| 摘要: | 研究背景
根據世界衛生組織西元2007年的資料表示六十五歲以上老年人中每三個人就有一人發生跌倒。老年人跌倒會導致非致死性傷害 (如：骨折、腦出血及創傷等)，造成老年人活動功能下降或住院，進而增加醫療成本，甚至是跌倒誘發之死亡。根據過去文獻可將造成跌倒的危險因子分成兩大類：(1) 外生性危險因子：環境上因素，例如：空間設計不良、光線昏暗或不當的使用藥品、(2) 內生性危險因子包括年齡、性別、生理功能，例如頭暈、視覺障礙、步態不穩及疾病則以中風、糖尿病及夜尿症為主。過去許多文獻提及預防跌倒的方法，例如：使用跌倒風險評估量表，因為此一量表無法適用於每家醫院，導致預防跌倒效果不彰。近年研究指出預防跌倒有效的對策為找出該醫院之特定科別的危險因子後，再針對其危險因子給予介入，才能達到降低住院特定科別病人跌倒的目的。
研究目的
主要目的為找出此區域醫院住院病人與跌倒相關之危險因子：(1) 外在危險因子：跌倒時間、地點及跌倒前從事活動等；(2) 內在危險因子：性別、臨床科別、疾病及使用藥品等。次要目的為針對此醫院住院病人制定預防跌倒的措施。
研究方法
本研究為一回溯性橫切面研究 (retrospective cross-section study)，收錄所有此區域醫院3年間所有發生跌倒 (n = 309) 與沒有發生跌倒 (n = 51,412) 之住院病人，使用單變數邏輯斯迴歸分析方法計算出曾發生跌倒與未發生跌倒住院病人之勝算比 (Odds ratio) 及其95% 信賴區間 (95% confidence interval)，p < 0.05表示有顯著上的差異性，並分析出跌倒與其各種住院病人跌倒危險因子之間 （性別、年齡、科別、疾病及藥品等）的關聯性。
研究結果
全院住院病人跌倒率為每1,000位病人-天數中會發生0.8次跌倒，其中以復健科跌倒率最高，每1,000位病人-天數中會發生1.9次跌倒。本院住院病人之主要跌倒危險因子：(i) 內在危險因子為50歲以上、男性、復健科、中風和糖尿病(p < 0.05) 及併用3至5種藥品；(ii) 外在危險因子為凌晨2至3點、床邊及浴室。特別是復健科50歲以上住院病人單獨使用短效型 benzodiazepines或zolpidem 及併用兩項藥品者，皆會顯著增加跌倒風險 (p < 0.05)。
討論及結論
本研究結果證實，大於50歲之復健科住院病人為具有最高跌倒風險之族群，特別是併用大於4種以上藥品者跌倒的風險會隨之增加，因此針對上述此院的跌倒危險因子提出降低跌倒率的措施，(i) 醫師、藥師及護士共同評估住院病人的生理狀況及用藥情形、(ii) 衛教病人及其家屬、(iii) 於床旁標示高度跌倒風險族群、(iv) 降低床位、(v) 減少併用藥品數量，監測高跌倒風險藥品、(vi) 加強肌肉及骨骼強度、(vii) 使用尿布等措施。希望本研究所提出之預防跌倒的策略，可確實降低此區域醫院住院病人跌倒的發生率。
BACKGROUDNS
In 2007 WHO showed that one in every three elderly adults falls every year. Elderly falls cause unintentional fall-related injuries including fracture, brain injuries, trauma and fatal fall, all of which increased medical expenditures. Previous studies have categorized risk factors for falls as: (i) extrinsic factors including poor building design, insufficient light, and improper using medications; (ii) intrinsic factors including elderly, gender, decline in physical capability, disease like stroke, diabetes, and nocturia. Several previous studies suggest a fall prevention strategy of using fall risk assessment score to identify inpatients with a high-risk of fall. Recent studies show that fall prevention programs should be targeted inpatients with similar risk factors, and develop a fall prevention strategy or intervention.
OBJECTIVES
Primary aims of this study were to find the fall risk factors in this community hospital, and to classify them into (i) extrinsic risk factors such as falling time, falling place, and behavior before falling; (ii) intrinsic risk factors such as gender, clinical department, disease, using medication like polypharmacy and high-risk drugs. Secondary aim was to set up a fall prevention strategy for inpatients of this community hospital.
METHODS
This was a population-based cross-section study in Taiwan. The participants were inpatients who fell (n = 309) and those who did not fall (n = 51,412) during a three-year study period (July 2009 to July 2011) in this community hospital. The analysis of the association between risk factors and falling was done using the statistics method of univariate logistic regression analysis for odds ratio (OR) with 95% confidence interval (CI) and values of p < 0.05 were considered significant.
RESULTS
The fall rate of the hospitalized patients was 0.8 falls per 1,000 patient-days at this community hospital. The rehabilitation department was found to be associated with the highest fall rate of 1.9 falls per 1,000 patient-days. The fall risk factors in this hospital were: (i) intrinsic risk factor including age above 50 years old, male, rehabilitation department, stroke and diabetes (p < 0.05); (ii) extrinsic risk factors including getting to bath at midnight (2:00 to 3:00 a.m.), polypharmacy using 3 to 5 drugs. The present results showed that inpatients of the rehabilitation department who used short-acting benzodiazepines, zolpidem and/or both also significantly increased risk of fall (p < 0.05).
DISCUSSION AND CONCLUSIONS
The present results confirmed that elderly inpatients of the rehabilitation department were found to have highest fall rate. Based on risk factors of falls found in this hospital, we suggest the following falls prevention strategy for the rehabilitation department: (i) assessment of high risk patients by doctors, nurses, and pharmacists; (ii) education of patients and family members by physicians and enforced by nurses for falls prevention; (iii) labeling high-risk patients with “red poster”; (iv) lowing the height of bed; (v) reducing drug items and monitoring high-risk medications; (vi) physical therapy to strengthen muscle and bone, and (vii) using diaper in elderly. The present results may help to develop a preventive strategy for reducing inpatients’ falling rate at this community hospital. |
