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研究生:林瑞萍
研究生(外文):Jui-Ping Lin
論文名稱:改善急性心肌損傷病患之預後及縮短直接介入性心導管治療之院內策略評估
論文名稱(外文):Assess the Intra-hospital Strategies for Improving Outcome and Reducing the Door-to-Balloon Time in Acute Myocardial Injury
指導教授:邱文達邱文達引用關係
指導教授(外文):Wen-Ta Chiu
學位類別:碩士
校院名稱:臺北醫學大學
系所名稱:傷害防治學研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2008
畢業學年度:96
語文別:中文
論文頁數:91
中文關鍵詞:急性心肌損傷緊急直接介入性心導管治療術病人抵達急診室至接受氣球擴張之間隔時間
外文關鍵詞:Acute Myocardial InjuryPrimary Percutaneous Coronary InterventionDoor-to-Balloom time
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背景:心血管疾病多年來均為全球十大死因之首。在美國,每二十秒就有一人被診斷為急性心肌梗塞,其死亡率高達三成以上。緊急直接介入性心導管治療術可以有效地降低急性心肌梗塞的死亡率,且病患從急診室至完成氣球擴張所花費的時間愈短,就會有較佳的預後。本研究是藉由提升醫院管理機制,執行相關介入措施,縮短病人從急診室至完成氣球擴張的時間,探討其改善預後之成效分析。
方法:本研究係收集北區某社區型醫院自2004年01月01日至2007年12月31日,由急診室收入院並接受直接介入性心導管診療術之急性心肌梗塞病人之臨床資料,比較介入措施執行前(2004年01月01日到2006年06月30日)與介入措施執行後(2006年07月01日到2007年12月31日),病患從急診室至完成氣球擴張所花費的時間以及預後相關指標。相關之介入措施包括跨部門之協調、聯合研討會議、工作人員的在職教育與訓練、調整心臟專科醫師值班方式以及建立AMI-PPCI標準作業流程。
結果:收案總件數共計225人。平均發病年齡為63.4 ± 13.5歲;其中男性178人(79.1%);研究結果指出,介入措施執行前(114人)與介入措施執行後(111人)兩階段病人的基本人口學特質並無統計學上顯著的差異;經由介入措施的實施後,病人從急診室至建立靜脈輸液的時間縮短13分鐘(p<.05)、會診心臟專科醫師的間隔時間縮短72分鐘(p<.05)、轉送心導管室的間隔時間縮短31分鐘(p<.05),完成氣球擴張的間隔時間平均縮短46分鐘(p<.05)。上述介入措施明顯地降低了病人的疾病嚴重度(Killip),接受再次心導管治療的比率由39.5%降低為 6.3%(p<0.05),顯著提升預後品質,但死亡率在前後兩階段(6.1%與 8.1%),則沒有顯著之差異。
討論:本研究係國內首篇藉由醫院管理介入措施,包括跨部門之協調、聯合研討會議、工作人員的在職教育與訓練、調整心臟專科醫師值班方式(24小時院內待命)以及建立AMI-PPCI標準作業流程等,以縮短急性心肌梗塞病人自急診室至完成氣球擴張所花費的時間以及提升預後品質成效之臨床分析。
Background: Cardiovascular disease is the leading cause of death in the world. Acute myocardial infarction (AMI) occurred every 20 seconds in U.S. and approximately one-third AMI cases died. Primary percutaneous coronary intervention (PPCI) decreased mortality of AMI significantly and the door-to-balloon time is shorter, the prognosis is better. In this study, we tested whether intra-hospital administration efforts could short door-to balloon time and improve patient’s outcome or not.
Method: We collected AMI subjects who received PPCI in our hospital from 2004 Jan. 01 to 2007 Dec.31. We compare door-to balloon time and clinical outcome before- (from 2004. Jan.01 to 2006 Jun.30) and after- (2006 Jul. 01 to 2007 Dec.31) intra-hospital administration interventions. These interventions included inter-department coordination, regular combined meeting; staff education, cardiology specialist stay in hospital even during off-time and set up AMI-PPCI standard procedure.
Results: Totally 225 consecutive AMI subjects recruited and age was 63.4 ± 13.5 years, male accounted for 79.1%. There were no significant difference in patient’s characteristics between before-intervention group (114 cases) and after-intervention group (111 cases). Our data demonstrated administration interventions shorted door-to-I.V. set time significantly by 13 minutes (from 39 ± 10.1 to 16.7 ± 6.6 min, p<0.05), door-to-cardiology visit time was shorted by 72 minutes (from 185.9 ± 26.9 to 113.9 ± 15.9 min, p<0.05), door-to-cath lab time was shorted by 31 minutes (from 276 ± 24.6 to 245.3 ± 27.5 min, p<0.05), and door-to-balloon time was shorted by 46 minutes (from 308 ± 25.3 to 261.8 ± 27.8 min, p<0.05) in the after-intervention group. These interventions improved patients’ outcome in decrease of severity of illness (Killip Classification) and reduction of need of repeat revascularization (re-PCI 39.5% to 6.3%, p<0.05) significantly, but no significant differences was found in mortality rate (6.1% vs. 8.1%) between two groups.
