臺灣博碩士論文加值系統

研究目的： 1.探討院內非預期心跳停止病人於事件發生前6－10小時改良式早期預警評分系統分數表現；2.探討影響院內非預期心跳停止病人在改良式早期預警評分系統判定為高危病人分數之相關因素。
研究方法：本研究採病歷回顧的方式，納入新北市某區域教學醫院內外科病房過去6年（2010年5月至2016年5月）非原疾病病程可預期之心跳停止事件通報之案例，以改良式早期預警評分系統作為事件發生前6－10小時分數表現的評分工具。本研究進行方式，內容及資料收集均通過人體試驗委員會認證同意。
研究結果：共152位院內非預期心跳停止病人納入分析。研究族群年齡範圍落在31－98歲，平均年齡74.3歲，具有2個或2個以上共病者占79.6﹪。非預期心跳停止事件發生前6－10小時改良式早期預警評分系統平均得分分數為3.63，符合改良式早期預警評分系統判定為高危病人分數者占54.6﹪。以卡方檢定方式比較改良式早期預警評分系統得分數高低級別間與院內非預期心跳停止病人人口學特性及共病指數間之差異，結果顯示：內科屬性病人，具有充血性心衰竭、失智症、慢性肺部疾病及偏癱共病者以及共病指數分數大於等於4分者均為影響改良式早期預警評分系統分數高危之相關因素(p < .05 與p < .01）。
結論：院內非預期心跳停止病人於事件發生前6－10小時符合改良式早期預警評分系統判定為高危病人者僅占54.6﹪，故改良式早期預警評分系統作為院內非預期心跳停止事件發生指標仍有待評估。但仍建議將改良式早期預警評分系統應用於醫院資源較少的單位作為病人初步病程管理的評估工具，依據評估結果決定是否需要加強監測指標或立即啟動緊急醫療團隊小組提供適當處置，如此能減少院內嚴重不良事件或非預期心跳停止事件的發生並降低院內死亡率。

Purpose: This study aimed to investigate (1) the performance of the modified early warning score (MEWS) measured at 6-10 hours before unexpected in-hospital cardiac arrest (IHCA);and (2) factors associated with a MEWS score indicative of IHCA.
Methods: This was a retrospective study. Medical records of cases reported as having IHCA in the medical and the surgical wards of one regional teaching hospital in New Taipei City for the past six years (May 2010 to May 2016) were reviewed. The MEWS was used to score the risk of IHCA and its scores at the time of 6-10 hours before the incident were calculated.
Results: A total of 152 unexpected IHCA cases was included. Patients’ ages ranged from 31 to 98, and the average age was 74.3. At 6-10 hours before the IHCA events, the average MEWS score was 3.63. Only 54.6% of cases qualified as the MEWS’ definition of high-risk IHCA patients. Logistic regression results revealed that medical wards and the Charlson Comorbidity Index were significantly and independently associated with the MEWS score.
Conclusion: Only 50% of the IHCA patients could be identified by a score of MEWS ≥4 at 6 to 10 hours before the event. The utility of the MEWS as an early warning tool for identifying IHCA events remains to be determined.
However, it is suggested that the MEWS may be applied in the medical ward or the units with less medical resource as a preliminary assessment tool of patients at risk of physiological deterioration in the future, and based on the evaluation results to determine whether the patient needs any further close-up monitoring, and hopefully reducing the occurrence of serious adverse events and hospital mortality.

