加護病房重症病人因病況危重而插置氣管內管使用呼吸器以提供呼吸道支持，並放置各式侵入性導管進行積極治療及監測，因此限制病人活動並強制臥床休息。隨著急性期過後，病人因臥床不動導致肌肉萎縮、活動能力下降，嚴重者影響心肺功能，使呼吸器脫離困難，延長加護病房住院天數。本研究目的在探討加護病房執行病人早期復健活動，對於提升身體活動能力、縮短加護病房住院天數及呼吸器使用天數之成效。本研究採類實驗法以資料回溯方式，於研究醫院之成人加護病房進行研究，將病人分為實驗組I (35位)、實驗組II (33位)及對照組(52位)，三組共120人。實驗組兩組依創新開發的加護病房早期復健活動(Early goal-directed mobilization, EGDM)照護流程，並以加護病房活動量表(ICU mobility scale, IMS)評估病人活動程度提供合適復健活動，實驗組I由物理治療師進行每日一次EGDM措施，實驗組II由護理師及物理治療師進行每日兩次EGDM，對照組未實施EGDM僅實施常規照護。資料收集透過電子病歷收集2016年1月1日至2019年12月31日三組病人資料，以卡方檢定、獨立樣本t檢定、配對樣本t檢定、單因子變異數分析、迴歸分析等統計方法進行分析。研究結果：與對照組比較，實驗組I與實驗組II的加護病房呼吸器使用天數及加護病房住院天數未達顯著差異；介入不同方案EGDM，實驗組I及實驗組II於復健期間前後比較IMS均有進步，而實驗組II 之IMS進步分數較實驗組I為多；介入不同方案EGDM，比較實驗組I及實驗組II復健期間第一次IMS兩組間無差異，而復健期間最後一次IMS則為實驗組II較實驗組I進步程度顯著；實驗組(實驗組I與實驗組II)之IMS進步分數越多，加護病房呼吸器使用天數越短；實驗組(實驗組I與實驗組II)之IMS進步分數越多，加護病房住院天數縮短，但未達統計上顯著差異。結論：介入EGDM與提升重症病人身體活動能力(IMS)及縮短加護病房呼吸器使用天數相關，而加護病房住院天數則需要更多的研究探討以證實其成效。

Background and Aim: The critical patients who stay in intensive care unit (ICU) are usually suffered from insertion of endotracheal tube and ventilator support because of serious illness and the need of airway protection. In addition, they also have some invasive catheters on the bodies for close monitoring. These instruments and the usage of sedative drugs limit their muscle activity and ability passively. As we known, bed-ridden for a long time will cause muscle atrophy, decrease activity of extremities with negative effects on their cardiovascular function in this kind of patients. It also increases the possibility of difficult ventilator weaning and extended staying in ICU. Hence, implementing the early goal-directed mobilization (EGDM), a novel rehabilitation program, in these patients in ICU may be one of the solution for resolving these problems. The aim of this research is to evaluate the impact of EGDM on the increase of activity, shortening days of staying and using ventilator in ICU.
Methods: This study reviewed the adult patients who receiving critical care in ICU in a medical center retrospectively. A total of 120 patients were enrolled for analysis and were divided into three groups: group I (n=35), group II (n=33) and control group (n=52). The EGDM in once daily would be conducted in patients of group I by physical therapists. The EGDM in twice daily would be conducted in patients of group II by registered professional nurses and physical therapists. The patients of control group received bed-side care without EGDM implementation. The patients’s activity and ability would be evaluated by the ICU mobility scale (IMS).The medical information of the three groups of patients were collected from Jan 1st,2016 to Dec 31st, 2019. The statistical analysis used Chi-square test, independent and paired sample T-tests, and logistic regression analysis.
