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系統識別號 U0026-1001201117212000
論文名稱(中文) 急診醫療專業人員對老年人跌倒評估及處置之認知與現況分析
論文名稱(英文) Perception and Current Status of Assessment and Management for the Elderly with Falls among Emergency Medical Professionals
校院名稱 成功大學
系所名稱(中) 老年學研究所
系所名稱(英) Institute of Gerontology
學年度 99
學期 1
出版年 100
研究生(中文) 吳錦蓉
研究生(英文) Chin-Jung Wu
學號 tc6984051
學位類別 碩士
語文別 中文
論文頁數 112頁
口試委員 指導教授-張家銘
口試委員-紀志賢
口試委員-陳清惠
中文關鍵字 急診醫療專業人員  老年人跌倒  認知  跌倒評估 
英文關鍵字 emergency medical professionals  elderly falls  perception  fall assessment 
學科別分類
中文摘要 跌倒在老年族群不僅有高度盛行率及再發生率,還可能會造成嚴重傷害甚至死亡。但多
數老年人在跌倒後48小時內會因跌倒傷害入急診尋求治療,所以急診對於跌倒的評估及預防其實是很重要的單位。然而在忙碌的工作環境之下,急診醫療人員對老年跌倒評估及處置的
想法和執行程度都可能影響這群跌倒老年人的預後和再次跌倒的發生。因此本研究目的旨在探討南台灣急診醫療人員對老年人跌倒評估及處置的認知差異與執行現況。
本研究採橫斷式研究設計,並分為兩部分進行資料收集,包括結構式問卷與病歷回顧。問卷施測對象為急診醫師和護理人員,內容為研究者參考美國老年醫學會所制定的跌倒預防準則,以及老年人跌倒的臨床評估方式SPLATT所設計,包含「評估項目的重要性想法」、「自評執行程度」、「困難因素」與「自評在急診應該要執行的評估處置項目」等部分,並以多變項分析探討急診醫療人員的特質與跌倒評估認知的相關性。病歷回顧對象則為55歲以上因跌倒入急診的老年患者,且收集醫療人員紀錄在病歷中實際有執行的評估及處置項目後,進行描述性統計分析,再與問卷資料整合探討急診醫療人員的認知與實際現況之相關性。
本研究共取得113位急診醫療人員之問卷。研究結果顯示:在重要性想法方面,醫療人員整體上認為與跌倒有關的各評估項目是重要或非常重要;使用多因子迴歸分析後發現,認為在急診執行老年跌倒評估及處置是很重要的醫療人員,其特質為:自評瞭解老年跌倒評估者(p=0.029) 以及曾處置過老年人因跌倒入急診者(p= 0.043)。在各項跌倒評估的執行程度方面,醫療人員整體上自評大多或一定會執行;使用多因子迴歸分析後發現,自評在急診較會執行老年跌倒評估及處置的人員特質為:自評瞭解老年跌倒評估者(p=0.007)以及急診服務年資≦3年者(p= 0.019)。在困難因素方面,較多醫療人員認為時間有限、人力不足、照顧者為外籍看護以及急診缺乏老年跌倒照會機制是執行評估之困難;使用多因子迴歸分析後發現,認為在急診執行跌倒評估較無困難的人員特質為:有執行過老年跌倒評估者(p=0.013)。在自評應該要執行的評估處置項目上,發現職別呈現較多的差異,醫師自評應該在急診執行的評估項目多於護理人員,但也發現醫師自評較不應該在急診執行的項目皆屬於衛教部分,而護理人員則是急慢性病況或是身體系統的評估。
II
本研究亦取得167份老年跌倒患者的急診病歷。研究結果顯示有十一項跌倒評估的實際執行程度少於一成,包含:跌倒後在地上停留的時間(1.8%)、是否需協助才能站起來(1.2%)、過去是否曾經跌倒(7.8%)、日常活動功能(8.4%)、工具性日常活動功能(0%)、居家安全環境(0%)、是否有接受視力評估(6.0%)、藥物評估(9.0%)、測量躺-站血壓(2.4%)、認知功能評估(2.4%)以及步態平衡檢查(10.2%)。在問卷與病歷的整合分析中發現僅四項評估為醫療人員認為重要
,並自評在急診應該要且一定會執行,而實際上也的確有執行的項目,包含:詢問跌倒地點、慢性疾病情況、測量生命徵象與評估受傷部位;其餘項目卻呈現醫療人員認為重要,但實際執行程度偏低的狀況。
本研究結果顯示,台灣急診醫療人員雖然認為跌倒評估是重要的,但實際執行比率卻偏低,此結果或許不能只用時間有限或人力不足做為無法在急診執行跌倒評估的解釋,而是要探討國內急診是否尚未注意老年人跌倒之議題,因此需加強相關的宣導及教育,並建立跌倒評估流程的概念,且期望未來能發展適合國內急診使用之跌倒篩檢或評估工具。更重要的是
老年人跌倒並非單一科別即可處理的議題,因此連結相關的科部及討論才能有效減少跌倒的發生,以提供老年跌倒患者更適切的照顧。
英文摘要 Not only high prevalence and recurrence rates, falls in the elderly population also result in serious injuries and death. Because most of older adults will be sent to the Emergency Department (ED) for treatment within 48 hours after a fall-related injury occurs, the ED is an important unit for the assessment and prevention of falls. However, on such a busy environment, the perception and implementation of assessment and management of elderly falls among Emergency Medical Professionals (EMPs) will affect the prognosis and the incidence of recurrent falls. Therefore, the aim of this study is to investigate the perception and current practice of assessment and management for the elderly with falls among EMPs in southern Taiwan.