目 次 頁 數
致 謝 ..................................... Ⅰ
中文摘要 ..................................... Ⅱ
英文摘要 ..................................... Ⅳ
目 錄..................................... Ⅵ
圖表目次 ..................................... Ⅷ
第一章 緒論
第一節 研究動機與重要性........................ 1
第二節 研究目的............................... 3
第二章 文獻查證
第一節 院內非預期心跳停止的重要性............... 4
第二節 院內心跳停止與共病指數之相關性........... 6
第三節 預警評分系統的背景與發展................. 8
第四節 預警評分系統相關研究與成效............... 12
第五節 研究工具的選擇及應用..................... 14
第六節 總結................................... 16
第三章 研究方法
第一節 研究設計及資料來源...................... 17
第二節 資料收集方法............................ 18
第三節 資料處理與統計分析........................ 21
第四章 研究結果
第一節 社會人口學基本屬性及共病指數分布........... 23
第二節 非預期心跳停止病人於改良式早期預警評分系統分
數表現.................................. 28
第三節 改良式早期預警評分系統分數高危之相關因素.... 30
第五章 討論
第一節 非預期心跳停止病人於改良式早期預警評分系統得
分敏感度................................ 34
第二節 影響改良式早期預警評分系統分數高危之相關因素. 36
第三節 改良式早期預警評分系統靈敏度及應用.......... 38
第四節 研究限制.................................. 41
第六章 結論與建議................................ 42
參考資料
中文部份........................................ 43
英文部份........................................ 44
附錄
附錄一 Charlson Comorbidity Index.............. 52
附錄二 Modified early warning score systems.... 53
附錄三 人體試驗委員會人體試驗許可書............... 55

圖表目次
表一 早期預警評分系統相關發展預測模型及警示值........ 11
表二 非預期心跳停止病人社會人口學基本屬性描述........ 25
表三 非預期心跳停止病人共病指數得分分布情形.......... 27
表四 非預期心跳停止病人於改良式早期預警評分分數表現...29
表五 影響改良式早期預警評分系統分數高危之相關因素.....32
表六 影響改良式早期預警評分系統分數高危因素之羅吉斯迴
歸分析........................................ 33

中文部份
內政部統計處（2017，10月25日）．內政部統計通報106年第25週．
取https://www.moi.gov.tw/stat/node.aspxcate_sn=-1 &belong_sn=5514&sn=6491
衛生福利部全球網站中文版（2017，06月19日）．105年國人死因統計
結果．取https://www.mohw.gov.tw/cp-16-33598-1.html
衛生福利部台灣病人安全資訊網（2017，12月21日）．台灣病人安
全通報系統2016年TPR年報．取http://www.patientsafety. mohw. gov.tw/Content/Downloads/List01.aspx?SiteID=1&MmmID =621273303702500244
孔明何（2003）．重症病患之疾病嚴重程度評分系統．於林少琳主編．
重症醫學與護理（一版，5-8頁）．台北：五南
任宏飛、劉常清、李繼平（2013）．改良早期預警評分系統在預測急診
搶救室患者病情中的應用研究．華西醫學．28（10），1601－1604。
邱俊仁、徐國基、吳鋼治、邱浩彰、楊國卿、侯勝茂、張嘉宇、賴寶
琴、施玉珊、鄭瑞楠、廖若雯、廖熏香（2014）．以醫療品質突
破系列提升院內心跳停止事件急救之照護品質．台灣醫學．18（2），226－237。
張玉英、石根萍（2009）．改良早期預警評分早期識別急診潛在為重患
者臨床分析．中華實用診斷與治療雜誌．23（12），1246－1247。

英文部份
Acute Medical Care. (2007). The right person, in the right setting - first time. Report of the Acute Medicine Task Force. London: Royal College of Physicians. doi: 10.7861/clinmedicine.9-6-553
Alam, N., Hobbelink, E. L., Tienhoven, A. J., Ven, P. M., Jansma, E. P., Nanayakkara, P. W. B. (2014). The impact of the use of the Early Warning Score (EWS) on patient outcomes: A systematic review. Resuscitation, 85, 587-594. doi: 10.1016/j.resuscitation.2014.01.013
Bokhari, S. W., Munir, T., Memon, S., Byrne, J. L., Russell, N. H, Beed, M. (2010). Impact of critical care reconfiguration and track-and-trigger outreach team intervention on out-comes of hematology patients requiring intensive care admission. Annals of Hematology, 89(5), 505-512. doi: 10.1007/s00277-009-0853-0
Brady, W. J., Gurka, K. K., Mehring, B., Peberdy, M. A., O’Connor, R. E. (2011). In-hospital cardiac arrest: Impact of monitoring and witnessed event on patient survival and neurologic status at hospital discharge.
Resuscitation, 82(7), 845-52. doi:10.1016/j. resuscitation.2011.02.028
Capan, M., Ivy, J. S., Rohleder, T., Hickman, J., Huddleston, J.H. (2015). Individualizing and optimizing the use of early warning scores in acute medical care for deteriorating hospitalized patients. Resuscitation, 93, 107-112. doi: 10.1016/j. resuscitation.2014.12.032
Charlson, M. E., Pompei, P., Ales, K. L., MacKenzie, C. R. ( 1987) A new method of classifying prognostic comorbitidy in longitudinal studies: development and validation. Journal of Chronic disease, 40(5), 373-383.