Conclusion: This is the first study in Taiwan to show that intra-hospital administration effort including education, inter-department coordination, regular combined meeting and cardiology specialist standby in hospital in off-time can short the door-to-balloon time and provide better clinical outcome in patients who received PPCI for acute myocardial injury.
中文摘要…............................................................................................i
英文摘要…...........................................................................................iii
第一章 緒論..........................................................................................6
第一節、研究背景..........................................................................6
第二節、研究動機..........................................................................8
第三節、研究目的…............................................................……..11
第四節、名詞定義….....................................................................12
第二章 文獻探討..................................................................................13
第一節、急性心肌梗塞..................................................................13
第二節、直接介入性心導管診療術................................................17
第三章 研究方法..................................................................................19
第一節、收案方式.........................................................................19
第二節、研究架構.........................................................................20
第三節、資料收集.........................................................................21
第四節、介入措施.........................................................................22
第四章 研究結果..................................................................................25
第一節、描述性分析......................................................................25
第二節、與預後有顯著相關之類別變項.........................................31
第三節、與預後有顯著相關之數值變項..........................................33
第四節、介入措施之成效結果........................................................34
第五節、實施介入措施前後階段之變項分析...................................36
第五章 討論..........................................................................................38
第六章結論與建議.................................................................................43
參考資料…............................................................................................44
附件一 AMI病患收案一覽表.................................................................47
附件二 AMI-PPCI標準工作流程…..............................................……..48
表一 個案類別變項之分析……………………………………………….49
表二 個案數值變項之分析……………………………………………….58
表三 與預後顯著相關之類別變項….……………………..…………..…61
表四 與預後顯著相關之數值變項….…………………….….…….….…64
表五 介入措施的前後兩階段無顯著差異之類別變項….….….….….…67
表六 介入措施的前後兩階段有顯著差異之類別變項….…..……..……72
表七 介入措施的前後兩階段之數值變項………………………….……74
表4-1 兩階段年齡統計………………………………………..…………75
表4-2 兩階段性別統計……………………………………….….………76
表4-3 兩階段過去病史表現統計…………………………………..……77
表4-4 兩階段家族史統計…………………………………………..……78
表4-5 兩階段吸煙習慣表現統計…………………………………..……79
表4-6 兩階段喝酒習慣表現統計……………………………………..…80
表4-7 兩階段BMI類別表現統計…………………………………..…..81
表4-8 兩階段體溫表現統計…………………………………..…………82
表4-9 兩階段整體血壓表現統計…………………………………..……83
表4-10 兩階段收縮壓表現統計……………………………………..……84
表4-11 兩階段舒張壓表現統計……………………………………..……85
表4-12 兩階段有自覺症狀至就醫間隔時間統計….………………..…..86
表4-13 兩階段症狀典型表現統計……….……………………….…….87
表4-14 兩階段心電圖結果統計…………………………………….…..88
表4-15 兩階段疾病嚴重度統計………………………………………...89
表4-16 兩階段預後結果統計……………...………..……………..……90
表4-17 實施介入措施後各間隔時間統計…….…………………….….91
圖4-1 兩階段年齡統計…………………….………………….………..75
圖4-2 兩階段性別統計………………….………………………….…..76
圖4-3 兩階段過去病史表現統計…………….………………….……..77
圖4-4 兩階段家族史統計………………….……………………….…..78
圖4-5 兩階段吸煙習慣表現統計………………………………………79
圖4-6 兩階段喝酒習慣表現統計………………………………………80
圖4-7 兩階段BMI類別表現統計……………………………………..81
圖4-8 兩階段體溫表現統計……………………………………………82
圖4-9 兩階段整體血壓表現統計………………………………………83
圖4-10 兩階段收縮壓表現統計…………………………………………84
圖4-11 兩階段舒張壓表現統計…………………………………………85
圖4-12 兩階段有自覺症狀至就醫間隔時間統計………………………86
圖4-13 兩階段症狀典型表現統計………………………………………87
圖4-14 兩階段心電圖結果統計…………………………………………88
圖4-15 兩階段疾病嚴重度統計…………………………………………89
圖4-16 兩階段預後結果統計……………………………………………90
圖4-17 實施介入措施後各間隔時間統計………………………………91
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