院內心跳停止(in-hospital cardiac arrest，IHCA)是一項重要、且具有高風險性的病人安全問題。院內心跳停止的發生與否，是醫院對於住院病人生命安全監測以及維護的重要品質指標。成人一般住院病人發生「非預期心跳停止」，急救後恢復期的死亡率仍相當高，存活出院的機會亦僅有12-17%。事件一旦發生，會帶給病人致命性的傷害，對家庭及社會所造成的影響也相當大，因此如何預防院內非預期心跳停止事件的發生，改善心肺復甦急救患者的預後與存活率，已是各醫療院所刻不容緩的重要任務。在臨床照護上，能否提早察覺病人出現心跳可能停止的徵兆，以及緊急醫療團隊能否及時介入，都是病人獲得良好處置與提高生存率的決定性因素。
本研究首先由重症醫學中心、內科部、急診部、護理部與心臟血管中心攜手組成品管圈，統計改善前、中、後共三年一個月，近百萬住院人日數，進行全面的改善。採用「醫療照護失效模式與效應分析」(Healthcare Failure Mode & Effects Analysis，HFMEA）手法，探討未考量到之處，並透過對標準作業流程的檢視，參考先前的院內心跳停止事件原因分析，找出其中的系統問題，以病人為中心(patient-centered)來思考設計，創立八項對策，包括「引進完整國際早期警示系統(NEWS)為全院早期警示系統」、「採用NEWS變化指數當指標將總分達7分以上，且＞ 前3次時段中總分最高者，列入警示」、「於醫師資訊管理及病歷書寫雙系統採用持續燈示提醒」、「於護理師床邊資訊系統採用高風險病人姓名變色提醒」、「早期警示系統病房專用動態看板」、「設計早期警示系統動態螢幕保護程式」、「由急診及重症醫師組成早期警示監控團隊」、「成立早期警示監控團隊Line群組，加強團隊內無縫溝通」及「早晨第一件事先看ＮＥＷＳ」、「值班第一件事先看ＮＥＷＳ」列為早期警示教育重點，因此得以達成目標。
本研究改善了「院內心跳停止IHCA發生密度」及「院內心跳停止IHCA發生率」的兩個主目標，分別由0.38 ‰降至0.20 ‰，以及2.53 ‰降至1.32 ‰ (p<0.05)；同時也獲得到多方面提升附加效益。經由改善「醫師對早期警示系統認同程度」及「醫護人員對早期警示系統認知」，得以改善「醫療爭議每月平均發生人次」、「醫療爭議發生密度」及「加護病房周轉率」，並且進一步提升「第一次心律紀錄為心室顫動(VF)或無脈搏頻脈(VT)IHCA存活出院比率」、「全院IHCA後48小時存活率」、「全院IHCA後出院存活率」和「全院IHCA後48小時存活病人中成功出院比率」，因而降低「全院IHCA病人院內死亡密度」及「全院IHCA病人院內死亡率」，使得本院約多搶救47位病人寶貴的生命。

《Research issue》
In-hospital cardiac arrest (IHCA) is an important patient safety issue with a high risk nature in hospitals. Monitoring the incidence of IHCA is a very important indicator of quality improvement. The majority of initially resuscitated adult IHCA patients die during hospitalization, and only 15-20% of them survive to discharge. Once the event occurs, the patient will suffer fatal injuries and the impact on his family and society will be tremendous. How to early detect deteriorating patients, prevent IHCA and subsequently improve the prognosis of patients becomes an important task in various medical institutes. In clinical setting, both early detection of warning signs of IHCA and timely intervention of rapid response teams improve outcome.

《Research design》
In this study, we conducted a Quality Control Circle (QCC) with a multidisciplinary team involving staffs of Department of Medicine, the emergency department (ED), cardiovascular center, intensive care unit (ICU) and nursing. We surveyed nearly one million patient-days of hospitalization in a total of three years and achieved a comprehensive improvement. We used Healthcare Failure Mode and Effects Analysis (HFMEA) approach to identify inefficient steps in the IHCA pathway and to assess the efficacy of strategies designed patient-centered to expedite this process. We finally created eight designs, including "the introduction of the national early warning system (NEWS) as a hospital-wide clinical alarming system", "the use of 3-subsequent crescendo NEWS total score reaching ≧7 points as a warning ", "the continuous flashing light as a reminder in health information system", "the changing color as a reminder in nursing information system", "the real-time kanban showing NEWS in each ward", "the real-time screen saver showing NEWS in each computer", "the monitoring the NEWS day-and-night by a rapid response team composed of ED and ICU doctors", "the establishment of NEWS Line group to facilitate intra-group communication" and educating staffs deeply in their heart " the first thing in the morning is to look at NEWS ", and "the first thing on duty is to look at NEWS". Finally, we are able to achieve our goals.

《Research Results & Contribution》
In this study, we improved both the density and the incidence of IHCA, from 0.38 ‰ to 0.20 ‰, and 2.53 ‰ to 1.32 ‰ respectively. Additionally, we have achieved more benefits via improving the awareness and the identity of an early warning system¬-—NEWS. We decreased the occurrence of medical disputes and increased the ICU turnover rate. We also enhanced the survival-for-48 hours and survival-to-discharge rate of IHCA patients no matter the initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia. As a result, we reduced the in-hospital mortality rate & mortality density. It is estimated that we will successfully rescue an average of 47 additional patients from death annually.

論文審定書 i
誌謝 ii
中文摘要 iii
英文摘要 v
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 2
第二章 文獻探討 3
第一節 醫療照護失效模式與效應分析 (Healthcare Failure Mode and Effect Analysis) 3
第二節 臨床警示系統 (Clinical Alarm System) 5
第三節 電子監控系統 7
第四節 快速醫療反應小組 8
第三章 院內心跳停止 (In-hospital Cardiac Arrest) 現況 10
第一節 本院院內心跳停止現況分析 10
第二節 國內同儕醫院院內心跳停止現況趨勢 11
第三節 國際同儕院內心跳停止現況趨勢產業現況趨勢 12
第四章 研究方法 13
第一節 成立HFMEA團隊 13
第二節 主題選定與名詞定義 14
第三節 研究架構與作業流程圖 15
第四節 數據收集 16
第五節 執行危害分析 21
第六節 對策擬訂 22
第七節 對策實施與檢討 38
第五章 效果確認與實證分析 48
第一節 有形成果之比較 48
第二節 主目標之目標達成率 51
第三節 有形成果比較(附加效益) 51
第四節 無形成果 62
第五節 標準化及效果維持 63
第六章 結論與建議 65
第一節 標竿學習與創新手法 65
第二節 檢討與改進 74
第三節 管理意涵 75
參考文獻 77

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