臺灣博碩士論文加值系統

非預期心跳停止事件是衡量醫院醫療品質的重要指標。未能預先警告患者緊急情況的病情變化可導致與醫病溝通失去信任且造成家屬與醫療團隊身心疲憊。過去的臨床預警系統未能完成的呈現出病患的住院風險，這也導致醫生無法在病患病情轉變時完全且即時的掌握患者的病況。
創新的臨床警訊系統對病人進行全面的風險評估，同時提供適當的臨床醫護照護，減少醫院發生非預期心跳停止事件，提供病人更好的照護。創新臨床警訊系統包括過往臨床警訊系統評估的9項評核細項外，再加入符合台灣醫療現況所需要的評核項目，例如跌倒評估、家屬照護、咳痰能力和是否有簽屬放棄急救的同意書。透過紅黃綠燈的信號區分疾病嚴重度，因此醫護團隊可以快速掌握病人病情變化。所有住院病人的臨床警訊評估系統評估由醫生、專科護理師和護理師等人完成，當病人的病情從黃燈或綠燈變為紅燈時，臨床警訊系統會主動發送簡訊以通知醫生，以便可以立即警示出現緊急和病情不斷變化的病人。臨床警示系統的另一個應用是能對於不穩定住院病患導入分級護理照護，和分級醫療照護，例如快速反應小組的。
創新臨床警訊系統的改良有以下成果，將2017年的數據與2014年的數據進行比較，病危啟動急救事件數量從每月6.2次下降到每月2.8次;非預期心跳停止事件的事件從每月5.7次下降到每月2.1次;急救患者的生存率從29.8％上升到48.6％。包括70％的病危啟動急救事件發生時落於黃色或紅色警告區域。
本研究展示了臨床警訊系統的卓越性，致力於不斷改善病患的醫療照護品質。這種創新項目可以推行到其他醫院，使台灣和國外的其他醫院受益。

Unexpected cardiac arrest is an important indicator of hospital medical quality. Failure to pre-alert the emergency of a patient’s condition can result in communication breakdown with family and staff being left physically and mentally exhausted. Past clinical warning systems did not incorporate patient’s hospitalization risk factors, leaving physicians without the full grasp of the patient’s full condition in an emergency situation.
This project, entitled “Clinical alert system” was designed and implemented to allow comprehensive risk assessment of patients while delivering appropriate clinical care, resulting in better quality provided to patients by reducing the unexpected cardiac arrest events in the hospital. This system includes the past Clinical alert system (CAS) assessment of nine projects, Taiwan’s national project of clinical care needs such as fall risk assessment, family care support, cough power, and whether to sign do not resuscitation. The signal of red and green light distinguishes the severity of the disease so medical staff can rapidly master the changes in the patient’s condition. Electronic medical records mandated the completion of the clinical alert systems for all hospitalized patients. This assessment was completed by physicians, nurse practitioners and nurses. When patient''s condition changes from yellow or green light to red light, the clinical alert system proactively sends a newsletter to inform the physician, so that those who are offsite can immediately be warned of the emergent and changing conditions of the patients. One of the application to the “Clinical alert system,” includes the introduction of the nurse grading care guidelines as well as the rapid response team in the patient''s emergency.
Comparing the data results in 2017 with that of 2014, the numbers of emergency calls initiated due to critical illness dropped from 6.2 times/per month to 2.8 times/per month; the events of unexpected cardiac arrest dropped from 5.7 times/per month to 2.1 times/per month; the survival rate of patients with first-aid increased from 29.8% to 48.6% as a result of this improvement in the clinical alert system. 70% of the incidents are now captured in the yellow or red light warning areas.
This project demonstrated the excellence of the clinical alert system in striving to continuously improve the medical quality of patient care. This type of innovative projects can be replicated to benefit other hospitals in Taiwan and abroad.

