急性中風病患的派遣員辨識、救護技術員院前檢傷、與院前中風通報之評估

Assessment of Dispatcher Recognition, Prehospital Triage, and Prehospital Notification for Patients with Acute Stroke

10.6342/NTU201700197

謝明儒

緊急醫療系統 ； 中風 ； 栓溶治療 ； 派遣員 ； 院前中風指標 ； 院前通報 ； emergency medical service system ； stroke ； thrombolytic therapy ； dispatcher ； prehospital stroke scale ； prehospital notification

國立臺灣大學流行病學與預防醫學研究所學位論文

2017年

博士

簡國龍;馬惠明

英文

背景與目標：過去研究顯示中風病患利用緊急醫療系統可早點到達急診，促進病患接受栓溶治療。在台灣，緊急醫療系統對於中風照護的特徵和效應，並未被詳細地研究。本研究的目標為:(1) 了解緊急醫療系統派遣員辨認中風病患的相關因子，及派遣員與報案民眾的通話特徵；(2) 評估現場救護技術員利用新型院前中風評估工具辨識中風的準確度; (3) 了解進行院前通報對於院內處置的效應。 方法：本研究利用多中心中風登錄資料，並連結緊急醫療系統之報案通話紀錄與電子化派遣系統後，收集中風病患的報案電話內容、病患的過去病史、病患於院前和院內所接受的緊急處置與時間、與現場救護技術員是否進行到院前通報之資料。資料收集完整後，對於報案者和派遣員間的通話特徵，派遣員辨認中風的相關因子，現場救護技術員執行新型院前中風評估工具的準確度，和院前通報對於病患接受頭部電腦斷層與接受栓溶治療的時間效應進行評估。 結果：約有一半的報案民眾為中風病患的親密家屬，包括配偶、兒女。不到1%為中風病患本人報案。約有四成的報案民眾會主動提及疑似病患發生中風，然而僅有17.9%的派遣員會用中風當作救護原因進行派遣。主動提及中風或辛辛那提到院前中風指標之相關症狀、派遣員遵從派遣標準作業流程與派遣員能辨認出中風病患相關。新型到院前中風評估工具，敏感度為65%，特異度為98%。和辛辛那提到院前中風指標比較起來，具有相當的敏感度和改善的特異度。為中風病患進行院前通報，可縮短入院至完成電腦斷層時間間隔中位數(13 vs 19分鐘, p 值 < 0.001)，且有趨勢減少入院至開始接受栓溶治療時間間隔中位數(63 vs 68分鐘, p 值為0.14)。 結論：派遣員遵從派遣標準作業流程、現場救護技術員執行新型院前中風評估工具並進行到院前通報，可改善緊急醫療系統內中風病患的醫療照護品質。

Background and Objectives: Previous studies revealed that stroke patients utilizing emergency medical service (EMS) arrived in the emergency department earlier. Thus, it facilitated thrombolytic therapy. In Taiwan, the characteristics and the effect of EMS system on stroke care were not well studied. The objectives of the study were (1) to understand the characteristics of the communication between the caller and the dispatcher among the calls for stroke patients and the factors associated with recognition of stroke by dispatchers; (2) to evaluate the accuracy of identification of stroke patients by on-scene emergency medical technicians (EMTs) with the novel stroke assessment instrument; (3) to understand the effect of prehospital notification on the in-hospital management. Methods: Our study used the multicenter stroke registry connected to the tape recording and computerized dispatch systems. Thus, the data of telephone recording, past history of the patients, the prehospital and in-hospital management timeliness, and whether prenotification was performed could be collected. The characteristics of the communication between the caller and the dispatcher, the factors associated with recognition of stroke by dispatchers, the accuracy of a novel stroke assessment instrument, and the effect of prehospital notification on the time for patients receiving brain computed tomography and thrombolytic therapy were evaluated. Results: About half of the callers were close family members, including the spouses, daughters, and sons. Less than 1% of the callers were the patients themselves. In addition, about 40% of the callers spontaneously reported that the patients were suspected as having a stroke. Nevertheless, only 17.9% of the dispatcher determined stroke dispatch for stroke patients. Stroke or symptoms of the Cincinnati Prehospital Stroke Scale (CPSS) reported by the callers spontaneously, and the dispatch protocol followed by the dispatcher were associated with dispatcher recognition of stroke. The sensitivity and the specificity of the novel instrument were 65% and 98%. The novel instrument had comparable sensitivity and improved specificity when compared with the CPSS. Prehospital notification for stroke patients shortened the median of the door-to-computed tomography time (13 vs 19 minutes, p < 0.001) and had a trend to decrease the median of the door-to-needle time (63 vs 68 minutes, p = 0.14). Conclusion: The dispatcher following the protocol, on-scene EMTs utilizing novel stroke assessment instrument and performing prehospital notification improved the quality of medical care of stroke patients in the EMS system.

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