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博碩士論文 etd-0802114-094930 詳細資訊
Title page for etd-0802114-094930
論文名稱
Title
持續改善急性心肌梗塞病患照護品質研究
Improvement of Quality of Care of Patients with Acute Myocardial Infarction
系所名稱
Department
畢業學年期
Year, semester
語文別
Language
學位類別
Degree
頁數
Number of pages
63
研究生
Author
指導教授
Advisor
召集委員
Convenor
口試委員
Advisory Committee
口試日期
Date of Exam
2014-06-05
繳交日期
Date of Submission
2014-09-02
關鍵字
Keywords
品管圈、胸痛、到院前心電圖、ST節段上升急性心肌梗塞
ST-elevation myocardial infarction, Chest pain, quality control circle, pre-hospital electrocardiogram
統計
Statistics
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中文摘要
研究目的: ST節段上升急性心肌梗塞治療需把握治療黃金12小時,越早送達有心導管治療處理能力的醫院,越早治療成效就越好。診斷ST節段上升急性心肌梗塞的第一步工具就是十二導程心電圖,如果可以提前將心電圖機帶到病患呼救第一現場執行,訓練消防局救護人員初步判讀,可以提早診斷以及後續直接送往有適當處理能力的醫院治療。由於在國內尚未有成熟機制進行到院前心電圖檢查,本研究目的在於運用品管圈方法,尋找適當之運作模式,針對高雄市胸痛病患進行到院前進行十二導程心電圖檢查,並對醫院做無線傳輸,以提早啟動治療團隊,縮短病患治療時間。
研究方法: 於2011年9月至2014年2月,在高雄市選擇六處消防分隊各配置一部可無線傳輸十二導程心電圖機,藉由品管圈活動推展胸痛病患進行到院前心電圖檢查。依現況分析針對人員、設備、時間、地點及流程五項重點,運用柏拉圖及80-20法則,發現九項缺陷。再依缺陷特性以品管圈「問題解決型」與「課題達成型」方法,以五個具體對策改善各項缺陷:改善消防救護人員及119勤務中心人員對心肌梗塞治療認知與心電圖操作訓練、建置可攜式即時傳輸與自動判讀十二導程心電圖機、確立心電圖執行地點及病人輸送作業、改善心電圖傳輸作業效率、建立稽核與獎勵制度,使作業能順利推展。胸痛尋求消防局救護車協助病患, 區分為導入到院前心電圖作業前期、正值導入中期、與導入後期。分析到院前心電圖執行率(%)、胸痛到心肌再灌流時間 (I2B)、以及到院至心肌再灌流時間(D2B)。
研究結果: 導入到院前心電圖作業後,目前共執行175人次到院前心電圖,其中發現14位ST節段上升急性心肌梗塞病人,分別送往高雄市七家具有緊急導管處理能力之醫院進行治療。到院前心電圖執行率為33.6%,達成預期目標值20%。十四位病患皆成功完成緊急心導管治療,住院期間死亡率為0%。搶救病患I2B時間從243分縮短為111分鐘。D2B時間為53.5分鐘,遠低於台灣平均值及國際準則建議值90分鐘。本研究推展胸痛病患到院前心電圖檢查並利用無線傳輸及雲端技術,使心導管治療醫院提早準備,縮短病患胸痛到心肌再灌注時間,改善臨床治療成效。透過品管圈的方法,運用問題解決與課題達成型模式,分析問題找出對策,在高雄市消防局、衛生局與多家醫院協力合作下,創造一個可行的運作模式。
Abstract
OBJECTIVE: Early reperfusion of obstructive coronary artery is very important to outcomes of patients with ST-elevation myocardial infarction (STEMI). Use of pre-hospital electrocardiogram (ECG) provides early diagnosis of STEMI and reduces reperfusion time. However, it is a challenging work to set up pre-hospital ECG program in Taiwan. The purpose of this article is to investigate barriers and how to improve of pre-hospital ECG implementation rate by using quality control circle (QCC) methods.
METHODS: A multidisciplinary team,including physicians, nurses of Kaohsiung Veterans General Hospital,staffs of fire bureau and department of health,Kaohsiung city government were organized since Sep. 2011. Hybrid QCC methods with both problem solving and task achieving methods were used. The key interventions including: 1. Improve emergency medical technicians (EMT) and 119 staffs training program;2. Set up pre-hospital automatic interpretation ECG system with immediate ECG transmission over mobile networks;3. Set up standard operative procedure of 12-lead ECG examination and patient transportation to a hospital with appropriate ability of percutaneous cardiac intervention;4. Increase the efficiency of ECG examination and transmission with 12 lead ECG accessory device;and 5. Set up incentive auditing and inter-hospital communication system. The consecutive chest pain patients received pre-hospital ECG from Jan. 2011 to Feb. 2014 in 6 different fire brigades at Kaohsiung city were enrolled. The patients were divided into three groups: pre-interventional, interventional and post-interventional group. The ECG implementation rate is defined as chest pain patients received pre-hospital ECG divided by all patients with chest pain.
