精神科急性病房護理品質指標閾值之建立及其相關因素之回溯世代研究

Retrospective Cohort Study on Establishing Threshold of Indicators of Nursing Care and the Related Factors in Acute Psychiatric Wards

10.6142/VGHN.201812_35(4).0008

劉淑言(Shu-Yen Liu)；陳美碧(Mei-Bih Chen)

護理品質指標 ； 意外事件 ； 閾值 ； indicators of nursing care ； incidence of accidents ； threshold

榮總護理

35卷4期（2018 / 12 / 01）

399 - 408

繁體中文

本研究目的在訂定精神科急性病房跌倒、暴力、自傷（殺）三項護理品質指標之閾值，並分析影響三項品質指標之意外事件發生率的相關因素，以作為擬定改善措施之參考。本研究採回溯世代研究(retrospective cohort study)設計，以台灣北部某醫學中心於2007年1月1日至2012年12月31日期間住精神科急性病房共99床之病人為研究樣本；資料來源為取樣期間資訊室住院病人資料檔、醫療品質管理中心異常事件通報電子檔及護理業務指標資料檔，採檔案分析的方式串聯相關資料庫的檔案後以Excel軟體進行資料轉檔、除誤、串檔與歸戶等處理，再以SPSS統計軟體進行描述性與推論性統計。研究結果顯示，跌倒、暴力、自傷（殺）發生率分別為0.03%-0.28%、0.02%-0.07%、0.003%-0.06%，以六年平均發生率設定醫學中心精神科急性病房跌倒閾值為0.11%、暴力閾值為0.05%、自殺閾值為0.02%；「病人年齡」、「佔床率」、「直接護理時數」等因素與意外事件發生率達統計上顯著差異。建議同屬性病房可建立護理人力資料庫，並依每日病人動態適時、機動性調整支援人力。

This study analyzed the threshold of falls, self-harm (suicide), and violence among acute psychiatric patients and analyzed the related factors for accident rates as the basis for future interventions. A retrospective case-control study design was used in this study. Data underwent archival analysis and were retrieved from the electronic archival files of Taipei Veterans General Hospital from over 2007-2012. The information covers 99 beds, which was the total bed number of the acute psychiatry ward. Accident-related events included falls, violence, and self-harm as recorded in the patient information system and unusual event notification database. Nursing care information was adapted from the nursing index database. Each event threshold was established by using the mean incidence over the 6 years. The factors related to accident-related nursing indicators higher than the threshold were analyzed through multiple linear regression. The average rate of occupied beds was 91.95% ± 0.05%. The incidences of falls, violence, and self-harm were 0.03%-0.28%, 0.02%-0.07%, and 0.003%-0.06%, respectively. The threshold of fall incidences was set at 0.11%. The threshold of violence incidences was set at 0.05%, and the threshold of self-harm incidences was set at 0.02%. Significant differences were observed for age, occupied rate, and nursing hours with the incidence of accidents. The results suggest that a flow of nursing staff resources, according to the bed occupancy rate, should be established to adjust manpower and reduce the incidence of accident-related events in acute psychiatric wards.

