非都會區域醫院緊急心導管介入性治療急性心肌梗塞的時間分析

An Analysis of Door-to-Balloon Time for ST Elevation Myocardial Infarction in a Rural Regional Hospital

李木壤(Mu-Jang Lee)

指導教授 ： 李金德

高雄醫學大學/健康科學院/醫務管理學研究所碩士在職專班/碩士(2011年)

摘要

背景
急性心肌梗塞患者接受緊急心導管介入性治療的成效，跟抵達急診就診到心臟冠狀動脈恢復通暢，心肌再灌注的時間(Door To Balloon time; DTB)長短有直接相關。DTB時間愈長，病人的預後愈差，死亡率也愈高。DTB時間的研究大多來自都會型區域醫院以及醫學中心。本研究針對非都會區域醫院急性心肌梗塞病患接受緊急心導管介入性治療的時間進行分析。
目的
主要研究目的為發掘延遲的預測因子與可能縮短時間的方法，並探討DTB時間的縮短是否可改善非都會區域醫院急性心肌梗塞的治療成效及降低醫療資源耗用。
方法
本研究是採用病歷回溯方式，調閱屏東縣某區域醫院急診室收治入院，接受緊急心導管介入性治療的急性心肌梗塞病例。研究收案日期是自2004年11月01日至2010年12月31日。收案病例分成DTB 90分鐘以內和超過90分鐘兩組，進行分析比較。
結果
研究期間共收案153名病患，DTB 90分鐘以內的組別有90人，超過90分鐘的組別有63人。影響DTB時間的因素包括10分鐘內執行完心電圖(P<0.001)、白班(P=0.001)和小夜班 (P=0.002) 就診(相對於大夜班)、胸痛發作時間在六小時以內(P=0.001) 和六至十二小時(P=0.029)(相對於超過24小時)、以及有家屬陪同(P=0.004)。DTB 90分鐘之內的病患在加護病房日數(4.6 vs 6.4日；P=0.032)與總住院日數(10.1 vs 13.8日；P=0.050)較短。在死亡率方面，DTB 90分鐘之內的病患有較低的住院心因性死亡率(4.4% vs 14.3%；P=0.032)和90天死亡率(6.7% vs 17.5%；P=0.037)。在醫療費用方面，DTB 90分鐘之內的病患也較低(264156 vs 321982 元;P=0.022)。
結論
本文研究結果顯示即使在醫療資源較缺乏的非都會地區，設備、人力規模次於醫學中心的區域醫院，使用緊急心導管介入性治療急性心肌梗塞並縮短DTB時間，依然是改善急性心肌梗塞患者死亡率有效的策略。而藉由縮短DTB時間，也可減少加護病房住院日數，總住院日數，及總醫療費用。

關鍵字

急性心肌梗塞 ； 緊急心導管介入性治療 ； Door-to-Balloon Time

並列摘要

Background
In patients with acute myocardial infarction treated with primary percutaneous coronary intervention, the effect of treatment is directly related to the length of “door to balloon” (DTB) time. Longer DTB time results in poorer prognosis and higher mortality rate. Most of the studies about DTB time come from regional hospitals and medical centers in urban areas. This study aims to analyze DTB time of the patients with acute myocardial infarction undergoing primary percutaneous coronary intervention in a rural area.
Objective
One of the purposes of this study is to explore the causes of delay and find the strategy to shorten DTB time. The other purpose is to determine whether shortening DTB time could improve the effect of the treatment and decrease the consumption of medical resources for the patient with acute myocardial infarction in a rural area.
Method
We reviewed retrospectively the medical records of the patients with acute myocardial infarction, visiting emergent department of a regional hospital in Ping-Dong county. The period of the study was from Nov 11, 2004 to Dec 31, 2010. The included cases were divided into two groups (DTB time within or more than 90 minutes) to compare statistically.
Result
153 patients were included during the study period. 90 patients were in the group with DTB time within 90 minutes, and 63 patients with DTB time more than 90 minutes. Factors affecting DTB time included door-to-electrocardiogram time within 10 minutes(P<0.001), patient presenting during working hours between 8:01 and 16:00 (P=0.001) and on-call hours between 16:01 and 24:00 (P=0.002) compared with on-call hours between 0:01 and 8:00, the onset of chest pain less than six hours (P=0.001) and between 6 to 12 hours (P=0.029) compared with chest pain more than 24 hours, as well as family member accompanying (P=0.004). The patients with DTB time within 90 minutes had fewer days in intensive care unit (4.6 vs 6.4 days; P=0.032) and the total length of stay. They also had lower rates of cardiogenic mortality during hospitalization (4.4%vs 14.3%; P=0.032) and mortality at 90-day follow up (6.7%vs 17.5%; P=0.037). In terms of medical expenses, patients with DTB time within 90 minutes were fewer than the other group (264156 vs 321,982 NT; P =0.022).
Conclusion
This study indicates that DTB time shortening is a effective strategy to lower the mortality rate of patient with acute myocardial infarction, even treated in a rural regional hospital which is relatively short of medical resources and has smaller scales of equipments and crew than a medical center. It can reduce the hospitalized days in intensive care unit, the total length of stay, and medical costs.

並列關鍵字

acute myocardial infarction ； primary percutaneous coronary intervention ； door to balloon time.

參考文獻

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