RESULTS: The ECG implementation rate increased from 0% in pre-interventional group, to 0.6% in interventional group,to 33.6% in post-interventional group (p<0.001). Total 14 patients with STEMI were detected in 175 chest pain patients received pre-hospital ECG. The patients with STEMI,average door to balloon time was 53.5 minutes, average ischemia to balloon time was 111 minutes and in-hospital mortality was 0%.
CONCLUSIONS: The key factor to improved pre-hospital ECG implementation rate in Kaohsiung city is cooperation of hospital、Fire bureau and department of health of government . Comprehensive EMT education program and development of an ECG accessory device were also critical to set up the pre-hospital ECG system.
目次 Table of Contents
論文審定書 i
誌謝 ii
摘要 iii
Abstract v
目錄 vii
表目錄 ix
圖目錄 x
第一章 緒論 1
第一節 研究背景 1
第二節 研究動機 1
第三節 研究目的 2
第二章 文獻回顧與理論 3
第一節 急性心肌梗塞流行病學 3
第二節 急性心肌梗塞致病之生理機轉 3
第三節 急性心肌梗塞診斷 3
第四節 急性心肌梗塞治療方法 4
第五節 改善急性心肌梗塞病患治療時效研究 5
第六節 國內改善急性心肌梗塞病患治療時效研究 8
第三章 現況分析 9
第一節 目前國內ST節段上升急性心肌梗塞病患治療流程 9
第二節 現有作業模式問題 11
第三節 選擇到院前心電圖作為改善理由 12
第四章 研究方法 14
第一節 研究目標 14
第二節 研究設計 14
第三節 研究樣本 17
第五章 研究結果 18
第一節 改善前數據收集 18
第二節 現況問題分析 18
第三節 目標設定 21
第四節 問題解析與對策擬定 22
第五節 對策實施與檢討 31
第六節 標準化 42
第七節 實施結果 44
第六章 討論 48
第七章 結論與建議 50
參考文獻 51
參考文獻 References
中文與網站參考文獻
1. 行政院衛生署 http://www.doh.gov.tw
2. 中華民國心臟學會,2007,缺血性心臟病 ST節段上升急性心肌梗塞治療指引
16. 財團法人醫院評鑑暨醫療品質策進會 http://www.tjcha.org.tw
17. 鍾朝嵩,2009,品管圈活動推行與營運,和昌出版社。
18. 簡茂椿譯,狩野紀昭,課題達成型QC STORY,中衛發展中心。

英文參考文獻
3. Curtis JP, Portnay EL, Wang Y, et al: The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction-4. J Am Coll Cardiol 2006;47:1544-1552.
4. Terkelsen CJ, Lassen JF, Norgaard BL, et al: Reduction of treatment delay in patients with ST-elevation myocardial infarction: impact of pre-hospital diagnosis and direct referral to primary percutaneous coronary intervention. Eur Heart J 2005;26:770-777.
5. Ortolani P, Marzocchi A, Marrozzini C, et al: Clinical impact of direct referral to primary percutaneous coronary intervention following pre-hospital diagnosis of ST-elevation myocardial infarction. Eur Heart J 2006;27:1550-1557.
6. Hutchison AW, Malaiapan Y, Jarvie I, et al: Prehospital 12-lead ECG to triage ST-elevation myocardial infarction and emergency department activation of the infarct team significantly improves door-to-balloon times: ambulance Victoria and Monash HEART Acute Myocardial Infarction (MonAMI) 12-lead ECG project. Circ Cardiovasc Interv 2009;2:528-534.
7. Braunwald E, 2012. Braunwald’s heart disease, a textbook of cardiovascular medicine (9th ed.) 1187-1110. Elsevier Saunders
8. Thygesen K, Alpert JS, White HD. Universal definition of myocardial infarction.Eur Heart J 2007; 28:2525–2538
9. Fuster V, Walsh RA, Harrington RA ,2011. Hurst’s the heart (13th ed.) 1360-1370. McGraw-Hill
10. Keeley, E.C., Boura, J.A., Grines, C.L. 2003. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials, Lancet; 361: 13–20
11. Feng-Yu K, Wei-Chun H,Kuan-Rau Chiou,Guang-Yuan M,et. al. The effect of failure mode and effect analysis on reducing percutaneous coronary intervention hospital door-to-balloon time and mortality in ST segment elevation myocardial infarction. BMJ Qual Saf. 2013 Aug;22(8):626-38
12. Rathore S.S., Curtis J.P., Chen J. et. al, 2009. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study, BMJ;338: b1807
13. Hannan, E. L., Zhong, Y., Jacobs, A.K. et. al ,2010. Effect of onset-to-door time and door-to-balloon time on mortality in patients undergoing percutaneous coronary interventions for ST-Segment elevation myocardial infarction, Am. J. Cardiol ;106:143–147
14. Dhruva VN, Abdelhadi SI, Anis A, et al: ST-Segment analysis using wireless technology in acute myocardial infarction (STATMI) trial. J Am Coll Cardiol 2007;50:509-513
15. Wall T, Albright J, Livingston B, et al: Pre-hospital ECG transmission speeds reperfusion for patients with acute myocardial infarction. N C Med J 2000;61:104-108.
19. Diercks DB, Kontos MC, Chen AY, Pollack CV, et. al, Utilization and Impact of pre-hospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction, J. Am. Col. Cardiol 2009; 53: 161-166
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