Title

血液腫瘤住院病人血流感染危險因子之相關性探討

Translated Titles

An exploration of bloodstream infection risk factors on hospitalized hematological malignancy patient

Authors

王曉婷

Key Words

血流感染 ; 中心靜脈導管 ; 血液腫瘤病人 ; Bloodstream Infection ; Central Venous Access Device ; Hematological malignancy patient

PublicationName

中山醫學大學護理學系學位論文

Volume or Term/Year and Month of Publication

2017年

Academic Degree Category

碩士

Advisor

徐明儀

Content Language

繁體中文

Chinese Abstract

背景:中心靜脈導管是血液腫瘤科病人接受化學藥物給藥的一項重要途徑,但易因血流感染而影響預後。國外針對裝置中心靜脈導管血液腫瘤病人的血流感染之相關研究很多,但國內較少。故本研究預探討裝置中心靜脈導管血液腫瘤住院病人血流感染之危險因子。 目的:探討裝置中心靜脈導管血液腫瘤住院病人血流感染之危險因子。 設計:採回溯性研究設計。 方法:以南部某醫學中心的電子病歷為資料庫。研究工具為血液腫瘤科病人危險因子資料收集單,並經過專家效度審查,資料來源為醫療及護理病歷,自變項為病人屬性:年齡、性別、血液腫瘤疾病診斷分類、體能狀況、查爾森共病症指數、絕對嗜中性白血球(Absolute Neutrophil Count;以下簡稱ANC)低下持續天數、ANC低下的數值、主觀性整體營養狀況評量表分數(The Patient-Generated Subjective Global Assessment;以下簡稱PGSGA)、感染徵象、中心靜脈導管,干擾變項為危險因子,分二大部分:在醫療處置部分為有無接受抗微生物劑、有無接受類固醇、有無居住正壓保護隔離病房、有無接受白血球生長刺激因子、接受化學藥物的劑量、有無接受輸血、有無接受脊髓腔注射化學藥物、有無接受侵入性處置;在護理處置部分為內植式輸液塞(Subcutaneous Infusion Port;以下簡稱Port-A)彎針置留天數、一週內Port-A彎針穿刺次數、接觸性皮膚炎、使用輸液管路的數目、敷料更換的方式,依變項為中心靜脈導管血流感染狀況、菌種、住院天數、Port-A底座留置天數及週邊置入中心靜脈導管(Peripheral Inserted Central Catheter;以下簡稱PICC)留置天數,所得結果運用統計軟體分析,以描述性統計呈現個案基本屬性及危險因子,再以T-檢定、卡方檢定、變異數分析、邏輯式回歸分析確立血流感染之危險因子。 研究結果:本研究結果總共有405人,中心靜脈導管血流感染有122人(30.1%),血流感染密度2.5‰(465人次/186,897住院人日數*1000)。研究結果顯示住院平均天數、ANC低下數值、ANC持續低下天數、感染徵象(發燒、寒顫、低血壓)、敷料更換的方式、使用輸液管路的數目會影響有無中心靜脈導管血流感染。ANC低下小於等於500/mm3的血流感染率比ANC低下大於500/mm3的血流感染率高9.38倍、ANC持續低下1〜7天的血流感染率比ANC無低下的血流感染率高4.48倍、ANC持續低下8天以上的血流感染率比ANC無低下的血流感染率高14.33倍、非依常規換藥的血流感染率比依常規換藥的血流感染率高2.29倍。

