應用出院準備服務於慢性阻塞性肺疾病之成效探討

Evaluation of the discharge planning intervention on COPD patients

王憲華(Shian-Hua Wang)

指導教授 ： 盧美秀 ； 陳品玲

臺北醫學大學/護理學院/護理學研究所/碩士(2000年)

摘要

出院準備服務可達成縮短病人住院日數、增進自我照顧知識及能力、提昇病患及家屬的滿意程度、及提昇護理人員工作滿意程度等成果。慢性阻塞性肺疾病是病程漫長的慢性疾病，患者常因易發生呼吸短促現象，而有不必要的活動限制，進而使生活品質大受影響，能在患者住院期中提供完整的後續照顧訊息，予以出院準備服務之照護模式，應可提昇其疾病因應能力，減少症狀之嚴重度，維持疾病慢性穩定狀態，並改善生活品質。 本研究採類實驗設計法，於四個護理人員學資歷相當、胸腔內科病人分佈相當的內科單位中，以隨機方法選出二單位作為實驗組推行出院準備服務照護模式，二單位作為控制組執行常規照護模式，以符合收案條件之慢性阻塞性肺疾病患者為研究對象，探討出院準備服務對COPD病患住院天數?出院後四週內非預期性就診率?自我照顧認知及能力變化?生活品質變化?及住院醫療費用之影響。兩組病患均於入院時及出院時、出院4週後分別完成「病患自我照顧認知評量表」、「自我照顧能力評量表」、及「生活品質評量表(SOLQ)」。認知評量表及SOLQ量表採專家效度，信度以Cronbach α 顯示，自我照顧認知評量表為0.83，生活品質評量表之各次項目分別為生理功能0.92、因應技巧0.79、情緒功能0.77、照護滿意度0.96，出院準備服務專責協調師間一致性採KAPPA信度檢定為0.77~0.84。由於個案數少，各項收集資料先以無母數統計考驗進行分析。 研究結果顯示：推行出院準備服務照護模式後，慢性阻塞性肺疾病患者之自我照顧認知顯著提升，自我照顧能力及生活品質中之因應技巧及情緒功能可獲改善；而由於研究設計的疏忽，致平均住院日、平均醫療費用未見顯著差異；但與去年同期比較，住院日數可縮短，且在健保局支付金額調升後平均醫療費用未見顯著增加；對個案出院後4週內非計畫性就醫率未見顯著差異。 由於個案數較少，各項結果之推論力及解釋力薄弱，尚待繼續收集達具檢力之慢性阻塞性肺疾病患者後，才能具體評值出院準備服務之成效。

關鍵字

出院準備服務 ； 慢性阻塞性肺疾病患者 ； 照護成效

並列摘要

Discharge planning can shorten the length of hospital stay, facilitate patient self-care, promote patient satisfaction, and prevent readmissions. COPD evolves from a long period of lung destruction, which results in dyspnea. Dyspnea can limit patients'' activities, which leads to great effects on their quality of life. Providing integrative discharge planning should be able to build-up patient coping skills, to lessen the severity of the disease, and to improve quality of life. A quasi-experimental study was conducted. Four internal medicine units where the background of nursing staff and the COPD caseload are selected and compared. By randomization, two units were assigned as the intervention group and the other two as the control group. Patients of the intervention group had been treated with integrative discharge planning while the control group received traditional discharge service. Patients who met the inclusion criteria were recruited. The effects of discharge planning on the following outcomes were to be examined: length of stay, unexpected medical visits four weeks after discharged, knowledge and skills of self-care, health related quality of life, and hospital expenses. All eligible patients had to complete "The Knowledge of Patient Self-Care Questionnaire (KPSCQ)", "The Skill of Patient Self-Care Scale (SPSCS)", and "The Seattle Obstructive Lung Disease Questionnaire (SOLQ)" by the time of admission, discharged and four weeks after discharged. Expert validity was conducted for the KPSCQ and SOLQ. Internal reliability of KPSCQ was 0.83 (Cronbach''s ?). Reliability of physical function, emotional function, coping skills and treat satisfaction of the SOLQ was 0.92, 0.77, 0.79, and 0.96, respectively. Inter-rater reliability was 0.77 -0.84 (Kappa). Nonparametric statistical test were exercised temporarily because of insufficient case number. The results demonstrate that implementing the discharge planning can significantly facilitate COPD patients to gain knowledge of self-care, to improve skill of self-care, coping skills, and to lessen emotional burdens. The length of stay and the average hospital expenses did not significantly reduce because of the study flaws. However, according to the experiment, the length of stay for the intervention group was found significantly shorter than the COPD patients at the same period last year. Moreover, the hospital expenses of the intervention group did not significantly increase even though the insurance payment had been increased by the Bureau of National Health Insurance. No significant difference was found between the intervention group and the control group of unexpected medical visits. Due to the insufficient number of case study, the inference and explanation of this experiment are limited. The effects of the discharge planning on COPD patient outcomes are yet to be determined as more cases are collected and studied.

並列關鍵字

discharge planning ； chronic obstructive pulmonary disease ； patient outcome

參考文獻

邱怡玟、蔡素華、李選(民88)?探討慢性阻塞性肺疾病住院患者之憂鬱狀況與日常生活功能的相關性?護理研究，7(2)，145-155。

張雪真節譯(民83)?歐美國家醫療体制與保險制度?台北:行政院衛生署。 曾淑津、黃秀梨(民86)?慢性阻塞性肺疾病患者的疾病認知、醫囑遵從行為及心理感受之探討?護理研究，5(4)，308-319。

嚴毋過(民83)?台北市各公、私立醫院慢性病患者住院就醫狀況暨對長期照護需求分析?台北:台北市政府衛生局。 嚴毋過、吳淑瓊、許菁菁、陳宏輝(民85)?台北市公私立醫院非急性病人的盛行率?長期照護需要與態度?護理研究，4(2)，151-159。

蕭光明(民85)?慢性阻塞性肺疾病?胸腔醫學，11(4)，230∼239。 魏玲玲等合譯(1989)?下呼吸道疾病病人的護理?盧美秀總檢閱，內外科護理(中冊)?台北:華杏。 戴玉慈、張丹蓉、羅美芳(民87)?台灣地區之出院準備服務-試行計劃成果分析?慈濟醫學，10(1)，61-67。

Bull, M.J.(1994). Patients’ and professionals’ perceptions of quality in discharge planning. Jorunal of Nursing Care Quality,8(2), 47-61.