Chen, C. T., Chiu, P. C., Tang, C. Y., Lin, Y. Y., Lee, Y. Z., How, C. K., Yen, H. T., Huang, M. S. (2016). Prognostic factors for survival outcome after in-hospital cardiac arrest: An observational study of the oriental population in Taiwan. Journal of the Chinese Medical Association, 79(1), 11-16. doi: 10.1016/j.jcma. 2015.07.011
Chen, F. C., Su, C. M., Li, C. J., Le, W. H., Kung, C. T. (2009) . The use of charlson comorbidity index for patients receiving inhospital unexpected resuscitation by a cardiac arrest team : clinical outcome and implications. Journal of Taiwan emergency medicine, 11(2), 35-42.
Churpek, M. M., Yuen, T. C., Huber, M. T., Park, S. Y., Hall, J. B., Edelson, D. P. (2012). Predicting cardiac arrest on the wards: a nested case-control study. Chest, 141(5), 1170-1176. doi: 10.1378/chest.11-1301
Churpek, M. M., Yuen, T. C., Huber, M. T., Park, S. Y., Hall, J. B., Edelson,
D. P. (2012). Derivation of a cardiac arrest prediction model using ward vital signs. Crit Care Med, 40(7), 2102-2108. doi: 10.1097/CCM.0b013e 318250aa5a
Drower, D., McKeany, R., Jogia, P., Jull, A. (2013). Evaluating the impact of implementing an early warning score system on incidence of in-hospital cardiac arrest. New Zealand Medical Journal, 126(1385), 26-34.
Gao, H., McDonnell, A., Harrison, D, A., Moore, T., Adam, S., Daly, K., Esmonde, L., Goldhill, D. R., Parry, G. J., Rashidian, A., Subbe, C. P., Harvey, S. (2007). Systematic review and evaluation of physiological track and trigger warning system for identifying at-risk patient on the ward. Intensive Care Med, 33, 667-679. doi: 10.1007/s00134-007-0532-3
Georgaka, D., Mparmparousi, M., Vitos, M. (2012). Early Warning Systems. Hospital Chronicles, 7(1), 37-43.
Gill, R. D. (1992). Multistate life‐tables and regression models. Mathematical Population Studies, 3(4), 259-276. doi.org/10.1080/08898489209525345
Harrison, G. A., Jacques, T., McLaws, M. L., Kilborn, G. (2006). Combinations of early signs of critical illness predict in-hospital death-the SOCCER study (signsof critical conditions and emergency responses). Resuscitation, 71(3), 327-334.doi:10.1016/j. resuscitation. 2006.05.008
Hii, C. H., Chien, H. H., Juan, C. W. (2013). The clinical characteristics and outcomes of in-hospital cardiac arrest patients with successful resuscitation in a teaching hospital in central Taiwan. Journal of Emergency and Critical Care Medicine, 24(3), 77-88.
Nishijima, I., Oyadomari, S., Maedomari, S., Toma, R., Igei, C., Kobata, S., Koyama, J., Tomori, R., Kawamitsu, N., I Yamamoto, Y., Tsuchida, M., Tokeshi, Y., Ikemura, R., Miyagi, K., Okiyama, K., Iha, K. (2016). Use of a modified early warning score system to reduce the rate of in-hospital cardiac arrest. Journal of Intensive Care, 4, 12. doi.org/10.1186/s40560 -016-0134-7
Hodgetts, T. J., Kenward, G., Vlackonikolis, I., Payne, S., Castle, N., Crouch, R., Ineson, N., Shaikh, L. (2002). Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital. Resuscitation, 54(2), 115-123. doi:10.1016/S0300-9572(02)00098-9
Jerng, J. S., Ko, W. J., Lu, F. L., Chen, Y. S., Huang, S. F., Yu, C. J., Wang, M. J., Lin, F. Y. (2008). Incidence and significance of clinically abnormal events in a tertiary referral medical center: implementation of the clinical alert system (CAS). Jounal of the Formosan Medical Association, 107(5), 396-403. doi: 10.1016/S0929-6646(08)60105-9
Kause, J., Smith, G., Prytherch, D., Parr, M., Flabouris, A., Hillman, K. (2004). A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom--the ACADEMIA study. Resuscitation, 62(3), 275-282. doi:10.1016/j.resuscitation.2004.05.016
