非創傷成人病患到院時死亡之預後分析研究

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doi:10.6831/TMU.2007.00059

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非创伤成人病患到院时死亡之预後分析研究

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

简定国 , 硕士　　导师：蔡行瀚　　

繁体中文 DOI： 10.6831/TMU.2007.00059

到院时死亡；预後分析；院外心脏停止；地区差异性；存活率；恢复自发性循环；目击者；紧急医疗救护系统； 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)

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摘要 │ 被引用文献 (1) │ 国际计量

摘要〈TOP〉

题目：非创伤成人病患到院时死亡之预後分析研究
	
背景：全国各医院急诊室均有到院时死亡（DOA, Death-On-Arrival）的病患。医护人员常会面临病患家属或朋友的问题是：「医生，病人还有救吗？」。DOA病患的存活之机率为何？与到院前之反应时间、紧急医疗救护处置、救护技术员素质有没有因果关系？病患出院时的功能如何？值得研究探讨。
美国和加拿大的研究报告显示院外心脏停止（OHCA, Out-Hospital-Cardiac-Arrest）的存活率是相当低的，平均小於6.4％。在台湾地区到院时死亡（DOA）或院外心脏停止（OHCA）之存活率约在1-7.2％之间。近年来，随着医疗科技的进步及紧急医疗救护系统（EMS, Emergency Medical System）的发展，存活率有上升的趋势。
本研究收集由同组急诊医师在不同位置（都市vs 乡镇）的医院急诊室，研究分析到院时死亡的病人之存活预後，了解其存活率的情况并探讨影响病患存活率的因素，以及存活率是否有地区之差异性。
材料及方法：收集民国九十四年整年度（自2005年1月1日至2005年12月31日止）马偕纪念医院台北院区及淡水院区所有到院时死亡的非创伤成人病患，为研究材料。收集资讯来源包括到院前之救护纪录表，病人於医院的急救记录单、急诊病历以及住院病历。参考Utstein style设计问卷来登录资料，问卷内容主要变项包括：年龄、性别、院区、到院方式、有无目击者、紧急医疗救护系统反应时间、抵达医院时间、救护技术员到达前是否有人执行CPR、到院後医院医师决定是否急救、医院急诊纪录到院的日期及时间、急诊室急救时之最初心律、是否有恢复自发性循环 (ROSC, Return Of Spontaneous Circulation) 、离开急诊室的日期及时间、循环恢复後病患住院病况、循环恢复後病患活着出院之机率、猝死原因认定及实验室检查报告等。
统计分析则使用描述性统计，计算平均值、中位数、标准差、最大值、最小值、百分比及频率。类别变项使用卡方氏检定及费雪精确检定；连续性变项则使用独立t检定。p < 0.05 则判定统计上有显着差异。统计软体采用SPSS.12.0版。

结果：非创伤成人到院时死亡的病患有330人，其平均年龄为67.6岁，最小为19岁，最大为100岁。有31位（9.4％）病人因已明显死亡，在家属同意下於急诊室未再施予急救，排除於本研究之对象。其余299位有施予急救的病人，有117位恢复自发性循环（ROSC），比例为39.1％；其中71位病人住院（23.7％）。但是只有21人活着出院（7.0％）；包括3位（1％）可以自由活动；3位（1％）需卧床，可与外界良好沟通；其余15人（5.0％）则为植物人状态。故只有6位（2.0％）病人，算是真的急救成功。
分析两院区紧急医疗救护系统（EMS），台北院区与淡水院区平均反应时间（3.9分钟 vs 7.7分钟）及求救到送医时间（20.6分钟 vs 30.0分钟）台北院区皆较淡水院区为短，统计上有显着差异。而ROSC（44.3％ vs 27.7％ ）与有生命蹟象住院（29.8％ vs 12.4％）台北院区的机率也较淡水院区高，统计上亦有显着差异。至於病患活着出院的机率，台北院区虽较淡水院区高2倍以上（8.5％ vs 3.6％），但未达统计上显着差异（p＝0.098）。
急救後恢复循环（117位）的分析，以台北院区、老人（>65岁）、有目击者、求救到送医院时间短、非心脏致死及非低体温等较高，统计上皆有显着差异。
经急救恢复循环後，活着出院（21位）的分析，以成人（15-65岁）、有目击者（真正活着出院的病患皆有目击者）、求救到送医院时间短、心脏病致死、血液的酸硷度较高、钾离子浓度正常及急诊最初心律为心室频脉等较高，统计上有显着差异；而性别、院区、到院方式、反应时间、血红素、体温及ROSC的时间，则统计上无显着差异。
分析台北院区台北市消防队中级与高级救护员对到院时死亡病人的影响。发现高级救护员收到电话求救到救护车送病人到医院所需平均时间较中级救护员长（25.4分钟 vs 19.0分钟），统计上有显着差异。接受高级救护员救护之DOA病患的ROSC（p=0.016）、活着住院及活着出院的比例亦较中级救护低，但是後两者未达统计上显着差异。
结论：本研究发现到院时死亡的非创伤成人病患其存活率为7.0％。经急救恢复循环後，影响活着出院的病人之因素以(1)有目击者、(2)成人（15-65岁）、(3)求救到送医院时间短、(4)心脏病导致DOA、(5)血液的酸硷度较高、(6)钾离子浓度正常、(7)急诊最初心律为心室频脉为重要因素，统计上有显着差异；而性别、院区、到院方式、反应时间、救护技术员等级、血红素、体温及ROSC的时间，则统计上无显着差异。

并列摘要〈TOP〉

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.

被引用文献 (1) 〈TOP〉

张惠娟(2016)。到院前心肺功能停止病患恢复自发性循环之到院前相关因素探讨-以嘉义某区域教学医院为例。长荣大学医务管理学系(所)学位论文。2016。1-75。

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