English Abstract

Background:Central venous catheter is an important method for cancer patients in the Department of Hematology and Oncology to receive chemotherapy treatment. However, patients receiving this procedure are susceptible to bloodstream infections, therefore the prognoses of patients are adversely affected. Objective: The objective was to explore the bloodstream infection risk factors in hospitalized hematological malignancy patients with central venous catheter. Design:Retrospective studies were employed. Methods:Electronic medical records (EMR) from a medical center in southern Taiwan were used as the database. Self-prepared forms were used as research tools for risk factor data collection from patients in the Department of Hematology and Oncology. Medical and nursing records were used as the source of information. Independent variables were patient attributes (age, gender,central venous catheter, site of infection, diagnostic classification of hematological malignancies, physical status (Eastern Cooperative Oncology Group,ECOG), Charlson comorbidity index (CCI), number of days of low absolute neutrophil count(ANC), low ANC value, the patient-generated subjective global assessment(PG-SGA)score,disturbance variables were risk factors Risk factors were categorized into two groups:(1)medical treatment-related factors — including whether the patients were admitted to the protective environment of positive pressure isolation rooms, the dose of chemical drugs, the use or not-use of antimicrobials, steroids, white blood cell growth stimulating factor, as well as whether received blood transfusions;(2)nursing care-related factors — including the number of infusion lines used simultaneously, whether the dressings were changed according to the care routines, days of Port-A curved needle placement, the number of Port-A curved needle placement in a week, and contact dermatitis), and the dependent variables were the central venous catheter bloodstream infection status, days of hospitalization and bacterial species. The results obtained were analyzed using statistical software. The basic attributes and risk factors of individual cases were presented with descriptive statistics, and the bloodstream infection risk factors were then established using Student's t-test, analysis of variance(ANOVA)and logistic regression analysis. Results:According to the results of the study, there were total of 405 persons; among them, the central venous catheter-related bloodstream infection rate was 122 persons (30.1%).The bloodstream infection rate was 2.5 events/ days of stay *1000. This study showed that the average number of days in hospital, values of neutropenia, days of neutropenia, infection sign (fever, shivering, low blood pressure), and change of dressing would affect the central venous catheter-related bloodstream infection. The odds ratio of bloodstream infection rate of neutropenia not exceeding 500/mm3 was 9.38times higher than that of neutropenia exceeding 500/mm3.The odds ratio of bloodstream infection rate during the period between 1 and 7 days of the absolute neutrophil count (ANC) was 4.48times higher than that of non ANC, the bloodstream infection rate during the period more than 8 days of ANC was 14.33 times higher than that of non ANC, and the odds ratio of bloodstream infection rate of non-routine dressing is 2.29 times higher than that of routine dressing.