Kellett, J., Kim, A. (2012). Validation of an abbreviated Vitalpac Early Warning Score (ViEWS) in 75,419 consecutive admissions to a Canadian regional hospital. Resuscitation, 83(3), 297-302. doi: 10.1016/j. resuscitation.2011.08.022
Kim, W. Y., Shin, Y. J., Lee, J. M., Huh, J. W., Koh, Y., Lim, C.-M., Hong, S. B. (2015). Modified Early Warning Score Changes Prior to Cardiac Arrest in General Wards. PLoS ONE, 10(6), 1-11. http://doi.org/10.1371 /journal.pone.0130523
Kruisselbrink , R., Kwizera, A., Crowther, M., Fox-Robichaud, A., O''Shea, T., Nakibuuka, J., Ssinabulya, I., Nalyazi, J., Bonner, A., Devji, T., Wong, J., Cook, D. (2016). Modified Early Warning Score (MEWS) Identifies Critical Illness among Ward Patients in a Resource Restricted Setting in Kampala, Uganda: A Prospective Observational Study. PLoS ONE 11(3), 1-13. https://doi.org/10.1371/journal.pone.0151408
Kyriacos, U., Jelsma, J., James, M., & Jordan, S. (2014). Monitoring Vital Signs: Development of a Modified Early Warning Scoring (Mews) System for General Wards in a Developing Country. PLoS ONE, 9(1), e87073. http://doi. org/10.1371/journal.pone.0087073
Lin, M. H., Peng, L. N., Chen, L. K., Chen, T. J., Hwang, S. J. (2012). Cardiopulmonary resuscitation for hospital inpatients in Taiwan: An 8-year nationwide survey. Resuscitation, 83(3), 343-346. doi: 10.1016/j. resuscitation.2011.09.006
Morgan, J. M., Williams, F., Wright, M. (1997). An early warning scoring system for detecting developing critical illness. Clin Intensive Care, 8, 100-114.
Michael, D. B., Gaye, E. M., Stephen, A. B., Bruce, P. W., Jeremy, N. A., Tuan, V. N. (2002). Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital:
preliminary study. BMJ, 324, 2-5. doi: 10.1136/ bmj.324.7334. 387
Merchant, R. M., Yang, L., Becker, L. B., Berg, R. A., Nadkarni, V., Nichol, G., Carr, B.G., Mitra, N., Bradley, S. M., Abella, B. S., Groeneveld, P.,W. (2011). Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med, 39(11), 2401–2406. doi:10.1097/CCM. 0b013e3182257459
Meester, K. D., Hellemansa, D. K., Verbrugghec, W., Jorensc, P. G., Verpootene, G. A., Bogaerta, V. (2013). Impact of a standardized nurse observation protocol including MEWS after Intensive Care Unit discharge. Resuscitation, 84, 184-188. doi: 10.1016/j.resuscitation. 2012.06.017
Moon, A., Cosgrove, J. F., Lea, D., Fairs, A., Cressey, D. M. (2011). An eight year audit before and after the introduction of modified early warning score (MEWS) charts, of patients admitted to a tertiary referral intensive care unit after CPR. Resuscitation, 82(2), 150-154. doi: 10.1016 /j.resuscitation.2010.09.480.
Morrice, A., Simpson, H. J. (2007). Identifying level one patients. A cross-sectional survey on an in-patient hospital population. Intensive Crit Care Nurs, 23(1), 23-32. doi:10.1016/j.iccn.2006.07.001
Nishijima, I., Oyadomari, S., Maedomari, S., Toma, R., Igei, C., Kobata, S., Koyama, J., Tomori, R., Kawamitsu, N., Yamamoto, Y., Tsuchida, M., Tokeshi, Y., Ikemura, R., Miyagi, K., Okiyama, K., Iha, K. (2016). Use of a modified early warning score system to reduce the rate of in-hospital cardiac arrest. Journal of Intensive Care, 4, 12. doi:10.1186/s40560-016 -0134-7
Patel, M. S., Jones, M. A., Jiggins, M., Williams, S. C. (2011). Does the use of a "track and trigger" warning system reduce mortality in trauma patients? Injury, 42(12), 1455-1459. doi: 10.1016/j.injury.2011.05.030.
Paterson, R., MacLeod, D. C., Thetford, D., Beattie, A., Graham, C., Lam, S., Bell, D. (2006). Prediction of in-hospital mortality and length of stay using an early warning scoring system: clinical audit. Clin Med, 6(3),
281-284.
