非創傷成人病患到院時死亡之預後分析研究

Analysis of predictors of hospital outcome in Non-Traumatic Death-On-Arrival adult patients

簡定國(Ding-Kuo Chien)

指導教授 ： 蔡行瀚

臺北醫學大學/公共衛生暨營養學院/傷害防治學研究所/碩士(2007年)

https://doi.org/10.6831/TMU.2007.00059

摘要

題目：非創傷成人病患到院時死亡之預後分析研究

背景：全國各醫院急診室均有到院時死亡（DOA, Death-On-Arrival）的病患。醫護人員常會面臨病患家屬或朋友的問題是：「醫生，病人還有救嗎？」。DOA病患的存活之機率為何？與到院前之反應時間、緊急醫療救護處置、救護技術員素質有沒有因果關係？病患出院時的功能如何？值得研究探討。
美國和加拿大的研究報告顯示院外心臟停止（OHCA, Out-Hospital-Cardiac-Arrest）的存活率是相當低的，平均小於6.4％。在台灣地區到院時死亡（DOA）或院外心臟停止（OHCA）之存活率約在1-7.2％之間。近年來，隨著醫療科技的進步及緊急醫療救護系統（EMS, Emergency Medical System）的發展，存活率有上升的趨勢。
本研究收集由同組急診醫師在不同位置（都市vs 鄉鎮）的醫院急診室，研究分析到院時死亡的病人之存活預後，了解其存活率的情況並探討影響病患存活率的因素，以及存活率是否有地區之差異性。
材料及方法：收集民國九十四年整年度（自2005年1月1日至2005年12月31日止）馬偕紀念醫院台北院區及淡水院區所有到院時死亡的非創傷成人病患，為研究材料。收集資訊來源包括到院前之救護紀錄表，病人於醫院的急救記錄單、急診病歷以及住院病歷。參考Utstein style設計問卷來登錄資料，問卷內容主要變項包括：年齡、性別、院區、到院方式、有無目擊者、緊急醫療救護系統反應時間、抵達醫院時間、救護技術員到達前是否有人執行CPR、到院後醫院醫師決定是否急救、醫院急診紀錄到院的日期及時間、急診室急救時之最初心律、是否有恢復自發性循環 (ROSC, Return Of Spontaneous Circulation) 、離開急診室的日期及時間、循環恢復後病患住院病況、循環恢復後病患活著出院之機率、猝死原因認定及實驗室檢查報告等。
統計分析則使用描述性統計，計算平均值、中位數、標準差、最大值、最小值、百分比及頻率。類別變項使用卡方氏檢定及費雪精確檢定；連續性變項則使用獨立t檢定。p < 0.05 則判定統計上有顯著差異。統計軟體採用SPSS.12.0版。

結果：非創傷成人到院時死亡的病患有330人，其平均年齡為67.6歲，最小為19歲，最大為100歲。有31位（9.4％）病人因已明顯死亡，在家屬同意下於急診室未再施予急救，排除於本研究之對象。其餘299位有施予急救的病人，有117位恢復自發性循環（ROSC），比例為39.1％；其中71位病人住院（23.7％）。但是只有21人活著出院（7.0％）；包括3位（1％）可以自由活動；3位（1％）需臥床，可與外界良好溝通；其餘15人（5.0％）則為植物人狀態。故只有6位（2.0％）病人，算是真的急救成功。
分析兩院區緊急醫療救護系統（EMS），台北院區與淡水院區平均反應時間（3.9分鐘 vs 7.7分鐘）及求救到送醫時間（20.6分鐘 vs 30.0分鐘）台北院區皆較淡水院區為短，統計上有顯著差異。而ROSC（44.3％ vs 27.7％ ）與有生命蹟象住院（29.8％ vs 12.4％）台北院區的機率也較淡水院區高，統計上亦有顯著差異。至於病患活著出院的機率，台北院區雖較淡水院區高2倍以上（8.5％ vs 3.6％），但未達統計上顯著差異（p＝0.098）。
急救後恢復循環（117位）的分析，以台北院區、老人（>65歲）、有目擊者、求救到送醫院時間短、非心臟致死及非低體溫等較高，統計上皆有顯著差異。
經急救恢復循環後，活著出院（21位）的分析，以成人（15-65歲）、有目擊者（真正活著出院的病患皆有目擊者）、求救到送醫院時間短、心臟病致死、血液的酸鹼度較高、鉀離子濃度正常及急診最初心律為心室頻脈等較高，統計上有顯著差異；而性別、院區、到院方式、反應時間、血紅素、體溫及ROSC的時間，則統計上無顯著差異。
分析台北院區台北市消防隊中級與高級救護員對到院時死亡病人的影響。發現高級救護員收到電話求救到救護車送病人到醫院所需平均時間較中級救護員長（25.4分鐘 vs 19.0分鐘），統計上有顯著差異。接受高級救護員救護之DOA病患的ROSC（p=0.016）、活著住院及活著出院的比例亦較中級救護低，但是後兩者未達統計上顯著差異。
結論：本研究發現到院時死亡的非創傷成人病患其存活率為7.0％。經急救恢復循環後，影響活著出院的病人之因素以(1)有目擊者、(2)成人（15-65歲）、(3)求救到送醫院時間短、(4)心臟病導致DOA、(5)血液的酸鹼度較高、(6)鉀離子濃度正常、(7)急診最初心律為心室頻脈為重要因素，統計上有顯著差異；而性別、院區、到院方式、反應時間、救護技術員等級、血紅素、體溫及ROSC的時間，則統計上無顯著差異。