Results: Compared to the control group, the days of using ventilator and staying in ICU did not achieve significant difference between the patients in group I and II. However, improvement of IMS were both achieved in group I and II. Furthermore, the IMS of group II was more improved than of group I. Although the IMS revealed no significant difference in both groups during the first course of EGDM, The IMS of group II achieved significant improvement than of group I in the last EGDM program. In addition, the more IMS improved, the less days of ventilator dependent achieved. The more IMS score improved, the trend of less staying in ICU achieved.
Conclusion: implementing the EGDM is associated with increase the IMS for critical patients in ICU and shorten the days of ventilator usage. But days of staying in ICU needs more research to confirm its effectiveness.

論文審定書 i
致謝 ii
中文摘要 iii
Abstract iv
目錄 vi
圖目錄 viii
表目錄 ix
第一章 緒論 1
第一節 研究背景、重要性及動機 1
第二節 研究目的 3
第二章 文獻查證 4
第一節 重症病人制動之影響 4
第二節 早期復健活動之相關探討 7
第三節 加護病房呼吸器使用天數相關探討 14
第四節 加護病房住院天數相關探討 18
第三章 研究方法 22
第一節 研究架構 23
第二節 研究假設 25
第三節 研究對象與場所 26
第四節 研究步驟 28
第五節 變數測量 33
第六節 研究倫理 35
第七節 資料分析與統計 36
第四章 研究結果 38
第一節 研究對象之基本資料分析 39
第二節 實驗組與對照組加護病房呼吸器使用天數之差異分析 45
第三節 實驗組與對照組加護病房住院天數之差異分析 46
第四節 實驗組不同復健方案的介入對IMS之影響 47
第五節 IMS分數的增加對於加護病房呼吸器使用天數之影響 49
第六節 IMS分數的增加對於加護病房住院天數之影響 50
第五章 討論與建議 51
第一節 討論與建議 52
第二節 研究限制與建議 62
第六章 結論 64
參考文獻 65
附錄一 加護病房病人早期復健活動照護流程 72
附錄二 加護病房活動量表(ICU mobility scale, IMS) 73
附錄三 人體研究倫理審查委員會-人體研究計畫同意函 74

中文部分：
1. 王筱珮、羅美芳(2019)·重症後虛弱症·台灣醫學，23(4)，513-521。
2. 王義民、黃煜為、林姿伶、陳思穎(2009)·重症病患的營養支持·重症醫學雜誌，10(3)，229-241。
3. 毛舒茵、劉美媛(2018)·主觀整體營養評估與客觀臨床數值與外科重症病人預後相關性探討·健康科技期刊，4(2)，1-19。
4. 白玉珠、董金蓮、洪曉佩、鄒怡真、楊惠菁、黃朱貝（2007）·病人下床活動訓練與脫離呼吸器之相關性研究·源遠護理，1(2)，42-51。
5. 行政院主計處(2018年11月)·國情統計通報‧取自：https://www.dgbas.gov.tw/
public/Data/811816151DBUFAVDH.pdf
6. 李宜純、許重梅、謝慧觀、薛清香、李寶琳、林惠釧（2016）·重症多神經病變與肌肉病變的診斷、危險因子及預防方法·呼吸治療，15（2），37-49。
