發展創新之高級救命術急救團隊合作模式「NTUH Airway-Circulation-Leadership-Support (NTUH A-C-L-S)」並評估其訓練成效

Development of a Novel Teamwork Model “NTUH Airway-Circulation-Leadership-Support (NTUH A-C-L-S)” for Advanced Life Support Team Training

楊志偉(Chih-Wei Yang)

指導教授 ： 賴美淑

共同指導教授 ： 馬惠明

國立臺灣大學/公共衛生學院/流行病學與預防醫學研究所/博士(2018年)

https://doi.org/10.6342/NTU201802202

摘要

研究背景
高級救命術是醫療照護者不可或缺的急救技能，近來的高級救命術指引中，強調團隊合作對於急救品質的重要性，建議在教育訓練中導入團隊合作訓練的架構元素，並發展有效的評估工具來進行評核與回饋。目前在台灣對於高級救命術的訓練中，仍缺乏建置急救團隊合作訓練的評估方式、訓練規範與模式。
材料與方法
本研究內容及其研究方法包含:
研究一:發展急救團隊合作模式NTUH Airway-Circulation-Leadership-Support (NTUH A-C-L-S)及其訓練架構。首先藉由觀察性研究，邀請三位專家透過20部急救團隊影像回顧(Video review)進行急救團隊現況問題分析，並探討重要缺失及可能原因；接著採用質性內容分析研究法(qualitative content analysis)，研究者根據上述問題原因分析提出解決方案策略，並利用質性內容分析研究法中的總結性內容分析(summative approach)發展急救團隊合作架構NTUH A-C-L-S、及其訓練課程與示範影片。
研究二: 發展急救團隊表現評估表。首先由三位專家制定新的急救團隊表現評估表各項評量指標及尺規定義；接著驗證急救團隊表現評估表之信效度，包括:內容效度之檢測、評估者間信度(Inter-rater Reliability)、評估表內部一致性(Internal Consistency)及效標效度(Criterion-related Validity)。
研究三: 比較傳統高級救命術訓練與創新之急救團隊模式NTUH A-C-L-S訓練成效。採用群體隨機對照實驗研究設計，受試者急救團隊以病房為單位隨機分派為對照組及實驗組，兩組皆會接受急救核心課程:包括1.5個小時的授課加上1.5小時的核心技能演練，實驗組在急救核心課程之外，會有20分鐘的急救團隊合作模式NTUH A-C-L-S介紹，包括10分鐘的說明以及10分鐘的示範影片討論。接著在各個病房中進行實境高擬真情境模擬(in-situ high-fidelity simulation)，比較兩組團隊急救效率之變項(即各種關鍵急救措施介入之時效，包括:確認脈搏的時間(Time to checking pulse)、開始胸部按壓的時間(Time to first chest compression)、開始正壓通氣的時間(Time to first ambu-bagging)、開始第一次去顫電擊的時間(Time to first defibrillation)、開始施打急救藥物的時間(Time to first medication)、開始嘗試氣管內管插管的時間(Time to first intubation attempt))、及急救效果之變項(即各種關鍵急救措施介入之品質，包括本研究所發展及驗證之急救團隊表現評估表總體分數及各分項分數之比較)。
結果與討論
研究一的問題分析中，發現急救團隊在急救過程中問題之原因類型有技術性技能(Technical skills)及非技術性技能(Non-technical skills)兩大類，其中非技術性技能包括角色分配(Role assignment)、狀況察覺與監測(Situation awareness / monitoring)、相互支援(Mutual support)、溝通(Communication)等問題面向。研究者透過質性分析研究法，針對急救團隊之問題原因與解決策略解構出創新之急救團隊分工架構NTUH A-C-L-S及其對應之執行任務與適當位置，並據此發展創新之急救團隊合作訓練課程與示範影片。
研究二中透過三位專家共識後擬定之評估表共有17項評估指標，評量尺規採用完全做到(Fully achieved)(2分)、部分做到(Partially achieved)(1分)、及沒有做到(None achieved)(0分)之評分系統。針對評估表進行驗證的研究中，S-CVI/UA及S-CVI/Ave分別為0.94及0.99，整體分數的評估者間信度ICC為0.990 (0.979-0.995)，評估表整體的內部一致性Cronbach alpha為0.99。急重症組在整體分數上明顯高於非急重症組(29.07 vs. 22.27, p <0 .001)。
研究三中總共召募台大醫院泛內科及泛外科共15個病房、299名醫護人員，其中對照組7個病房、共29組急救團隊(149人)，實驗組8個病房、共27組急救團隊(150人)。在急救效率變項中，實驗組比起對照組在確認脈搏的時間(Time to checking pulse) (4.04 vs. 15.15, p<0.05)、開始胸部按壓的時間(Time to first chest compression) (21.46 vs. 43.55, p<0.01)、開始第一次去顫電擊的時間(Time to first defibrillation) (123.61 vs. 227.05, p<0.05)、及開始嘗試氣管內管插管的時間(Time to first intubation attempt) (244.31 vs. 325.38, p<0.05)有顯著的縮短。在急救效果的變項中，實驗組比起對照組在急救團隊表現評估表有顯著較高的總分(74.65 vs. 54.48, p<0.05)。
結論
根據現有急救團隊問題分析與質性內容分析而發展出之創新急救團隊合作模式NTUH A-C-L-S及其訓練架構與示範影片，能夠讓醫療照護者在高擬真情境模擬的環境下，提供較有效率及效果之急救品質。

