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    Title: 抗煞動線管制設計對於院內感染控制之影響
    Authors: 何美鄉;楊招瑛;李建賢;黃富源;張珩;張上淳
    Contributors: 輔英科技大學 健康事業管理學位學程
    Keywords: 動線管制;SARS院內感染;發燒篩檢站;六標準差;洗手;sars nosocomial infection;traffic control;fever screen station;six sigma;handwashing
    Date: 2003
    Issue Date: 2010-11-16 11:34:16 (UTC+8)
    Abstract: 研究目的: 西元2003年春SARS疫情,台灣度過了早期的「三零時期」,終仍爆發和平事件而進入「院內感染期」。後經松山院區「動線管制」(1、發燒篩檢站、分流進入醫院;2、污染分區:集中照護、醫病分道;3、洗手節點之設置)的感染控制措施,初步觀察顯有降低院內感染率之傾向,並開啟「疾病控制期」之到臨。然而該研究之限制並無法遽下定論。因此本回朔性分析研究之目的在於探討「動線管制」對於醫療機構抗SARS成效及醫護人員保護性之影響,並尋求動線管制抗SARS之理論基礎。 研究方法: 收集台北及高雄兩大都會區所有曾收治或遭受SARS攻擊的醫學中心、區域醫院、地區醫院及其後之安養機構作為研究對象。將上述之研究對象依醫療工作者HCW及民眾是否發生SARS臨床之院內感染,同時輔以血清學篩檢結果,分為實驗組醫院及對照組醫院兩組。以問卷調查,現場訪視、錄音照相等紀錄收集資料,比較此兩組醫院包含動線管制在內之各項保護性措施,統計並評估最適當之保護性因子以作為預防類似疫情或院內感染之參考。 主要發現: 本研究以單項變數分析發現包括「動線管制」之相關概念諸如:發燒篩檢站、急診分流、集中照護污染分區、病房淨空、隔板分區、動線規劃、醫病分道、洗手設備等均達p<0.001之高度統計意義,而呈現保護員工免於SARS院內感染之效果。進一步利用多重變項迴歸分析(multiple logistic regression)發現「發燒篩檢站設立」(p<0.01)與 「急診洗手設備增加」 (p=0.03)此二變項達到統計學上顯著意義,可做為預防院內感染爆發的重要保護措施。 結論: 動線管制固為煞疫時期之全新理論,然而有限之台灣經驗加上本研究之結論推演,其包含發燒篩檢等基本分層、分流、分區、分塊、分級之「流程管理」架構,應可為傳染性疾病或生物戰之有效措施。本研究重要之另一保護性因子為「洗手設備增加」;洗手原本即為為院內感染管制最基本之重要步驟。然而承平時期所達成之洗手率僅30%左右。在疫情高峰時,經動線管制之設計,工作人員身處管制區內得以避免因分區混淆不明而導致意外污染清潔區環境表面,亦可阻斷因帶手套而忽略洗手導致交叉感染之通病。經由侷限流程於動線管制區內,再配以交通節點之「洗手設備配置增加」,將得以達成六標準差之感染控制,意即經由絕對之洗手行為而阻斷SARS傳播最重要之接觸性交叉感染。本研究同時發現免於員工受到感染之對照組醫院亦能同時保護病患及家屬免於SARS之院內感染,阻斷SARS逐波傳染之惡性循環鏈。此一發現印證抗SARS初期「醫護第一、病人次之」之理論實為抗SARS成功之戰略決策基礎。 建議事項: 本研究顯示出對於類似嚴重傳染性疫情,防疫時之整合性(integration)防護概念。隨著致病原傳染性之強弱及疫情之緩滯嚴重,因應疫情之強弱,於不同階段,宜因勢施予不同功能、多重面向之防疫及行政統合管理等措施。發燒篩檢站之設立經證實為保護醫院之重要因子,而醫院急診內化之議題應嚴肅以對。然本研究亦發現入院時均無發燒亦無肺炎之發燒篩檢防疫漏洞,爾後防疫之設計建議加強疫區接觸史之病史(包括住院史)問診;而對高峰疫情時,除發燒篩檢站外,亦建議設置經動線設計之「住院病患觀察區」。針對可能接觸史之病患均建議於此區待至潛伏期過後,方得住進醫院建築主體。上述動線管制模式應能有效應用於傳播模式類似之天花疫情。而動線管制理論基礎來源之「六標準差」流程分級管理之觀念,亦可應用於致病機轉不盡相同之禽流感疫情。本研究宜參考時間序列之特性,再經survival model做統計之後續分析。
    Owing to the highly contagious character of SARS virus, either through droplet/airborne or contact transmission, Health-care workers (HCWs) are at highest risk in acquiring SARS infection while caring SARS case patients in hospitals and become the amplifier of the nosocomial outbreak. Although personal protective equipment (PPE) and negative pressure isolation room (NPIR) were implemented as recommended by health authorities, nosocomial SARS infection among HCWs still occurred. The concept of ?HHH?HH?H?HTraffic Control?HHH?HHH, which include triage and dispatch of the patient (eg. fever screening station) before entering the hospital, zone of protection to confine patient in the contaminated zone and the HCWs in the clean zone, and integrated checkpoint of hand washing, was introduced during the later phase of anti-SARS fighting in most of the hospital around Taiwan in an attempt to minimize transmission of nosocomial SARS infection in HCWs and has some promising effect to stop the SARS epidemic. As the epidemic subsided, a retrospective analysis for the protective efficacy of traffic control in preventing healthcare worker from contracting SARS nosocomial infection was conducted. A total of 51 hospitals which had taken care of SARS patients during SARS epidemic around northern and southern Taiwan were interviewed and analyzed for the efficacy of protective measurements during SARS epidemic. Of them, 18 hospitals belonged to HCWs affected hospitals, while the remaining 33 hospitals had no HCW that acquired nosocomial SRAS infection. Statistical analysis by Mantel-Handel uni-variant method showed that fever screening stations, triage of fever patients, cohorting the SARS patients, separate of entrance/passway between patients and HCWs, increasing facilities of handwashing all demonstrated a significant protective effect (p<0.001). By multiple logistic regression, fever screening station and increase handwashing facilities in ER had shown to be a significant factors in protecting HCWs. The present study also demonstrated that by protecting HCWs in the hospitals through effective control measures, civilians were also protected from contracting nosocomial SARS infections. In conclusion, we speculated that some HCWs still transmitted SARS by direct/indirect casual contact . Fever screening station may prevent inefficient clean/dirty area distinction which would result in accidental nosocomial SARS transmission. Although the importance of hand washing in controlling nosocomial infection has been well-established, an average compliance rate of 30% has always been a problem in the real-world practice. In the setting of SARS caring with barrier precautions and PPEs, a possible false perceived lack of need to wash hands if gloved. The strategic installation of alcohol dispensers to enforce hand disinfection in between zones of risk is an important aspect of Integrated Infection Control Strategy. Through traffic control, we apply the concept of 6 sigma and facilitate the standard precaution so as to increase the awareness and a vigilant adherence to routine handwashing when working in between zones of risk, thus to minimized transmission of SARS.
    Appears in Collections:[健康事業管理系] 研究計畫

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