7. 李明芬、許祥純、林孟志(2008) ·積極營養介入對使用呼吸器之急性呼吸衰竭患者之效益探討·臺灣營養學會雜誌，33(1)，30-38。
8. 李書琦、陳怡如、劉乃瑜、陳欽明、黃惠美(2018)·比較執行早期下床活動與ABCDE組合照護對內科加護病房病人呼吸器使用天數之影響·物理治療，43(2)，119-192。
9. 李珮琳、呂欣茹(2005)·加護病房之病人安全－以呼吸器相關肺炎(VAP)感染與Acinetobactor baumannii相關因素分析及護理措施為例·慈濟醫學雜誌，17(4)，47-50。
10. 何菊修、陳宗鷹(2005)·急性術後疼痛·慈濟醫學雜誌，17(6_S)，43-50。
11. 吳麗娟、歐乃欣、劉淑媛、陳佳慧(2012)·住院老年病患之功能下降與其預防·台灣醫學，16(5)，545-549。
12. 吳淑芬、吳清平、謝國洲、黃忠智(2010)·應用肺部復原治療於加護病房之成效初探·台灣急診專科醫師期刊，2(4)，115-119。
13. 林碧珠、林瓊珠、姚吟蓮(2001)·脊椎手術後疼痛控制－必要時每四小時靜脈滴注Demerol之效果探討·護理雜誌，48(2)，49-58。
14. 邱韋欽 (2009)·APACHE II評估表對中部某醫學中心外科加護病房死亡率之估計與分析(中山醫學大學醫學研究所碩士論文)，取自https://hdl.handle.net/11296/7qge68。
15. 邱艷芬(1995)·重症期間之代謝變化與護理·護理雜誌，42(2)，7-13。
16. 翁麗雀、鄭綺(1996)·開腹手術病人止痛劑(demerol)要求時疼痛程度及相關因素之探討·長庚護理，7(1)，45-55。
17. 郭瑞萍、翁靜美、陳金玫(2015)·護理人員在術後疼痛照護中的挑戰·領導護理， 16(4)，11-20。
18. 陳玉枝(2003)·加護病房醫療品質影響因素之探討·榮總護理，20(2)，171-183。
19. 陳秀蓮、唐福瑩(2002)·疾病嚴重度評估反其護理應用·榮總護理，19(1)，71-79。
20. 陳季涵、周幸生(2015)·重症病人譫妄的群組照護·領導護理，16(1)，2-10。
21. 陳欽明、曾桂玲、黃佩珍、鄭高珍(2006)·內科加護病房非計劃性拔管之探討·中華民國急救加護醫學會雜誌，17(1)，13-23。
22. 黃惠美(2016)·早期下床活動-縮短加護病房病人呼吸器使用天數·奇美醫訊，112, 40-41。
23. 童惠芳、白玉珠、林柏瑤、陳美娟、蔡雅琪（2012）·分析手臂運動訓練對病人脫離呼吸器之成效·護理暨健康照護研究，8(2)，138-148。
24. 張于娟、陳玉如(2017)·以護理人員為主導的實證照護措施於呼吸器脫離之運用·台灣醫學，21(2)，208-217。
25. 詹依熒、林家慧、李玉英、陳美娟(2017)·運用早期活動計劃協助一位呼吸器依賴病人脫離呼吸器·彰化護理，24(3)，93-105。
26. 劉欣怡、鄭惠如(2019，11月)·降低加護病房非計畫性氣管內管滑脫率·論文發表於元培醫事科技大學主辦之2019健康管理學術研討會暨國際尖端醫學論壇·新竹市：元培醫事科技大學。
27. 劉詩玉、謝佳容(2018)·不同身體質量指數之重症病人其營養支持狀況與臨床結果·臺灣營養學會雜誌，42(4)，111-120。
28. 盧淑芬、陳季涵、尚婉明、周幸生(2012)·重症病人導管相關血流感染的預防與照護·護理雜誌，59(4)，5-11。
29. 鍾旻珊、黃琪津、葉淑玲、林月娥、賀倫惠、陳淑卿(2016)·肺部復健運動介入對使用呼吸器重症病患之成效—系統性文獻回顧·護理雜誌，63(3)，94-104。
30. 龍芳、曾惠筠、楊式興(2017)·發展重症呼吸治療品質監測指標之初探研究，呼吸治療，16(1)，1-13。
31. 顏淑婷、黃詩芳、陳仁隆、王志榮、沈延盛、應純哲(2015)·外傷嚴重度和住院天數相關性之探討，醫務管理期刊，16(4)，315-330。

英文部分：
1. Adler, J., & Malone, D. (2012). Early Mobilization in the Intensive Care Unit: A Systematic Review. Cardiopulmonary Physical Therapy Journal, 23(1), 5-13.
