個案管理介入唇裂新生兒手術前治療照護之成效分析

研究目的: 探討個案管理介入唇裂新生兒術前準備之成效以及建立更完善的唇裂新生兒就醫流程。藉由此研究暸解個案管理師在團隊的重要性，以及流程上是否有需要調整，使其患童在出生後能得到更好的醫療資源及提供家長更完善的諮詢方向。研究方法:回溯南部某醫學醫院顱顏中心病歷，調閱由二零一零年一月一日至二零一八年十二月三十一日的資料，並以二零一四年十二月三十一日為個案管理師開始介入區隔時間點，分為介入組及非介入組，分析個案管理介入對於唇裂新生兒手術前照護之改善程度，並用SPSS做各項之統計分析比較。研究結果: 本案共收案三百四十七位患童，男生為兩百十五(62％)位，女生為一百三十二(38％)位。1.其中唇裂(ICD-10:Q36.)一百五十六(25.2％)人，唇顎裂(ICD-10:Q37.)一百九十一(30.8％)人；有一百四十四人接受個案管理，無接受介入者有二百零三位；於院外出生者達兩百五十三位，院內出生者為九十四位；鼻撐器類型使用鼻型塑型器一百九十二(55.3％)位、配戴鼻膜者為四十九(14.1％)位，而術前無接受鼻撐器者為一百零六(30.5％)位。2.個案管理有無介入其開刀年齡(p=0.023)及鼻撐器使用(p=0.001)有顯著差異。經由產科轉介個案管理師提供產前諮詢，在院內生產比例從百分之二十四提升至百分之三十一。改善照護流程，初診年齡平均五十三天降至平均二十六天，手術年齡由平均一百五十二天改善為平均一百零八天，鼻撐器使用率由百分之五十六提升至百分之八十七，膠帶黏貼年齡也由十四天降至十一天，等待鼻型塑型器的時間仍維持十天左右。3.不完全唇裂使用鼻膜和個案管理師有無介入(p = 0.001)是有關係。結論:個案管理為顱顏中心重要之一環，除了控管照護流程的成效之外，還需要長時間追蹤患童，搭起醫病關係的橋樑，達到全人照顧的理想照顧目標。

關鍵字

個案管理；唇裂；術前治療；照護流程；鼻撐器

並列摘要

Objective: To investigate the effectiveness of case management in preoperative preparation of neonates with cleft lip and to establish a better protocol in cranial neonatal treatment. Through this research, we can understand the importance of the case manager in the team and whether there is a need to adjust the process so that the child can get better medical resources after birth and the parents can have better consultations. Methods: This study traced the medical records of the Craniofacial Centre of a medical hospital in South Taiwan from January 1, 2010 to December 31, 2018. These cases were divided into two groups as those with and without case management by the time point on December 31, 2014, when the case manager start to involve. The improvement in preoperative care was compared between the neonates with cleft lip in the presence or absence of case management and analyzed by SPSS. Results: A total of 347 children were enrolled, 215 (62%) for boys and 132 (38%) for girls. There were 156 (25.2%) children with cleft lip (ICD-10: Q36) and 191 (30.8%) with cleft lip and palate (ICD-10: Q37); 144 children were subject to case management, 203 were not; 253 were born outside the hospital, 94 were born in the hospital; 191 (55.3%) children had received treatment with nasoalveolar moulding, 49 (14.1%) with nasal comformer, and 106 (30.5%) without preoperative nose support. The results demonstrated there were significant difference of the age of operation (p =0.023) and the use of the nasal stent (p=0.000) of those children received case management than those not. The proportion of in-hospital production via obstetric referral to case manager for prenatal consultation increased from 24% to 31%, with reduction of the average age of the initial diagnosis from 53 days to 26 days, improvement of age of surgery from an average of 152 days to 108 days, increased rate of nasal stent use from 56% to 87%, and reduction of the age of adhesive tape use from 14 days to 12 days, while the waiting time for the nose molding was the similar 10 days. In addition, the use of nasal comformer was significantly associated with the involvement of case manager (p = 0.001). Conclusions: The case manager is an important staff in the craniofacial center. With the provision of an effective control of the caring process, the case manager has to follow the children for a long time, bridge the relationship between the child and the doctor, and achieve the ideal goal of holistic health care.