關鍵字

高級救命術 ； 評估表 ； 高擬真情境模擬 ； 非技術性技能 ； 團隊合作

並列摘要

Research Background
Advanced life support (ALS) has been important resuscitation skills for healthcare providers and the importance of teamwork has been emphasized in ALS guidelines recently. Implementation of teamwork models and development of valid assessment tools for ALS training are currently recommended. In Taiwan, implementation and evaluation of resuscitation teamwork training are still lacking.
Materials and Methods
The contents and methods of this research include:
Research 1: Developing an ALS teamwork training model NTUH Airway-Circulation-Leadership-Support (NTUH A-C-L-S). Firstly through an observational study, three experts were invited to review 20 resuscitation videotapes, analyze current problems of resuscitation teams and explore possible causes. Then through the summative approach of qualitative content analysis, researchers proposed the strategies of solutions based on problem analysis, and developed the resuscitation teamwork training model NTUH A-C-L-S.
Research 2: Developing an assessment form for resuscitation team performance. Three experts were invited to establish the items and rubrics of new assessment form for resuscitation performance. Then the validity and reliability of the assessment tool were verified by estimation of content validity, inter-rater reliability, internal consistency, and criterion-related validity.
Research 3: Comparing the effectiveness of traditional resuscitation training and innovative resuscitation teamwork NTUH A-C-L-S training. Cluster randomized controlled study design was applied and general wards recruited were randomly assigned into control group and experimental group. Both groups received the resuscitation core courses, including 1.5-hour didactic lecture and 1.5-hour resuscitation skills training. For experimental group, a 20-minute introduction of teamwork model NTUH A-C-L-S, including 10-minute illustration and 10-minute video-based demonstration, was applied in addition after the core courses. Each resuscitation team, grouped of 4-5 medical staff from the same ward, performed resuscitation during a 10-minute in-situ high-fidelity simulation. Effectiveness of resuscitation was compared between two groups, including efficiency (including “Time to checking pulse”, “Time to first chest compression”, “Time to first ambu-bagging”, “Time to first defibrillation”, “Time to first medication”, and “Time to first intubation attempt”) and quality of resuscitation (the scores of each item and in total of the validated assessment form for resuscitation performance).
Results and Discussions
In problem analysis of resuscitation performance of research 1, two categories, including technical skills and non-technical skills, were identified for causal analysis. Non-technical skills were further categorized into domains of role assignment, situation awareness / monitoring, mutual support, and communication. Through summative approach of qualitative content analysis, researchers formulated an innovative resuscitation teamwork model NTUH A-C-L-S, including respective tasks and suitable position of each team member, based on results of causal analysis and possible strategies of solution. The training model and demonstration videos were also developed based on the innovative teamwork model.
In research 2, through consensus of 3 experts, an assessment form including 17 evaluation items was formulated with rubrics of fully achieved (score of 2), partially achieved (score of 1), and non-achieved (score of 0). S-CVI/UA and S-CVI/Ave of the assessment form were 0.94 and 0.99 respectively. Inter-rater reliability of the total scores was examined by intra class correlation, which was 0.990 (0.979–0.995). The overall Cronbach alpha was 0.99. The critical group had significantly higher total scores than did the non-critical group (29.07 vs. 22.27, p < 0.001).
In research 3, 299 healthcare providers from 15 general wards of department of internal medicine and surgery in National Taiwan University Hospital were recruited. Among them, 7 wards (29 teams composed of 149 healthcare providers in total) were assigned as control group, and the other 8 wards (27 teams composed of 150 healthcare providers in total) were assigned as experimental group. As for efficiency parameters, experimental group had significantly shorter “Time to checking pulse” (4.04 vs. 15.15, p<0.05), “Time to first chest compression” (21.46 vs. 43.55, p<0.01), “Time to first defibrillation” (123.61 vs. 227.05, p<0.05), and “Time to first intubation attempt” (244.31 vs. 325.38, p<0.05) than control group. As for quality of resuscitation performance, experimental group had significantly higher total scores (74.65 vs. 54.48, p<0.05) than control group.
Conclusions
An innovative resuscitation teamwork model NTUH A-C-L-S was developed based on problems analysis and qualitative content analysis of current resuscitation performance. Application of this training model and demonstration videos for healthcare providers has been shown to result in more effective resuscitation performance in high-fidelity simulation.

並列關鍵字

advanced life support ； assessment form ； high-fidelity simulation ； non-technical skill ； teamwork

參考文獻

參考文獻References

1.楊志偉。談基本救命術及心肺復甦術。健康世界2012.3:1-6。

2.Safar P, Escarraga LA, Elam JO: A comparison of the mouth-to-mouth and mouth-to-airway methods of artificial respiration with the chest-pressure arm-lift methods. N Engl J Med 1958;258:671-7.

3.Kouwenhoven WB, Jude JR, Knickerbocker GG: Closed-chest cardiac massage. JAMA 1960;173:1064-7.

4.張朝煜。成人高級心臟救命術的歷史回顧。台灣醫界雜誌2009;52:34-6。