Topic Category 醫藥衛生 > 社會醫學
醫學院 > 護理學系
Reference
  1. 朱育增、吳肖琪(2010)•回顧與探討次級資料適用之共病測量方法,臺灣公共衛生雜誌,29(1),8―21。
    連結:
  2. 呂淑華、戴玉慈(2010)•病歷回顧研究之方法學,臺灣醫學,14(5),583―587。
    連結:
  3. 李耀泰、陳福民、沈仁達、郭宗正(2011)•對化學治療所引起延遲性嘔吐的治療,中華民國婦癌醫學雜誌,(1),1―14。
    連結:
  4. 林滿、王復德(2006)•靜脈內植式輸液塞在植入早期及接受後產生合併症機率•榮總護理,23(1),17―23。岳志瑛、李俊英、余春華、趙淑珍、符琰(2010)•成都市某醫學中心周邊置入中心靜脈導管合併症的現況及其相關護理,護理雜誌,57(3),79―85。
    連結:
  5. 洪敏瑛、邱文姿、陳淑娟、戴仕卿、蕭逸美(2013)•癌症病人嗜中性白血球低下臨床照護指引,腫瘤護理雜誌,(13),79―92。
    連結:
  6. 高雄長庚感染管制委員會(2017)•12D血流感染會報•公布於院內網頁。
    連結:
  7. 常傳訓、周育如、余璧如、殷秀妙、孫吉珍、董道興…張仙平(2009). 住院癌症病患營養篩檢工具之建立•中華民國癌症醫學會雜誌,25(3),206―215.
    連結:
  8. 張金堅(2013)•化學治療的常見副作用-嗜中性白血球低下性發燒,當代醫學(478),573―581。
    連結:
  9. 張黎露、張瀞文、周文珊、林思岑(2011)•癌症病人常用中心靜脈導管臨床照護指引,腫瘤護理雜誌,11,15―40。
    連結:
  10. 陳美珠、王復德、黃萬翠、陳瑛瑛(2015)•Port-A導管敷料更換頻率對注射部位及血流感染之影響•感染控制雜誌,25(5),205-213。
    連結:
  11. 陳美碧、謝麗鳳、林惠蘭、李淑貞、林純如、蔡欣玲(2004)•癌症病人之生活品質及其預測因子,榮總護理,21(4),352―362。
    連結:
  12. 楊佩瑄(2013)•護理人力不同配置比例對病人安全、照護品質和護理照護成本之影響•高雄市:高雄醫學大學護理學系研究所學位論文。
    連結:
  13. 詹明錦、王志堅(2014)•中心導管組合式照護措施之探討•感染控制雜誌,24(4),170-177。
    連結:
  14. 鄭如芬、周佩君(2013)•護理人員執行超音波導引周邊置入中心靜脈導管之發展•腫瘤護理雜誌,13(1),41―50。
    連結:
  15. 鄭健禹、洪健清(2008)• 發燒性嗜中性白血球低下症•當代醫學(420),803―805。
    連結:
  16. 蘇世強、林哲玲、王淑芬、曲佩芬、葉淑真、姜秀子、李聰明(2002)安寧病房-北部某醫學中心十年經驗•院內感染控制雜誌,12(2),87―94。
    連結:
  17. Apostolopoulou, E., Raftopoulos, V., Terzis, K., & Elefsiniotis, I. (2010). Infection Probability Score, APACHE II and KARNOFSKY scoring systems as predictors of bloodstream infection onset in hematology-oncology patients. BMC Infectious Diseases, 10, 135.
    連結:
  18. Bodey, G. P., Buckley, M., Sathe, Y. S., & Freireich, E. J. (1966). Quantitative relationships between circulating leukocytes and infection in patients with acute leukemia. Annals of Internal Medicine, 64(2), 328-340.
    連結:
  19. Charlson, M. E., Pompei, P., Ales, K. L., & MacKenzie, C. R. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of Chronic Disease, 40(5), 373-383.
    連結:
  20. Chen, I. C., Hsu, C., Chen, Y. C., Chien, S. F., Kao, H. F., Chang, S. Y., . . . Yeh, K. H. (2013). Predictors of bloodstream infection associated with permanently implantable venous port in solid cancer patients. Annals of Oncology, 24(2), 463-468.
    連結:
  21. Concannon, C., van Wijngaarden, E., Stevens, V., & Dumyati, G. (2014). The effect of multiple concurrent central venous catheters on central line-associated bloodstream infections. Infection Control Hospital Epidemiology, 35(9), 1140-1146.
    連結:
  22. Deyo, R. A., Cherkin, D. C., & Ciol, M. A. (1992). Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. Journal of Clinical Epidemiology, 45(6), 613-619
    連結:
  23. Dudeck, M. A., Weiner, L. M., Allen-Bridson, K., Malpiedi, P. J., Peterson, K. D., Pollock, D. A., . . . Edwards, J. R. (2013). National Healthcare Safety Network (NHSN) report, data summary for 2012, Device-associated module. American Journal of Infection Control, 41(12), 1148-1166.
    連結:
  24. Elixhauser, A., Steiner, C., Harris, D. R., & Coffey, R. M. (1998). Comorbidity measures for use with administrative data. Medical Care, 36(1), 8-27.
    連結:
  25. Fernandez-Ruiz, M., Puig-Asensio, M., Guinea, J., Almirante, B., Padilla, B., Almela, M., . . . Aguado, J. M. (2015). Candida tropicalis bloodstream infection: Incidence, risk factors and outcome in a population-based surveillance. Journal of Infection, 71(3), 385-394.
    連結:
  26. Freifeld, A. G., Bow, E. J., Sepkowitz, K. A., Boeckh, M. J., Ito, J. I., Mullen, C. A., . . . Infectious Diseases Society of, A. (2011). Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clinical Infectious Diseases, 52(4), e56-93.
    連結:
  27. Gao, Y., Liu, Y., Ma, X., Wei, L., Chen, W., & Song, L. (2015). The incidence and risk factors of peripherally inserted central catheter-related infection among cancer patients. Therapeutics and Clinical Risk Management, 11, 863-871.
    連結:
  28. Gerson, S. L., Talbot, G. H., Hurwitz, S., Strom, B. L., Lusk, E. J., & Cassileth, P. A. (1984). Prolonged granulocytopenia: the major risk factor for invasive pulmonary aspergillosis in patients with acute leukemia. Annals of Internal Medicine, 100(3), 345-351
    連結:
  29. Gudiol, C., Bodro, M., Simonetti, A., Tubau, F., Gonzalez-Barca, E., Cisnal, M., . . . Carratala, J. (2013). Changing aetiology, clinical features, antimicrobial resistance, and outcomes of bloodstream infection in neutropenic cancer patients. Clinical Microbiology and Infection, 19(5), 474-479
    連結:
  30. Heibl, C., Trommet, V., Burgstaller, S., Mayrbaeurl, B., Baldinger, C., Koplmuller, R., . . . Thaler, J. (2010). Complications associated with the use of Port-a-Caths in patients with malignant or haematological disease: a single-centre prospective analysis. European Journal of Cancer Care (English), 19(5), 676-681.
    連結:
  31. Hentrich, M., Schalk, E., Schmidt-Hieber, M., Chaberny, I., Mousset, S., Buchheidt, D., . . . Karthaus, M. (2014). Central venous catheter-related infections in hematology and oncology: 2012 updated guidelines on diagnosis, management and prevention by the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology. Annals of Oncology, 25(5), 936-947.
    連結:
  32. Hockenhull, J. C., Dwan, K. M., Smith, G. W., Gamble, C. L., Boland, A., Walley, T. J., & Dickson, R. C. (2009). The clinical effectiveness of central venous catheters treated with anti-infective agents in preventing catheter-related bloodstream infections: a systematic review. Criicalt Care Medicine, 37(2), 702-712.
    連結:
  33. Huang, C. T., Liu, C. J., Ko, P. S., Liu, H. T., Yu, Y. B., Hsiao, L. T., . . . Liu, C. Y. (2017). Risk factors and characteristics of blood stream infections in patients with newly diagnosed multiple myeloma. BMC Infectious Disease, 17(1), 33.
    連結:
  34. Jeon, C. Y., Neidell, M., Jia, H., Sinisi, M., & Larson, E. (2012). On the role of length of stay in healthcare-associated bloodstream infection. Infection Control and Hospital Epidemiology, 33(12), 1213-1218.
    連結:
  35. Khoshnevis, N., Ahmadizar, F., Alizadeh, M., & Akbari, M. E. (2012). Nutritional assessment of cancer patients in Tehran, Iran. Asian Pacific Journal of Cancer Prevention, 13(4), 1621-1626.
    連結:
  36. Kugler, E., Levi, A., Goldberg, E., Zaig, E., Raanani, P., & Paul, M. (2015). The association of central venous catheter placement timing with infection rates in patients with acute leukemia. Leukemia Research, 39(3), 311-313.