Peberdy, M. A., Cretikos, M., Abella, M., Devita, M., Goldhill, D., Kloeck, W., Kronick, S. L., Morrison, L. J., Nadkarni, V. M., Nichol, G., Nolan, J. P., Parr, M., Tibballs, J., Elise, W., Young, L. (2007). Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: An Utstein-style scientific statement A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiopulmonary, Preoperative, and Critical Care; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research. Circulation, 116(21), 2481-2500. doi: 10.1161/ CIRCULATIONAHA.107.186227
Peris, A., Zagli, G., Maccarrone, N., Batacchi, S., Cammelli, R., Cecchi, A., Perretta, L., Bechi, P. (2012). The use of Modified Early Warning Score may help anesthesists in postoperative level of care selection in
emergency abdominal surgery. Minerva Anestesiol, 78(9), 1034-1038.
Pompei, P., Ales, K. L., MacKenzie, C. R. (1987) . A new method of classifying prognostic comorbidity in longitudinal studies: development and validation . Journal of chronic disease, 40(5), 373-383. doi:10.1016
/0021-9681(87)90171-8
Prytherch, D. R., Smith, G. B., Schmidt, P. E., Featherstone, P. I. (2010). ViEWS--Towards a national early warning score for detecting adult inpatient deterioration. Resuscitation, 81(8), 932-937. doi:10.1016/j. resuscitation.2010.04.014
Robert, G., Stevens, A., Gabbay, J. (1999). Early warning systems for identifying new healthcare technologies. Health Technol Assess, 3(13), 1-118. doi: 10.3310/hta3130
Rothschild, J. M., Gandara, E., Woolf, S., Williams, D. H., Bates, D. W. (2010). Single-parameter early warning criteria to predict life-threatening adverse events. Journal of Patient Safety, 6(2), 97-101. doi: 10.1097 /PTS. 0b013e3181dcaf32
Rafati, H., Saghafi, A., Saghafinia, M., Panahi, F., Hoseinpour, M. ( 2011). Survival after In-Hospital Cardiopulmonary Resuscitation in a Major Referral Center during 2001-2008. Iranian Journal of Medical Sciences, 36(1), 50-53.
Rooijen, C. R., Ruijter, W., Dam, B. (2013). Evaluation of the threshold value for the Early Warning Score on general wards. The Netherlands Journal of Medicine, 71(1), 38-43.
Shiha, C. L., Lu, T. C., Jerng, J. S., Liu, Y. P., Chen, W. J., & Lin, F. Y. (1990). Clinical antecedents to in-hospital cardiopulmonary arrest. Chest, 72( 3) , 394-403. doi: 10.1016/j.resuscitation. 2014.01.013
Smith, G. B.(2010). In-hospital cardiac arrest: is it time for an in-hospital ''chain of prevention''?. Resuscitation, 81(9), 1209-1211. doi: 10.1016/ j.resuscitation.2010.04.017
Smith, G. B., Prytherch, D. R., Meredith, P., Schmidt, P. E., Featherstone, P. I. (2013).The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. Resuscitation, 84(4), 465-70. doi: 10.1016/j.resuscitation.2012.12.016
Smith, M. E. B., Chiovaro, J., O''Neil, M., Kansagara, D., Quinones, A., Freeman, M., Motu''apuaka, M., Slatore, C., G. (2014). Early Warning Scoring Systems: A Systematic Review. Washington (DC): Department of Veterans Affairs.
Stenhouse, C., Coates, S., Tivey, M., Allsop, P., Parker, T. (2000). Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward. British Journal of Anaesthesia, 84 (5), 663. doi: 10.1093/bja/84.5.663
Subbe, C. P., Kruger, M., Rutherford, P., Gemmel, L. (2001). Validation of a modified Early Warning Score in medical admissions. QJ Med ,94, 521-526. doi:10.1093/qjmed/94.10.521
Subbe, C. P., Davies, R. G., Williams, E., Rutherford, P., Gemmell, L. (2003). Effect of introducing the Modified Early Warning score on clinical
outcomes, cardio-pulmonary arrests and intensive care utilisation in acute medical admissions. Anaesthesia, 58(8), 797-802.
Suwanpasu, S., Sattayasomboon, Y. (2016). Accuracy of Modified Early Warning Scores for Predicting Mortality in Hospital: A Systematic Review and Meta-analysis. Journal of Intensive and Critical Care, 2(2), 1-11. doi: 10.21767/2471-8505.100029
Wang, H. Y., Chew, G., Kung, C. T., Chung, K. J., Lee, W. H. (2007). The use of Charlson comorbidity index for patients revisiting the emergency department within 72 hours. Chang Gung medical journal, 30(5), 437-444.