5 to HIV.
The qualitative study results of the third part of analyzing psychosocial impacts of infectious PI had been extracted into five themes: emotional distress, perceived threat of seroconversion, perceived lacking humanity support from work, altered professional enthusiasm, and positive adjustment.
Conclusions and Suggestions
The study suggests healthcare settings should provide different prevention education training and relevant preventive interventions to HCWs based on their job categories as location and mechanisms for highly infectious PI are different. It is necessary for healthcare settings to set up a single window reporting system and standard procedures after PI. Healthcare settings should also provide the most updated information and protect such HCWs’ rights as taking work-related injury leave and making referral to psychological consultations. The study also suggests government authorities supervise and audit healthcare settings to ensure their PI reporting and replace rates of using safety needles are in compliant with regulations. Furthermore, it may be necessary to conduct a cost and benefit analysis to explore whether the use of safety needles could reduce the PI incidence rate so as to reduce economic cost. The study results may also be used as a reference for future policy making.

並列關鍵字

percutaneous injury (PI) ； high infection risk ； Exposure Prevention Information Network (EPINet) ； seroconversion ； psychological impact

參考文獻

吳雪菁、郭育良、蕭淑銖 (2013)•醫療人員針扎之流行病學、經濟耗損與政策議題•臺灣公共衛生雜誌，32(5)，424-434。

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