    連結:
  37. Kutzscher, L. (2012). Management of irritant contact dermatitis and peripherally inserted central catheters. Clinical Journal of Oncolog Nursing, 16(2), E48-55.
    連結:
  38. Lebeaux, D., Larroque, B., Gellen-Dautremer, J., Leflon-Guibout, V., Dreyer, C., Bialek, S., . . . Fantin, B. (2012). Clinical outcome after a totally implantable venous access port-related infection in cancer patients: a prospective study and review of the literature. Medicine (Baltimore), 91(6), 309-318.
    連結:
  39. Lee, G. J., Hong, S. H., Roh, S. Y., Park, S. R., Lee, M. A., Chun, H. G., . . . Oh, J. S. (2014). A case-control study to identify risk factors for totally implantable central venous port-related bloodstream infection. Cancer Research and Treatment, 46(3), 250-260.
    連結:
  40. Leung, T. K., Lee, C. M., Tai, C. J., Liang, Y. L., & Lin, C. C. (2011). A retrospective study on the long-term placement of peripherally inserted central catheters and the importance of nursing care and education. Cancer Nursing, 34(1), E25-30.
    連結:
  41. Lisy, K. (2014). Prophylactic antibiotics for preventing Gram-positive infections associated with long-term central venous catheters in oncology patients: beneficial or not? Cancer Nursing, 37(4), 316-317.
    連結:
  42. Magill, S. S., Edwards, J. R., Bamberg, W., Beldavs, Z. G., Dumyati, G., Kainer, M. A., . . . Fridkin, S. K. (2014). Multistate Point-Prevalence Survey of Health Care–Associated Infections. New England Journal of Medicine, 370(13), 1198-1208.
    連結:
  43. Marin, M., Gudiol, C., Ardanuy, C., Garcia-Vidal, C., Calvo, M., Arnan, M., & Carratala, J. (2014). Bloodstream infections in neutropenic patients with cancer: differences between patients with haematological malignancies and solid tumours. Journal of Infection, 69(5), 417-423.
    連結:
  44. McNichol, L., Lund, C., Rosen, T., & Gray, M. (2013). Medical adhesives and patient safety: state of the science: consensus statements for the assessment, prevention, and treatment of adhesive-related skin injuries. Orthopedic Nursing, 32(5), 267-281.
    連結:
  45. Mermel, L. A., Allon, M., Bouza, E., Craven, D. E., Flynn, P., O'Grady, N. P., . . . Warren, D. K. (2009). Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clinical Infectious Disease, 49(1), 1-45.
    連結:
  46. Mollee, P., Jones, M., Stackelroth, J., van Kuilenburg, R., Joubert, W., Faoagali, J., . . . Clements, A. (2011). Catheter-associated bloodstream infection incidence and risk factors in adults with cancer: a prospective cohort study. Journal of Hospital Infection, 78(1), 26-30.
    連結:
  47. Park, K. H., Cho, O. H., Lee, S. O., Choi, S. H., Kim, Y. S., Woo, J. H., . . . Kim, S. H. (2010). Outcome of attempted Hickman catheter salvage in febrile neutropenic cancer patients with Staphylococcus aureus bacteremia. Annals of Hematology, 89(11), 1163-1169.
    連結:
  48. Peduzzi, P., Concato, J., Kemper, E., Holford, T. R., & Feinstein, A. R. (1996). A simulation study of the number of events per variable in logistic regression analysis. Journal of Clinical Epidemiology, 49(12), 1373-1379.