關鍵字

到院時死亡 ； 預後分析 ； 院外心臟停止 ； 地區差異性 ； 存活率 ； 恢復自發性循環 ； 目擊者 ； 緊急醫療救護系統

並列摘要

Title: Analysis of predictors of hospital outcome in Non-Traumatic Death-On-Arrival patients

Background: Death-on-arrival (DOA) patients appear in every emergency department (ED) in Taiwan as well as in other country. Medical personnel are often asked by their family or friends whether or not the patients can survive. What is the survival rate in DOA patients? Is the survival rate associated with the response time, emergent medical treatment, and the competence of the emergency medical technicians（EMTs）? What is the functional outcome of the survival patients after hospital discharge? These questions deserve more research and investigation.

Previous Studies in North America reported that the survival rate for Out-Hospital-Cardiac-Arrest (OHCA) is very low, on average lower than 6.4%. The survival rate for DOA and OHCA in Taiwan is around 1 - 7.2%. In recent years, with the advancement of medical technology and the development of the Emergency Medical System (EMS), the survival rate is increasing.

This study investigated the survival prognosis in DOA patients and discussed factors that would influence the survival rate of the patients. We hoped to examine whether there was a significant difference in survival rate between emergency departments at two different locations (city versus town) belongs to our hospital where the same group of emergency physicians served.

Materials and Methods: We recruited all non-traumatic adult DOA patients that were admitted to Mackay Memorial Hospital Taipei Branch Hospital and Tamshui Branch Hospital as our study subjects. Patient information was collected from records for the first aid before admission, records for CPR at ED, medical charts at emergency department and after admission to ward. The questionnaire was designed according to the Utstein style（the recommended guidelines for uniform reporting of data from out-hospital cardiac arrest）. Main variables in the questionnaire included: age, gender, which branch hospital admitted, mode of transportation to hospital, witnessed or not, the response time of EMS, the time from the scene to hospital , bystander CPR before the arrival of EMS personnel, whether or not emergency physician decided to do cardiopulmonary resuscitation, admission date and time to ED, the initial cardiac rhythm at ED, whether or not return of spontaneous circulation (ROSC), duration of resuscitation, leaving date and time from ED, whether survival to hospital admission, whether survival to hospital discharge, the possible cause of death identified, and laboratory data.

Descriptive statistics including means, medians, standard deviations, maximum, minimum, percentage and frequency were calculated. Chi-squared tests and Fisher’s exact tests were performed for categorical variables. We used independent samples t-tests for continuous variable. The significant level (α) of all statistical tests was set at 0.05. Analysis was conducted by using SPSS version 12.0.

Results: The study population comprised 330 non-traumatic adult DOA patients with an average age of 67.6 years (19-100 years). Thirty-one patients (9%) did not receive resuscitation with the approval of their families due to apparent irreversible death of the patients.

Among the rest 299 patients who received resuscitation, 117 had ROSC (39.1%). Seventy-one patients (23.7%) survived to hospital admission, while only 21 patients survived to hospital discharge. Three patients (1%) were able to carry on normal activity after discharge, and 3 patients became bed ridden but could communicate with other people well. The rest 15 cases were in a severe neurological deficits or persistent vegetative state after discharge. As a result, the resuscitation was truly successful only in 6 patients (2%).

Comparing the EMS between Taipei Branch Hospital and Tamshui Branch Hospital, statistically significant shorter response time and shorter time from receiving call to hospital were both observed in the Main Branch Hospital. The Main Branch Hospital also had significant higher proportion of ROSC (43.3% and 27.7%) and survival to hospital admission (29.8% vs 12.4%). As for the survival rate, although it was twice higher in Main Branch Hospital than in Tamshui Branch Hospital, this difference did not reach statistical significance (p=0.098).

Patients admitted to the Taipei Branch Hospital and elderly patients (>65 years old) had higher chance of ROSC. Chance for ROSC was increased with the presence of a witness, shorter time from receiving call to hospital, non-cardiac causes of death, non-hyperkalemia and non-hypothermia (all p-values <0.05).

After ROSC, the chance of survival to hospital discharge was increased in adult (15-65 y/o) comparing with elderly patients (>65 y/o). The presence of a witness (all patients survived to hospital discharge had a witness), shorter time from receiving call to hospital, cardiac cause of death, relative higher blood pH value, normal potassium concentration in blood, initial cardiac rhythm of VF/VT were also associated with higher chance of survival to hospital discharge.

Conclusion: The survival rate of non-traumatic adult DOA patient in our study was 7.0%. After ROSC, young age, short time from receiving call to hospital, cardiac cause of death, relative higher blood pH value, normal potassium concentration in blood, initial cardiac rhythm with VF/VT were statistically significant factors that would influence the chance of survival to hospital discharge. Gender, hospital admitted, mode of transportation, response time, hemoglobin, body temperature, and time of ROSC did not reach statistical significance level.

並列關鍵字

DOA (Death-On-Arrival) ； analysis of predictors of survival and hospital outcome ； OHCA (Out-Hospital-Cardiac-Arrest) ； differences at two different locations (city versus town) ； survival rate ； ROSC (Return Of Spontaneous Circulation) ； witness ； EMS (Emergency Medical System)

參考文獻

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