1. 裘苕莙、蘇貞云、陳曼君、吳肖琪、葉馨婷、吳欣怡、吳義勇(2013)。設訂單一醫療品質指標閾值應用於醫院不同科別合宜性之探討─以跌倒發生率為例。醫務管理期刊，14(4)，356-366。
   連結：
2. Aiken, L. H.,Clarke, S. P.,Sloane, D. M.,Sochalski, J.,Silber, J. H.(2002).Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction.Journal of American Medical Association,288(16),1987-1993.
3. Chi, M. T.,Jeang, S. R.,Pan, C. C.,Leu, S. J.,Chueh, C. M.(2008).Enhancing the capability of medical team to manage aggressive events in acute psychiatric wards.The Journal of Nursing,55(2),59-67.
4. Chou, K. R.,Lu, R. B.,Mso, W. C.(2002).Factors relevant to patient assaultive behavior and assault in acute inpatient psychiatric units in Taiwan.Archives of Psychiatric Nursing,16(4),187-195.
5. Cullen, A. E.,Bowers, L.,Khondoker, M.,Pettit, S.,Achilla, E.,Koeser, L.,Tulloch, A. D.(2018).Factors associated with use of psychiatric intensive care and seclusion in adult inpatient mental health services.Epidemiology Psychiatry Science,27(1),51-61.
6. Full, G. F.(2000).Fall in the elderly.American Fam Physician,5,1-14.
7. Jennings, B. M.,Loan, L. A.,Depaul, D.,Brosch, L. R.,Hildreth, P.(2001).Lessons learned while collecting ANA indicator date.Journal of Nursing Administration,31(3),121-129.
8. Kohn, L. T.,Corrigan, J. M.,Donaldson, M. S.(1999).To err is human: building a safer health system.Washington, DC:National Academy Press.
9. Lger, J. M.,Moulias, R.,Robert, P.,Vallas, B.,Chapuy, P.,Monfort, J. C.,Gerard, D.(2002).Agitation and aggressiveness among the elderly population living in nursing or retirement homes in France.International Psychogeriatrics,14(4),405-416.
10. Massachusetts Nurse Association(2005).Survey of doctors concerning RN staffing and patient care.Massachusetts:Opinion Dynamics Corporation.
11. Needleman, J.,Buerhaus, P.,Mattke, S.,Stewart, M.,Zelevinsky, K.(2002).Nurse-staffing levels and the quality of care in hospitals.New England Journal Medicine,346(22),1715-1722.
12. Slemon, A.,Jenkins, E.,Bungay, V.(2017).Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice.Nursing Inquiry,24(2),1-10.
13. Taylor-Watt, J.,Cruickshank, A.,Innes, J.,Brome, B.,Shah, A.(2017).Reducing physical violence and developing a safety culture across wards in East London.British Journal of Mental Health Nursing,6(1),35-43.
14. Wheatley, C.(2017).Nursing overtime: Should it be regulated?.Nursing Economic,35(4),213-217.
15. 尹裕君(2008)。護理人力、病人安全與護理品質。榮總護理，25(4)，350-356。
16. 台灣臨床成效指標系統(2016，5 月)．台灣臨床成效指標(TCPI) 清單急性精神科指標．2017 年2 月取自http://tcpi.tjcha.org.tw/tcpi/
17. 林秋芬、盧美秀、鍾春枝(2007)。護理品質指標之建構。長庚護理，18(4)，465-474。
18. 邱淑瑾、王萬琳、應立志、江蕙娟、林川雄(2014)。護理人員之工作環境與工作負荷對護理品質影響之研究。休閒事業研究，11(2)，41-53。
19. 侯伯勳、林志堅、卓良珍、陳展航、闕清模(1999)。精神科急性病房意外事件危險因素之回溯性分析。慈濟醫學雜誌，11(3)，271-278。
20. 張嘉蘋(2014)。癌症護理品質管制與監測。榮總護理，31(3)，20-26。
21. 陳玉枝、林麗華、簡淑芬(2002)。住院病患傷害性跌倒的影響因素與其醫療資源耗用之相關性。慈濟護理雜誌，1(3)，66-77。
22. 蔡秀敏、鄭靜瑜、劉淑如(2011)。護理敏感品質指標介紹─以美國護士協會及國家品質論壇為例。領導護理，12(3)，95-101。
23. 蔡佳吟、侯淑英(2010)。精神科急性病房預防跌倒改善專案。精神衛生護理雜誌，5(1)，29-39。
24. 蔡耀州、陳政友、蔡名世(2010)。嘉義縣某地區醫院護理之家及精神病房慢性住院病人跌倒傷害嚴重程度相關因素研究。健康促進暨衛生教育雜誌，30，87-107。
25. 邊立中、謝佳蓉、周桂如(2008)。精神科護理人力之現況分析。精神衛生護理雜誌，3(1)，46-51。