口腔健康照護計劃對「呼吸器相關肺炎」預防之成效

摘要背景: 台灣院內感染第二常見的是呼吸器相關肺炎，所謂呼吸器相關肺炎是指入院病患使用呼吸器48小時後所產生的肺炎，此肺炎很高的罹病率及死亡率，所以預防的方法相形重要。其中，經由實證照護指引的品質改善過程包括洗手、口腔護理、呼吸道處理及半坐臥是一項很可行的護理預防措施，所以我們必須深入研究口腔健康照護計畫，對於呼吸器相關肺炎的預防成效。研究目的: 本研究主要探討口腔健康照護計劃對降低呼吸器相關肺炎之成效。方法: 採類實驗研究設計，立意取樣方法；研究對象為南部某醫學中心成人加護病房中有人工氣道並使用呼吸器之病患，於96年3月至97年3月期間，先收集未介入護理措施下六個月之個案為控制組(N=100)，之後的六個月施行介入護理措施為實驗組(N=99)。控制組則僅執行各單位使用呼吸器病患之作業流程的一般常規護理措施，實驗組施行口腔健康照護計劃措施方案包含一般性的預防措施、呼吸道的處置、口腔護理、抬高床頭30∘等四部份，各組均持續執行四天之後，比較兩組於「呼吸器相關肺炎」的感染率、臨床肺部感染相關生理指標(CPIS)及口腔粘膜(OAG)的變化情形。結果 : 經資料分析研究結果歸納如下: 以chi-squid及獨立樣本t檢定(indepent t-test)結果，實驗組與控制組兩組之基本人口學屬性與相關的並資料皆無顯著差異(P>.05)，表示兩組的同質性高。進一步檢測之相關結果如下：實驗組發生呼吸性相關肺炎的比率(4/95)低於控制組(18/82)達統計上之顯著差異 (P< .05)。由於兩組的CPIS和OAG得分，沒有成常態分佈故以無母數分析法(Wilcoxon signed-rank test)之曼-惠特尼考驗(Mann-Whitney U test)進行比較，結果發現兩組間是有顯著差異(P<.05)。CPIS隨著時間的增加，執行口腔健康照護計劃可降低臨床肺部感染之機會。口腔健康照護計劃對口腔黏膜變化，隨著時間的增加，執行口腔健康照護計劃可降低口腔評估分數，改善口腔粘膜的狀況，同時也間接影響呼吸道感染的情形。結論: 口腔健康照護計劃可降低加護病房病患呼吸器相關肺炎的感染率。本研究結果可提供降低呼吸器相關肺炎感染率成效之實証資料，亦可成為護理人員常規口腔健康照護之實證依據，且可提供醫院長期護理照護政策之具體參考，降低病患使用呼吸器的時間、住院天數及死亡率，未來我們更應考量提供安全、有效、方便及容易使用之口腔健康器具設備，提供臨床護理人員的使用；進一步落實預防勝於治療，以提升病人安全及醫療照護品質。

關鍵字

口腔健康照護；呼吸器相關肺炎；預防

並列摘要

Abstract Background: Nosocomial pneumonia is the second most costly infection occurring in Taiwan hospitals. Ventilator-associated pneumonia (VAP), which is usually defined as an infection occurring greater than 48 hours after hospital admission in a patient requiring mechanical ventilation. It is associated with high mortality and morbidity and is considered one of the most difficult infections to diagnose and prevent. A quality improvement process to guide evidence-based care related to in wash-hand, mouth care, airway manage, semi-recumbent positions is also described. How to prevent VAP is very importance, so we must to research this oral health-care protocol for prevention of ventilator associated pneumonia. Purpose: To evaluate the effectiveness of an evidence-basedoral health-care protocol for prevention of ventilator associated pneumonia. Method: This study was conducted in the medical and surgical intensive care units in a University Hospital of 1400 beds from 1st March, 2007 to 31st March, 2008. A quasi-experimental non-randomized trial study design was used. A total of 199 mechanically ventilated patients enrolled. They were divided into two groups, study group (N=99) and control group (N=100). The control group was cared by routine nursing care procedures, and the study group was used the evidence-based oral health-care protocol (including wash-hand, mouth care, airway management and the semi-recumbent positions). Patients of each group were given the interventions for four consecutive days. Then, the incidence of the VAP, Clinical Pneumonia Infection Scale (CPIS) and the oral assessment scale were compared. Results : There were not statistically significant between two groups for demographic data, specialty, operation or not, reasons of intubation, severity of disease (APACHE II) and the comorbidity (P> 0.05). It indicated that the basic data are similar for both groups. The incidence of VAP was 4% (4/95) in the study group; and it was significantly lower than the control group, 21% (18/82) (P< 0.05). The mean of the CPIS scale was 4.2 (SD2.15) in the study group and 5.57(SD2.38) in the control group. On the other hand, the mean of the OAG scale was 9.16 (SD2.07) and 10.07 (SD1.79) in the control group. There were statistically significant correlations between CPIS and OAG scale in both groups using Wilcoxon signed-rank test (P< 0.05). Intriguingly, the CPIS was decreasing in value as the time length. As a result, the incidence of pneumonia was lowering. The OAG was decreasing as the time length and had a statistically significant result. It showed that the improvement of oral mucosa may be indirectly lowering the infection rate of the airway. Conclusion : The evidence-based oral health-care protocol is supported to be effective in the prevention of VAP in this study.This study results significant reductions in rates of VAP may be achieved by broader implemention of oral health-care protocol.In the future oral health-care protocol is effective nursing care interventions guideline for prevention of VAP. May be reductions in patient use ventilator time, length of stay, and mortality.