    連結:
  49. Raad, I., Kassar, R., Ghannam, D., Chaftari, A. M., Hachem, R., & Jiang, Y. (2009). Management of the catheter in documented catheter-related coagulase-negative staphylococcal bacteremia: remove or retain? Clinical Infectious Disease, 49(8), 1187-1194.
    連結:
  50. Rosa, R. G., & Goldani, L. Z. (2014). Factors associated with hospital length of stay among cancer patients with febrile neutropenia. PLoS One, 9(10), e108969.
    連結:
  51. Sabatier, C., Ferrer, R., & Valles, J. (2009). Treatment strategies for central venous catheter infections. Expert Opinion on Pharmacotherapy, 10(14), 2231-2243.
    連結:
  52. Schelenz, S., Nwaka, D., & Hunter, P. R. (2013). Longitudinal surveillance of bacteraemia in haematology and oncology patients at a UK cancer centre and the impact of ciprofloxacin use on antimicrobial resistance. Journal of Antimicrobial Chemotherapy, 68(6), 1431-1438.
    連結:
  53. Shim, J., Seo, T. S., Song, M. G., Cha, I. H., Kim, J. S., Choi, C. W., . . . Oh, S. C. (2014). Incidence and risk factors of infectious complications related to implantable venous-access ports. Korean Journal of Radiology, 15(4), 494-500.
    連結:
  54. Smith, A., Roman, E., Howell, D., Jones, R., Patmore, R., & Jack, A. (2010). The Haematological Malignancy Research Network (HMRN): a new information strategy for population based epidemiology and health service research. British Journal of Haematology, 148(5), 739-753.
    連結:
  55. Spoelstra, S. L., Given, C. W., Sikorskii, A., Majumder, A., Schueller, M., & Given, B. A. (2015). Treatment with oral anticancer agents: symptom severity and attribution, and interference with comorbidity management. Oncology Nursing Forum, 42(1), 80-88.
    連結:
  56. Su, C. H., Chang, S. C., Yan, J. J., Tseng, S. H., Chien, L. J., & Fang, C. T. (2013). Excess mortality and long-term disability from healthcare-associated staphylococcus aureus infections: a population-based matched cohort study. PLoS One, 8(8), e71055.
    連結:
  57. Terebelo, H., Srinivasan, S., Narang, M., Abonour, R., Gasparetto, C., Toomey, K., . . . Shah, J. J. (2017). Recognition of early mortality in multiple myeloma by a prediction matrix. American Journal of Hematology, 92(9), 915-923.
    連結:
  58. Timsit, J. F., Bouadma, L., Ruckly, S., Schwebel, C., Garrouste-Orgeas, M., Bronchard, R., . . . Lucet, J. C. (2012). Dressing disruption is a major risk factor for catheter-related infections. Crital Care Medicine, 40(6), 1707-1714.
    連結:
  59. Timsit, J. F., Mimoz, O., Mourvillier, B., Souweine, B., Garrouste-Orgeas, M., Alfandari, S., . . . Lucet, J. C. (2012). Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. Americal Journal of Respiratory and Critical Care Medicine, 186(12), 1272-1278.
    連結:
  60. Timsit, J. F., Bouadma, L., Ruckly, S., Schwebel, C., Garrouste-Orgeas, M., Bronchard, R., . . . Lucet, J. C. (2012). Dressing disruption is a major risk factor for catheter-related infections. Crital Care Medicine, 40(6), 1707-1714.
    連結:
  61. Toscano, C. M., Bell, M., Zukerman, C., Shelton, W., Novicki, T. J., Nichols, W. G., . . . Jarvis, W. R. (2009). Gram-negative bloodstream infections in hematopoietic stem cell transplant patients: the roles of needleless device use, bathing practices, and catheter care. American Journal Infection Control, 37(4), 327-334.
