派遣協助心肺復甦對到院前心跳驟停的影響

Dispatcher-assisted Cardiopulmonary Resuscitation Impacts on Out-of-Hospital Cardiac Arrest

柯昭穎(Chow-In Ko)

指導教授 ： 程藴菁

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(2022年)

https://doi.org/10.6342/NTU202200423

摘要

目的: 復甦指南指出對119執勤調度員輔助電話心肺復甦術(DATCPR)的加強指示和測量，可以提高旁觀者復甦急救壓胸的比率，但對存活率的提昇並不理想。本研究旨在調查水平式的電腦輔助派遣調度(CAD)系統中，多年持續執行一套全方位的DATCPR復甦指引，對於旁觀者壓胸率與對到院前心跳驟停患者存活率的影響。
方法: 以都市型緊急醫療之中央化電腦輔助派遣調度(CAD)系統為研究對象，該緊急醫療系統由呼叫到救護車調度的時間通常在60秒內。研究人員進行加強DATCPR 的全方位介入方案內容包括：(1)指南更改，(2)工作人員培訓，(3)CAD人因介面設計，(4)電子化評核，(5)回饋，(6)領導重建。因應此介入方案的實施並持續運行，我們設計進行三階段的提昇，第一階段針對執勤調度員，第二階段針對護理師調度員，第三階段實施品改作業。經由全社區的到院前心跳驟停登錄電子資料收集， 利用迴歸分析進行評估，將各個階段介入後的旁觀者壓胸率與患者存活率，與介入前一年同期的資料進行比較。
結果：在第 1 階段，介入側重於執勤調度員，心臟驟停辨識率由59.1%顯著上升至68.9% (p=0.01)，旁觀者心肺復甦壓胸率由18.5%顯著上升至30.4% (p<0.01)。心臟驟停辨識時間相似(44.5 vs. 49.8 s，p=0.24），調度員接到報案電話至壓胸指導時間顯著增加 (96.8 vs. 120.3 s，p=0.01），調度員接到報案電話至壓胸執行時間呈增加趨勢(160.7 vs. 190.3 s，p=0.09）。
在第2階段，介入側重於護理師調度員。旁觀者壓胸率從20.6%上升到35.0%（p<0.001），到達醫院後ROSC（恢復自發血循）率（10.4% vs. 6.6%，p = 0.037）與良好神經學回復率（CPC 1或2）（5.5% vs. 2.6%，p = 0.029）均顯著更高。在校正調整了驟停目擊情形、可去顫心律、年齡、性別和院前時間間隔等影響因子後，介入後良好神經學回復率仍然顯著提升。校正後比值比[(aOR)：2.1, 95%可信區間 (CI)：1.1-4.4]。
在第3階段，經過三年的持續介入，旁觀者壓胸率從23.5%上升到50.4%，約達兩倍增加(p<0.001)。到院後ROSC率顯著較高(6.2% vs. 8.7%，p=0.035)。持續ROSC（ROSC持續2小時）（22.3% vs. 26.8%，p=0.018），出院存活率（5.7% vs. 10.6%，p<0.001），以及良好神經學回復率（2.1% vs. 6.7%，p<0.001）在DATCPR三年三階段持續介入後，均有顯著提升。 經校正調整驟停目擊情形、可去顫心律、年齡、性別、院前時間間隔、有否氣管插管、有否靜脈注射腎上腺素、體外心肺復甦術干預和目標低體溫管理治療後，良好神經學回復率仍呈現顯著提升成效（aOR：2.1，95% CI=1.2 - 3.8，p=0.015）。
結論：本研究在大都市水平式調度的緊急醫療系統中，對於OHCAc患者，開發並展示調度員輔助心肺復甦術的多年期持續多維捆束性介入的成功實施。初期顯示出提高接線調度員對心臟驟停辨識率可提高旁觀者壓胸率。中期顯示多維捆束性DATCPR針對護理師調度員壓胸指導改善持續實施，與OHCA患者 旁觀者壓胸率和良好神經學回復率的顯著提升有關。多維捆束性DATCPR的長期實施與品管，則顯著提升OHCA患者旁觀者壓胸率、患者出院存活率和良好神經學回復率。鑑此，DATCPR應持續加強和推廣。