2. Arias-Fernández, P., Romero-Martin, M., Gómez-Salgado, J., & Fernández-García, D. (2018). Rehabilitation and early mobilization in the critical patient: systematic review. The Journal of Physical Therapy Science, 30(9), 1193-1201.
3. Büyükyilmaz, F. E., & Aşti, T. (2010). Postoperative pain characteristics in Turkish orthopedic patients. Pain management nursing, 11(2), 76-84.
4. Chambers, M. A., Moylan, J. S., & Reid, M. B. (2009). Physical inactivity and muscle weakness in the critically ill. Critical Care Medicine, 37(10), S337-346. doi: 10.1097/CCM.0b013e3181b6e974
5. Creutzeldt, C. J., & Hough, C. L. (2015). Get out of bed:Immobility in the neuro ICU. Critical Care Medicine, 43(4), 926-927. doi:10.1097/CCM.0000000000000836
6. Devlin, J. W., Skrobik, Y., Gélinas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., …Alhazzani, W. (2018). Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine, 46(9), 1532-1548. doi: 10.1097/CCM.0000000000003259
7. Donabedian, A. (1988). The Quality of Care How Can It Be Assessed ? JAMA. 260(12), 1743-1748. doi:10.1001/jama.1988.03410120089033
8. Doiron, K. A., Hoffmann, T. C., & Beller, E. M. (2018). Early intervention (mobilization or active exercise) for critically ill adults in the intensive care unit. Cochrane Database of Systematic Reviews, 3, 1-50. DOI: 10.1002/ 14651858. CD010754.pub2.
9. Dong, Z., Yu, B., Zhang, Q., Pei, H., Xing, J., Fang,W., …Song, Z.(2016). Early Rehabilitation Therapy Is Beneficial for Patients With Prolonged Mechanical Ventilation After Coronary Artery Bypass Surgery. Int Heart J, 57, 241-246.
10. Dunwoody, C. J., Krenzischek, D. A., Pasero, C., Rathmell, J. P., & Polomano, R. C. (2008). Assessment, Physiological Monitoring, and Consequences of Inadequately Treated Acute Pain. Journal of Perianesthesia Nursing, 23(1), S15-17.
11. Eggmann, S., Verra, M. L., Luder, G., Takala, J., & Jakob, S. M. (2018). Effects of early, combined endurance and resistance training in mechanically ventilated, critically ill patients: A randomised controlled trial. PLoS One, 13(11), 1-19. doi:10.1371/journal.pone.0207428
12. Filsoufi, F., Rahmanian, P. B., Castillo, J. G., Chikwe, J., & Adams, D. H. (2008). Predictors and Early and Late Outcomes of Respiratory Failure in Contemporary Cardiac Surgery. Chest, 133(3), 713-21. doi: 10.1378/chest.07-1028
13. Fuke, R., Hifumi, T., Kondo, Y., Hatakeyama, J., Takei, T., Yamakawa, K., Inoue, S., & Nishida, O. (2018). Early rehabilitation to prevent postintensive care syndrome in patients with critical illness:a systematic review and meta-analysis. BMJ Open, 8(5), 1-10.
14. Gosselink, R., Clerckx, B., Robbeets, C., Vanhullebusch, T., Vanpee, G., Segers, J. (2011). Physiotherapy in the Intensive Care Unit. Netherlands Journal of Critical Care, 15(2), 66-75.
15. Hodgson, C.L., Bailey, M., Bellomo, R., Berney, S., Buhr, H., Denehy, L., … Webb, S. (2016). A Binational Multicenter Pilot Feasibility Randomized Controlled Trial of Early Goal-Directed Mobilization in the ICU. Critical Care Medicine, 44(6), 1145-1152. doi: 10.1097/CCM.0000000000001643
16. Hodgson, C.L., Berney, S., Harrold, M., Saxena, M., Bellomo, M. (2013).
Clinical review: Early patient mobilization in the ICU. Critical Care,
17(1), 207-213. doi:10.1186/cc11820
17. Hoenig, H. M., & Rubenstein, L. Z. (1991). Hospital-Associated Deconditioning and Dysfunction. Journal of the American Geriatrics Society, 39(2), 220-222.