The study is a cross-sectional and retrospective design. Data were collected by using structured questionnaire and medical chart review. The EMPs including ED physicians and nurses were asked by self-reported questionnaire. The contents of survey was based on the “Guideline for the prevention of falls in older persons” by the American Geriatric Society (AGS) and the SPLATT. The questionnaire consisted of four major parts, including importance of fall assessment, degrees of self-reported assessment, barrier factors and the assessment items that should be implemented at ED. Data was analyzed using multiple regression to explore the correlation between demographic characteristics of EMPs and the perception of falls assessment. The medical chart for patients aged 55 years and older presenting to the ED after a fall were reviewed, and the implementation items recorded by EMPs were obtained. All data were analyzed using descriptive statistics, and the data of four major parts were compared to explore the relationship between EMPs’ perception and actual status of falls assessment and management.
A total of 113 EMPs were enrolled in this study. The EMPs thought all the items of fall assessment are important or very important. Multiple regression analysis of the characteristics of EMPs were those who reported understanding the assessment of elderly falls (p=0.029) and had ever cared the older people presenting to the ED after a fall (p= 0.043). In the implementation of fall assessment, most items were reported to be executed by EMPs. Multiple regression analysis of the characteristics of EMPs were those who reported understanding the assessment of elderly falls (p=0.007) and had the working experiences at ED less than 3 years (p= 0.019). In the barriers
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factors, most of EMPs thought the limited time, shortage of manpower, foreign caregivers and lack of consulting protocols for elderly falls were the barriers to implement assessment at the ED. In addition, multiple regression analysis of the characteristics of EMPs were those who had ever performed assessment of elderly falls (p=0.013), had less difficulty in implementing fall
assessment. There was difference between occupations of EMPs and self-reported
assessment items. Although the self-reported number of items were more among the emergency physicians than among the nurses, items related to educations of patients reported less to be implemented among emergency physicians, while assessment of acute and chronic diseases and physical examination reported less among nurses.
Reviews of medical chart, were obtained in 167 persons who presented to the ED after a fall. The rates of actual implementation for assessment items were less than 10%, including inquiry of staying on the ground (1.8%), assistance required to stand up (1.2%), a past history of falls (7.8%), activities of daily living (8.4%), instrumental activities of daily living (0%), home hazards (0%), visual examination (6.0%), medication reviews (9.0%), orthostatic hypotension (2.4%), cognitive function (2.4%) as well as gait or balance (10.2%). Only four items including location of fall, chronic diseases, vital signs and assessment of injuries were considered as important, and were reported that EMPs should and would assess and really implemented the assessment. While the remaining items were reported that the EMPs considered as important, but had lower degree of actual implementation.