關鍵字

派遣協助心肺復甦 ； 到院前心跳驟停 ； 緊急醫療系統 ； 心肺復甦 ； 旁觀者 ； 調度員 ； 存活 ； 預後

並列摘要

Purpose: The resuscitation guidelines indicate pre-arrival dispatcher-assisted telephone cardiopulmonary resuscitation (DATCPR) instructions and measurement to increase the rate of bystander CPR (BCPR); however, its short-term impact on survival is unsatisfied. This program investigates the multi-year impacts of continuing a comprehensive program implementation of DATCPR guidelines on BCPR and survival from OHCA (out-of-hospital cardiac arrest) in a horizontal computerized-aided dispatch (CAD) system.
Methods: A centralized CAD system in a metropolitan EMS is studied. Routinely in the system, the time from an EMS call to ambulance dispatch should be within 60 seconds. A comprehensive program to enhance DATCPR included (1) guideline-based protocol changes, (2) staff training, (3) ergonomic CAD interface, (4) computerized audit, (5) feedback, and (6) leadership rebuilding has been implemented and consistently run. We conducted a three-phase DA-CPR improvement program, in the first phase targeting the call-taker dispatcher, the second phase on nurse dispatcher, and the third phase implementing daily-basis quality improvement processes. The proportions of BCPR and survival for multi-years after the program, by collecting data from a community-wide OHCA e-Registry, implementation are compared with that of the same time duration in the prior year as the control group, using regression analysis for statistics.
Results: In phase 1, the bundle intervention focused on the call taker. The cardiac arrest recognition rate significantly increased from 59.1% to 68.9% (p=0.01), and the bystander CPR rate significantly increased from 18.5% to 30.4% (p<0.01). The call-to-recognition times were similar (44.5 vs. 49.8 s, p=0.24). The call-to-instruction times were significantly increased (96.8 vs. 120.3 s, p=0.01), and the call-to-compression time tended to increase (160.7 vs. 190.3 s, p=0.09).
For phase 2, the bundle intervention focused on the nurse dispatcher. The rate of BCPR went from 20.6% to 35.0% (p<0.001). Outcome of ROSC (return to spontaneous circulation) upon hospital arrival was significantly higher (10.4% vs. 6.6%, p=0.037), as was good neurological outcome CPC 1 or 2 (5.5% vs. 2.6%, p=0.029). After adjusting for witnessed arrest, shockable rhythms, age, sex, and prehospital time intervals, the good neurological outcome was still significantly higher after the intervention [adjusted odds ratios (aOR): 2.1, 95% confidence interval (CI]: 1.1-4.4)].
For phase 3, the rate of BCPR went from 23.5% to 50.4% after three years of intervention, which was about a double increase (p<0.001). The outcome of ROSC upon hospital arrival was significantly higher (6.2% vs. 8.7%, p=0.035). The outcome of sustained ROSC (remained ROSC after 2 hours) (22.3% vs. 26.8%, p=0.018), survival to hospital discharge (5.7% vs. 10.6%, p<0.001), and good neurological outcome (2.1% vs. 6.7%, p<0.001) were all significantly improved after the 3-year three-phase comprehensive program of DATCPR. The good neurological outcome was still significantly higher after the three-phase intervention (aOR: 2.1, 95% CI=1.2-3.8, p=0.015) after adjusting for witnessed arrest status, initial shockable rhythms, age, sex, prehospital time intervals, presence of endotracheal intubation, presence of intravenous epinephrine, intervention with extracorporeal CPR, and therapy with targeted temperature management.
Conclusions: For years, we developed and demonstrated successful implementation of a multidimensional bundle for dispatcher-assisted CPR for OHCA in a metropolitan horizontal dispatch EMS system. Initially improving call-taker dispatchers' cardiac arrest recognition performance would enhance the BCPR rate. The multi-year continuous implementation of DATCPR program to improve the chest compression instruction of nurse dispatcher was associated with significant improvements in the rates of BCPR and good neurologic outcomes after OHCA. The long-term implementation of the comprehensive DATCPR and quality improvement program reveals benefits of the rates of BCPR, patient survival to hospital discharge, and good neurologic outcomes after OHCA, and it should be further continuously reinforced and popularized.

並列關鍵字

Dispatcher-assisted Cardiopulmonary Resuscitation ； Out-of-hospital Cardiac Arrest ； Emergency Medical Service ； Cardiopulmonary Resuscitation ； Bystander ； Dispatcher ； Survival ； Outcome

參考文獻

1. Bobrow BJ, Spaite DW, Berg RA, et al. Chest compression only CPR by lay rescuers and survival from out-of-hospital cardiac arrest. JAMA 2010;304:1447–54.2.

2. Vaillancourt C, Stiell IG, Wells GA. Understanding and improving low bystander CPR rates: a systematic review of the literature. CJEM 2008;10:51–65.

3. Lester CA, Donnelly PD, Assar D. Lay CPR trainees: retraining, confidence and willingness to attempt resuscitation 4 years after training. Resuscitation 2000;45: 77–82.

4. Rea TD, Fahrenbruch C, Culley L, et al. CPR with chest compression alone or with rescue breathing. N Engl J Med 2010;363:423–33.5.

5. Lerner EB, Rea TD, Bobrow BJ, Acker JE 3rd, Berg RA, Brooks SC, Cone DC, Gay M, Gent LM, Mears G, Nadkarni VM, O'Connor RE, Potts J, Sayre MR, Swor RA, Travers AH. Emergency medical service dispatch cardiopulmonary resuscitation pre arrival instructions to improve survival from out-of-hospital cardiac arrest: A Scientific statement from the American Heart Association. Circulation. 2012;125:648-655.