18. Irwan, A. M. I. (2018). Effect of Active Mobilization on Patients in the Intensive Care Unit: A Systematic Review. International Journal of Caring Sciences, 11(3), 1942-1953.
19. Klein, K., Mulkey, M., Bena, J. F., & Albert, N. M. (2015). Clinical and psychological effects of early mobilization in patients treated in a neurologic ICU: a comparative study. Critical Care Medicine, 43(4), 865-873.
20. Knaus, W. A., Draper, E. A., Wagner, D. P., & Zimmerman, J. E. (1985). APACHE II:a severity of disease classification system. Critical Care Medicine, 13(10), 818-829.
21. Mendez-Tellez, P. A., & Needham, D. M. (2012). Early Physical Rehabilitation in the ICU and Ventilator Liberation. Respiratory Care, 57(10), 1663-1669.
22. Morris, P. E., Goad, A., Thompson, C., Taylor, K., Harry, B., Passmore, L., … Haponik, E. (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical Care Medicine, 36(8), 2238-2243.
23. Oliveira, A. B. F., Dias, O. M., Mello, M. M., Araújo, S., Dragosavac, D., Nucci, A., & Falcão, A. L. E. (2010). Factors associated with increased mortality and prolonged length of stay in an adult intensive care unit. Rev Bras Ter Intensiva, 22(3), 250-256.
24. Razazi, K., Thille, A. W., Carteaux, G., Beji, O., Brun-Buisson, C., Brochard, L., & Dessap, A. M. (2014). Effects of Pleural Effusion Drainage on Oxygenation, Respiratory Mechanics, and Hemodynamics in Mechanically Ventilated Patients. Annals of American Thoracic Society, 11(7), 1108-1024.
25. Schmidt, U. H., Knecht, L., & Maclntyre, N. R. (2016). Should early mobilization be routine in mechanically ventilated patients? Respiratory Care, 61(6), 867-875.
26. Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L.,…Kress, J. P.(2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients:a randomised controlled trial. Lancet, 373(9678), 1874-1882.
27. Sugiarto, N., & Darmawan, E. S. (2014). The Factors Affecting the Length of Stay in the Intensive Care Units of Pertamina Central Hospital in Indonesia Related to Healthcare Associated Infections. US-China Medical Science,11, 195-204. doi: 10.17265/1548-6648/2014.04.004
28. Tipping, C. J., Harrold, M., Holland, A., Romero, L., Nisbet, T., & Hodgson, C. L. (2017). The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review. Intensive Care Med, 43(2), 171-183. doi:10.1007/s00134-016-4612-0
29. Toptas, M., Samanci, N. S., Akkoc, I., Yucetas, E., Cebeci, E., Sen, O.,…Ozturk, S. (2018). Factors Affecting the Length of Stay in the Intensive Care Unit:Our Clinical Experience. Bio Med Research International, 20, 1-4. DOI:10.1155/2018/9438046
30. Wright, S. E., Thomas, K., Watson, G., Baker, C., Bryant, A., Chadwick, T. J., . . . Baudouin, S. (2017). Intensive versus standard physical rehabilitation therapy in the critically ill (EPICC): a multicentre, parallel-group, randomised controlled trial. Thorax, 73(3), 213-221. doi:10.1136/ thoraxjnl -2016-209858
31. Zang, K., Chen, B., Wang, M., Chen, D., Hui, L., Guo, S.,…Shang, F. (2019). The effect of early mobilization in critically ill patients: A metaanalysis. Nurs Crit Care, 1–8. DOI: 10.1111/nicc.12455