- 學位論文
臺北市救護技術員使用機械式心肺復甦術訓練自覺與測驗的差異
The Discrepancy Between Subjective and Objective Performance on Setup of Mechanical Cardiopulmonary Resuscitation (MCPR) Among Emergency Medical Technicians in Taipei
摘要
研究背景及目的 臺北市政府消防局已全面於救護車上購置機械式心肺復甦機（MCPR），訂定操作步驟（教材及影像），由緊急救護訓練教官指導，並藉由品管機制加以考核。但仍有部分救護員無法有效率地組裝MCPR，進而影響到院前心臟停止（OHCA）病人的存活率。本研究以臺北市消防局線上緊急救護技術員為對象，以到院前心臟停止病人用機械式心肺復甦機介入急救操作測驗為情境，找出影響客觀急救成績的因素。歸納其中可藉由外在改變的特質，以作為設計教育訓練之參考，並能達到因材施教。 研究方法 本研究為橫斷性研究，採無預警方式前往臺北市外勤各消防分隊收案，以三人一組方式進行。測驗前填寫問卷，並用抽籤決定急救工作分配；以急救模型模擬OHCA病人，供受測者操作MCPR，過程以攝影機記錄（錄影之表現為主要預後）。測驗後請受測者自評組裝MCPR所造成之中斷壓胸時間與急救過程整體表現，再由專家委員作客觀評分，進而分析自覺與客觀表現的差異。本研究有效樣本210人，問卷回收210份。資料以描述性統計、卡方檢定、Wilcoxon signed-rank test (matched pairs)、two-sample Wilcoxon rank-sum (Mann-Whitney) test及邏輯迴歸分析進行探討。 研究結果 EMT組裝MCPR自覺中斷壓胸中位數時間為10秒，客觀計時為16秒，兩者有顯著差異（p<0.001）；EMT自評團隊整體表現中位數成績為8分（滿分10分），客觀評分中位數成績為5.5分，兩者有顯著差異（p<0.001）。另外，將EMT2（中級救護技術員）和EMTP（高級救護技術員）分別分析之後發現，EMT2的急救相關知識和急救表現顯著相關，知識分數越高，急救表現越好；EMTP的急救信心越高，急救表現反而較差。分析團隊合作對於壓胸品質的影響發現，團隊合作分數較高，胸部按壓有完全回彈的比率和壓胸分率（chest compression fraction, CCF）皆顯著提高，前者為1.03倍（95% CI 1.01-1.05），後者為1.21倍（95% CI 1.03-1.43）。 結論與建議 執行CPR（特別是組裝MCPR）時很容易有過多不必要（且不自覺）的中斷壓胸時間；加強EMT對中斷壓胸時間的認知，將有助於提升壓胸品質。強化EMT2急救相關知識，增加EMTP團隊合作之精神，應能提升急救表現。團隊合作對於OHCA病人的急救至關重要。欲使MCPR發揮最大的功效，應著手進行團隊訓練模式的建立和指揮者（第三人）的引進、購置適當的擬真訓練器材、增加EMT訓練頻率、定期予以考核，如此一來將能有效提升CPR品質，OHCA病人存活率的提升也就指日可待。
並列摘要
Background Mechanical cardiopulmonary resuscitation (MCPR) devices have been broadly adopted in prehospital emergency care and fully equipped in every ambulance of Taipei City Fire Department (TFD). The quality assurance of MCPR includes formulated training materials, well-trained instructors, and quality control by the ambulance division of TFD. However, some emergency medical technicians (EMTs) cannot set up MCPR devices efficiently, leading to poor outcomes in out-of-hospital cardiac arrest (OHCA). Hence, we randomly selected EMTs in Taipei and tested their ability to set up MCPR devices in the prehospital setting, looking into factors which affect their performance. Methods In this cross-sectional study, we visited 45 stations of TFD without prior notice and tested a total of 210 EMTs. Three EMTs were tested each time as a team, and their roles were randomly assigned. They set up MCPR devices on a CPR training manikin, with the whole process being filmed. Each EMT would self-evaluate their overall performance and the time of chest compression interruptions. We then analyzed the differences between objective scores and those self-assessment scores with descriptive statistics, Chi-square test, Wilcoxon signed-rank test (matched pairs), two-sample Wilcoxon rank-sum (Mann-Whitney) test, and logistic regression. Results The median times of chest compression interruptions are 10 (subjective) and 16 (objective) seconds (p<0.001). The median overall scores are 8 (subjective) and 5.5 (objective) out of 10 (p<0.001). On the other hand, for EMT2, emergency medical knowledge positively correlated with overall performance (OR 2.15, 95% CI 1.31-3.52); for EMTP (paramedic), confidence negatively correlated with overall performance (OR 0.66, 95% CI 0.45-0.97). Finally, successful teamwork led to significantly higher percentage of complete chest recoil (OR 1.03, 95% CI 1.01-1.05) and chest compression fraction (CCF) (OR 1.21, 95% CI 1.03-1.43). Conclusion This study suggested that the recognition of chest compression interruptions is vital for EMTs to shorten those intervals and therefore improve the quality of chest compression. The correlation between knowledge/confidence and overall performance also provides insights for developing future EMT training courses. Moreover, our results once again underline the importance of teamwork during CPR and the installation of MCPR devices. A team-oriented EMT training model, the introduction of the third personnel (as team leader) for OHCA cases, more CPR training manikins for EMTs, as well as frequent practice and quality control, should increase the survival rate of OHCA patients in Taipei.