目次

摘要 I
Abstract III
目次 V
圖目錄 VIII
表目錄 IX
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 3
第二章 文獻查證 4
第一節 非預期性心跳停止事件 4
第二節 早期警示系統 6
第三節 臨床警示系統 10
第四節 其他臨床警示項目 11
第五節 電子化監控系統 14
第六節 快速醫療反應小組 16
第三章 院內非預期性心跳停止事件現況 18
第一節 本院病危啟動事件與非預期性院內心跳停止事件分析 18
第二節 本院舊有的住院病患分級系統 20
第三節 本院過去的臨床警示系統(CAS)運用 24
第四章 研究方法 33
第一節 成立跨團隊品管圈團隊 33
第二節 標竿學習 34
第三節 名詞定義與專案目的 36
第四節 問題確立與真因驗證 37
第五節 問題解決及策略精神 40
第六節 解決方法及執行過程 45
第五章 效果評值及研究結果 67
第一節 臨床警示系統啟動次數和住院病人燈號統計 67
第二節 不穩定病患運送評估統計 70
第三節 住院病人病危啟動事件(999事件)統計 71
第四節 院內不預期心跳停止事件統計 73
第五節 CAS護理分級照護率 75
第六節 非預期心跳停止事件急救後存活率 76
第七節 創新評核細項的統計分析 77
第八節 無形成果評價 78
第九節 團隊成果展現 79
第六章 討論 83
第一節 創新臨床警示系統對於非預期心跳停止事件的影響 83
第二節 創新臨床警示系統成功的要素 84
第三節 不穩定病患的運送評估 86
第四節 資訊系統在臨床警訊系統的幫助 87
第五節 臨床警訊系統的應用 88
第七章 結論與建議 92
第一節 結論 92
第二節 研究限制與建議 93
參考文獻 97
附件一、臨床警訊系統問卷 106
附件二、CAS護理分級照護指引 107
附件三、不穩定病患運送評估流程 114
附件四、P-0320-066臨床警訊系統作業流程104-08-V01 120


 
圖目錄
圖 3 1、舊有的住院分級系統 22
圖 3 2、舊有的臨床警訊呼叫系統作業流程 25
圖 4 1、不穩定病患運送評估流程 60
圖 4 2、臨床警訊系統作業流程 62
圖 5 1、臨床警訊系統上線前後之病危件數比較(月平均) 72
圖 5 2、臨床警訊系統上線前後之院內不預期心跳停止事件比較(月平均) 73
圖 5 3、臨床警訊系統改善前後急救病人嚴重度(紅黃燈)分佈情形 74
圖 5 4、非預期心跳停止發生率 75
圖 5 5、護理分級照護統計圖 76
圖 5 6、急救存活率 77
圖 5 7、無形成果評分雷達圖 79
圖 5 8、IHF銀獎獎狀 81
圖 5 9、IHF銀獎獎牌 81
圖 5 10、SNQ國家品質標章證書 82

 
表目錄
表2 1、GUIDE TO MEWS SCORING SYSTEM 8
表2 2、GUIDE TO MEWS SCORING SUSTEM 12
表3 1、2014年住院病人病危啟動事件發生月份統計表 19
表3 2、2014年院內不預期心跳停止事件統計表 19
表3 3、2014年院內不預期心跳停止事件發生時段統計表 19
表3 4、臨床警覺系統評估表 27
表3 5、啟動CAS狀況分析(依啟動月份分析) 28
表3 6、啟動臨床警訊呼叫系統CAS各職級的職責 29
表3 7、2014/9/01-2015/3/31護理人員啟動CAS通知醫師後處置情況(複選) 30
表3 8、2014/09-2015/03 各病房CAS登錄次數與啟動病危事件次數統計表 31
表4 1、圈的組成 33
表4 2、各醫院院內不預期心跳停止事件數與病危事件及運作方式 34
表4 3、病危事件啟動發生原因&職類別統計表(複選) 37
表4 4、臨床警訊系統評估表(CLINICAL ALERT SYSTEM, CAS) 47
表4 5、臨床警訊系統評估表(CLINICAL ALERT SYSTEM, CAS) 50
表4 6、病人運送安全稽核表 61
表4 7、啟動臨床警訊呼叫系統CAS各職級的職責 63
表4 8、課程暨宣導會議一覽表 64
表4 9、策略矩陣 64
表5 1、2016年1月份住院病人燈號統計表(排除兒科與加護病房) 68
表5 2、2017年1月~12月份住院病人燈號統計表(排除兒科與加護病房) 69
表5 3、2017年1~12月運送人員評估表 70
表5 4、住院病人病危啟動事件(999事件)發生月份統計表 71
表5 5、住院病人病危啟動事件(999事件)發生時之CAS燈號統計表 72
表5 6、院內不預期心跳停止事件統計表 73
表5 7、呼叫999與氧氣飽和度、昏迷、心律不整、跌倒之相關分析 78
表5 8、是否「3個月內有重覆性跌倒」對999發生有顯著差異。 78
表5 9、品管圈活動前後無形成果評價結果 79
表6 1、兒科臨床警覺系統評估表 (PEDIATRIC CLINICAL ALERT SYSTEM, PED-CAS) 89

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