    連結:
  62. Toure, A., Vanhems, P., Lombard-Bohas, C., Cassier, P., Pere-Verge, D., Souquet, J. C., . . . Chambrier, C. (2012). Totally implantable central venous access port infections in patients with digestive cancer: incidence and risk factors. American Journal Infection Control, 40(10), 935-939.
    連結:
  63. Yeoh, Z. H., Furmedge, J., Ekert, J., Crameri, J., Curtis, N., & Barnes, C. (2013). Central venous access device-related infections in patients with haemophilia. Journal Paediatrics and Child Health, 49(3), 242-245.
    連結:
  64. Yousif, A., Jamal, M. A., & Raad, I. (2015). Biofilm-based central line-associated bloodstream infections. Advances in Experimental Medicine and Biology, 830, 157-179.
    連結:
  65. 陳怡蓉、顏慶雲(2011)• 以專案方式提昇護理人員執行人工血管照護品質以降低病人血流感染率•護理雜誌,58(3),64―72。
  66. 陳敏鋑、黃采薇、趙子傑、簡淑慧、陳秋慧、陳瑞儀…顧乃平(2016)•癌症護理學,臺北市:華杏。
  67. 葉美玲、王采芷、魏秀靜、李皎正、梁淑媛、林玉萍、周成蕙、簡淑慧、葉淑惠、林寬佳(2012)•護理研究實務:評價、綜合及產生證據,臺北市:台灣愛思唯爾有限公司。
  68. 劉羽田、廖經綸、嵇達德、周啟馥、 林文博、陳春香...謝宜真(2012)•新編微生物學,臺北市:永大。
  69. 衛生福利部疾病管制署(2014)•新聞稿•取自http://www.cdc.gov.tw/professional/info.aspx?treeid=cf7f90dcbcd5718d&nowtreeid=f94e6af8daa9fc01&tid=59D8211F0E317A65
  70. 衛生福利部疾病管制署(2014)•中心導管組合式照護工作手冊•取自http://www.cdc.gov.tw/uploads/files/201511/b210316a-c7d5-4931-896c-850f352940cb.pdf
  71. 衛生福利部疾病管制署(2017)•健保特殊材料品項網路查詢服務•取自https://www.nhi.gov.tw/Query/query4.aspx?menu=20&menu_id=712&WD_ID=832
  72. 衛生福利部疾病管制署(2013)•侵入性醫療裝置相關感染監測定義•取自http://www.cdc.gov.tw/professional/info.aspx?treeid=beac9c103df952c4&nowtreeid=29e258298351d73e&tid=8793EB4A2AD1E5DB
  73. 衛生福利部疾病管制署(2014)•新版醫療照護相關感染監測定義•取自http://www.cdc.gov.tw/professional/info.aspx?treeid=beac9c103df952c4&nowtreeid=29e258298351d73e&tid=63DC78B180156753
  74. 衛生福利部疾病管制署 (2016)•台灣醫療照護相關感染監視資訊系統2015年監視報告•取自 http://www.cdc.gov.tw/professional/downloadfile.aspx?fid=EF51B4E7046B3F90
  75. 衛生福利部疾病管制署 (2016)•醫療照護相關感染個案資料之收集、整理及報表製作•取自 http://www.cdc.gov.tw/professional/info.aspx?treeid=beac9c103df952c4&nowtreeid=e8b486509475c582&tid=B9938EAE1FC1EE33
  76. 衛生福利部國民健康署(2017)•102年癌症登記報告•取自 http://www.hpa.gov.tw/Pages/List.aspx?nodeid=269
  77. Centers for Disease Control and Prevention (2016).National Healthcare Safety Network(NHSH). Retrieved from Resarch on Poverty Alleviation website: https://www.cdc.gov/HAI/surveillance/index.html
  78. Di Giacomo, M. (2009). Comparison of three peripherally-inserted central catheters: pilot study. British Journal of Nursing, 18(1), 8-16. Deyo, R. A., Cherkin, D. C., & Ciol, M. A. (1992). Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. Journal of Clinical Epidemiology, 45(6), 613-619.
  79. Oken, M. M., Creech, R. H., Tormey, D. C., Horton, J., Davis, T. E., McFadden, E. T., & Carbone, P. P. (1982). Toxicity and response criteria of the Eastern Cooperative Oncology Group. American Journal of Clinical Oncology, 5(6), 649-655.
  80. Sun, Y., Zhou, T., Li, Y., Wang, J., Jiao, J., Wang, H., & Geng, C. (2014). [Clinical application of totally implantable central venous port]. Zhonghua Wai Ke Za Zhi, 52(8), 608-611.