急診部急性冠心症臨床品質指標之建立與現況分析：以北部兩家醫院為例

Development of Clinical Quality of Care Indicators for Acute Coronary Syndrome in Emergency Departments and a Current Performance Analysis at Two Northern Hospitals

范傑閔(Chieh-Min Fan) ； 鍾國彪(Kuo-Piao Chung) ； 馬惠明(Mattheew Huei-Ming Ma) ； 陳文鍾(Wen-Jone Chen) ； 朱樹勳(Shu-Hsun Chu)

《中華民國急救加護醫學會雜誌》 17卷4期 (2006/12) Pp. 146-157

https://doi.org/10.30018/JECCM.200612.0002

摘要

前言：急性冠心症的早期診斷及治療，一直是急診部門的一大挑戰，但現今國內未有針對急診部門發展急性冠心症臨床品質指標，也未有相關照護品質現況之報告。
研究方法：第一階段以兩回合德菲法專家問卷，將有關急性冠心症之實證醫學臨床指引，經由專家群對於五項指標構面的評選，轉變成臨床品質指標。第二階段針對台北地區一家醫學中心（甲醫院）及一家區域教學醫院（乙醫院），以回溯性病歷資料萃取方式，分析自2004年10月01日到2005年03月31日間，此兩院急診部門急性冠心症品質指標表現。
結果：在五項指標構面全部考量下，則最後在15項潛在性指標中有7項指標入選，分別是評估性指標：急性冠心症病患到院10分鐘內完成12導程心電圖比率及急性冠心症病患有進行間隔六小時以上之心電圖追蹤比率，和治療性指標，Aspirin過敏之急性冠心症病患給予Clopidogrel比率、急性冠心症病患給予乙型阻斷劑比率、非ST段上升型急性冠心症病患給予Clopidogrel比率、非ST段上升型急性冠心症病患接受緊急心導管手術前給予GP Ⅱb/Ⅲa比率、及急性心肌梗塞病患在到院90分鐘內接受心導管手術比率。兩家研究醫院對於上述指標的整體表現分別為（甲／乙）：45.5%及44.3%，72.3%及56.8%，100%及0%，3.9%及5.6%，60.8%及32.1%，28.6%及0%，和20.8%及38.9%。
結論：在指標表現方面，評估性指標的表現，兩家研究醫院均需加強。在治療性指標方面，兩家研究醫院在急性冠心症病患給予Aspirin及Heparin率的表現上，和國外研究調查的結果相似。研究乙醫院在及時針對急性心肌梗塞病患完成心導管手術的表現上，已達國外的預設標準。兩家研究醫院在乙型阻斷劑投予率上的表現，和國外結果相較，差距相當大。對於非ST段上升型急性冠心症病患給予Clopidogrel及Glycoprotein Ⅱb/Ⅲa抑制劑的表現上，研究甲醫院的表現明顯比乙醫院好。

關鍵字

品質指標 ； 急性冠心症 ； 疾病別導向 ； 臨床指引 ； 德菲法

並列摘要

Background: The issue of quality of health care has been discussed widely and is a topic of current concern. Early diagnosis and timely treatment of patients suffering from acute coronary syndrome (ACS) are always a challenge in an emergency department (ED). Currently, there are not indicators available to measure quality of care for ACS in EDs across Taiwan.
Method: As a first stage, we developed summaries for each potential quality indicator; these were modified from various evidence-based clinical guidelines for ACS. A multidisciplinary expert panel rated the potential indicators using two rounds of the Delphi technique. This involved five dimensions of quality, including validity of the evidence, feasibility, impact on outcomes, room for improvement, and controllability. In the second stage, from 1(superscript st) Oct., 2004 to 31(superscript st) Mar., 2005, we retrospectively measured by chart abstraction using these indicators of ACS the performance at the EDs of two northern Taiwan hospitals, one medical center and one district teaching hospital.
Results: Seven indicators, made up of two evaluation indicators and five therapeutic indicators, were found to meet all five dimensions by the expert panel. These were rate of completion of an electrocardiogram within 10 minutes of presentation, cardiac markers follow-up when the ED stay is more than 6 hours, the use of Clopidogrel if there is Aspirin allergy, the use of a β-blocker on arrival, the use of Clopidogrel on non-ST elevated myocardial infarction (NSTEMI) patients, the use of Glycoptotein Ⅱb/Ⅲa inhibitor on NSTEMI patients with percutaneous coronary intervention (PCI) and PCI carried out within 90 minutes of arrival. The performances for these indicators at the two target hospitals were 45.5%/44.3%, 72.3%/56.8%, 100%/0%, 3.9%/5.6%, 60.8%/32.1%, 28.8%/0% and 20.8%/38.9%, respectively.
Conclusions: Both study hospitals need to improve their performance with respect to the evaluation indicators and the administration of a β-blocker. The performance for timely PCI after arrival was ideal at one of the study hospitals.

並列關鍵字

quality indicators ； acute coronary syndrome ； disease oriented ； clinical guidelines ； Delphi technique