Our results showed that the EMPs in Southern Taiwan thought the fall assessment was important, but the rates of actual implementation were low. Perhaps limited time or shortage of manpower are not the main reasons that EMPs did not pay attention to the issue of elderly falls. Thus, to educate and to establish the concept of fall assessment should be emphasized in Taiwan. In addition, a screening / assessment tool for elderly falls at ED should be developed to promote management. Nevertheless, the elderly falls may not be managed only by a single specialist. Coordination and discussion between related departments would reduce the rates of recurrent falls and will provide benefit for older people who falls.
論文目次 目錄
頁次
中文摘要......................................................................................................................................
I
英文摘要......................................................................................................................................
III
致謝..............................................................................................................................................
V
目錄..............................................................................................................................................
VI
第一章 緒論...............................................................................................................................
1
第一節 研究背景與動機...........................................................................................
1
第二節 研究重要性...................................................................................................
2
第三節 研究目的.......................................................................................................
3
第四節 研究問題與假設...........................................................................................
3
第二章 文獻探討.......................................................................................................................
4
第一節 跌倒流行病學...............................................................................................
5
第一項 跌倒盛行率與死亡率...................................................................
5
第二項 跌倒併發症與衝擊.......................................................................
6
第二節 跌倒危險因子...............................................................................................
7
第一項 內在因素.......................................................................................
7
第二項 外在因素.......................................................................................
8
第三項 環境因素.......................................................................................
8
第三節 跌倒評估及處置...........................................................................................
9
第一項 跌倒預防準則...............................................................................
9
第二項 跌倒評估與處置相關研究...........................................................
14
第三章 研究方法.......................................................................................................................
21
第一節 名詞定義.......................................................................................................
21
第二節 研究架構.......................................................................................................
21
第三節 研究設計.......................................................................................................
22
第一項 研究場所及對象...........................................................................
23
第二項 抽樣方式及樣本數.......................................................................
23
第四節 研究工具.......................................................................................................
23
第一項 研究工具內容...............................................................................
23
第二項 研究工具信、效度.......................................................................
25
VII
第三項 資料處理與分析...........................................................................
27
第四章 研究結果.......................................................................................................................
28
第一節 問卷基本概況...............................................................................................
28
第二節 急診醫療人員的人口特質與重要性想法、自評執行程度、困難因素以
及自評應該要執行的評估處置項目之關係...............................................
35
第三節 重要性想法、自評執行程度、困難因素以及自評應該要執行的評估處
置之預測因子...............................................................................................
51
第四節 病歷基本概況...............................................................................................
58
第五節 重要性想法、自評在急診應該要執行的評估項目、自評執行程度與實
際執行現況之關係.......................................................................................
63
第五章 討論...............................................................................................................................
68
第一節 急診醫療人員的人口特質與重要性想法、自評執行程度、困難因素以
及自評應該要執行的評估處置項目之關係...............................................
68
第二節 病歷基本概況...............................................................................................
78
第三節 重要性想法、自評在急診應該要執行的評估項目、自評執行程度與實
際執行現況之關係.......................................................................................
84
第六章 結論與建議...................................................................................................................
88
第一項 結論...............................................................................................................
88
第二項 研究限制.......................................................................................................
89
第三項 應用與建議...................................................................................................
90
參考文獻......................................................................................................................................
92
附件
附件一 專家效度名單...............................................................................................................
99
附件二 致專家效度鑑定涵.......................................................................................................
100
附件三 問卷評核表...................................................................................................................
101
附件四 「急診專業醫療人員對老年人跌倒評估及處置之認知、執行現況及困難」調查
問卷...........................................................................................................................
105
附件五 「急診對跌倒老年人的評估與處置項目」病歷調查表...........................................
109
附件六 簡易審查受試者同意書...............................................................................................
110
附件七 同意臨床試驗證明書...................................................................................................
111
附件八 同意計畫修正證明書...................................................................................................
112
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