急診部急性冠心症臨床品質指標之建立與現況分析…以北部兩家醫院為例

Abstract

前言：醫療品質的議題已被廣泛討論及重視，然而過去測量照護品質的指標少與實證醫學相連結，近來品質指標的發展方向則轉為疾病別導向，實證為基礎且兼顧流程面與結果面的指標系統。急性冠心症的早期診斷及治療，一直是急診部門的一大挑戰，但現今國內未有針對急診部門發展急性冠心症臨床品質指標。 研究目的：本研究為一先期試驗性研究，希望建立急診部門急性冠心症疾病別品質指標，並對台北地區兩家醫院進行現況分析。 研究方法：第一階段以兩回合德菲法專家問卷，將有關急性冠心症之實證醫學臨床指引，經由專家群對於五項指標構面的評選，轉變成臨床品質指標。第二階段針對台北地區一家醫學中心及一家區域教學醫院，以回溯性病歷資料萃取方式，分析自2004年10月01日到2005年03月31日間，此兩院急診部門急性冠心症品質指標表現。 研究結果：在五項指標構面全部考量下，則最後在15項潛在性指標中有7項指標入選，分別是評估性指標：急性冠心症病患到院10分鐘內完成12導程心電圖比率及急性冠心症病患有進行間隔六小時以上之心電圖追蹤比率，和治療性指標：Aspirin過敏之急性冠心症病患給予Clopidogrel比率、急性冠心症病患給予乙型阻斷劑比率、非ST段上升型急性冠心症病患給予Clopidogrel比率、非ST段上升型急性冠心症病患接受緊急心導管手術前給予Gp IIb/IIIa比率、及急性心肌梗塞病患在到院90分鐘內接受心導管手術比率。兩家研究醫院對於上述指標的整體表現分別為：45.51%及44.34%，72.34%及56.76%，100%及0%，3.91%及5.61%，60.78%及32.08%，28.57%及0%，和20.83%及38.89%。 討論：國外有關急性冠心症的品質指標均為整體住院照護所設計，因此本研究的結果，在評估性指標中，只有到院10分鐘內完成心電圖檢查在澳洲學者Scott的研究中有提出外，其於兩項指標並未在其他指標集或研究中提出。在治療性指標方面，幾乎所有的指標集或研究都強調早期使用Aspirin及乙型阻斷劑的重要性，以及冠狀動脈再灌流術(心導管及血栓溶解劑)的進行時間。另外本研究結果中對於Clopidogrel、Glycoprotein IIb/IIIa抑制劑及Heparin的使用，是其他指標集中沒有提出的。在指標表現方面，評估性指標的表現，兩家研究醫院均需加強。在治療性指標方面，兩家研究醫院在急性冠心症病患給予Aspirin及Heparin率的表現上，和國外研究調查的結果相似。研究乙醫院在及時針對急性心肌梗塞病患完成心導管手術的表現上，已達國外的預設標準。兩家研究醫院在乙型阻斷劑投予率上的表現，和國外結果相較，差距相當大。對於非ST段上升型急性冠心症病患給予Clopidogrel及Glycoprotein IIb/IIIa 抑制劑的表現上，研究甲醫院的表現明顯比乙醫院好。 結論：此為國內第一次針對急性冠心症臨床照護品質進行品質指標的建立，也是第一次針對急診部門建立單一疾病、過程面導向的品質評估標準。北部兩家醫院在急性冠心症品質指標的表現上，均需加強乙型阻斷劑的使用，普遍而言，研究甲醫院的表現優於乙醫院，但仍需加強縮短到院後接受緊急心導管的時間。

Background: The issue of quality of health care has been discussed widely and is a topic of current concern. However, the past indicators for performance measure connected with evidence-base medicine rarely. Current direction of developing quality indicators turns to disease-oriented, evidence-based, and concerning about both process and outcome. Early diagnosis and timely treatment of patients of acute coronary syndrome (ACS) always are the challenges in emergency department (ED). Currently, there are not indicators of quality of care for ACS in ED in Taiwan. Objective: In this pilot study, we hoped to develop the clinical quality of care indicators for ACS in ED and analyzed the current performance in two northern hospitals. Method: In the first stage, we developed summaries for each of the potential quality indicators modified from evidence-based clinical guidelines for ACS, and a multidisciplinary expert panel rated the potential indicators by used of two rounds of Delphi technique for 5 dimensions of quality, including validity of evidence, feasibility, impact on outcomes, room for improvement, and controllability. In the secondary stage, we retrospectively measured the performances of indicators for ACS in ED in two northern Taiwan hospitals, including one medical center and one district teaching hospital, from 1st Oct., 2004 to 31st Mar., 2005 by chart abstraction. Results: Seven indicators , 2 evaluating indicators and 5 therapeutic indicators, met the all 5 dimensions finally, and those were rate of Complete electrocardiogram within 10 minutes of presentation, Cardiac markers follow-up more than 6 hours when ED stay, Clopidogrel use if allergy to Aspirin, β-blocker at arrival, Clopidogrel on non-ST elevation myocardial infarction (NSTEMI) patients, Glycoptotein IIb/IIIa inhibitor on NSTEMI patients with percutaneous coronary intervention (PCI), and PCI within 90 minutes of arrival. The performances of these indicators in the two objective hospitals were 45.51%/44.34%, 72.34%/56.76%, 100%/0%, 3.91%/5.61%, 60.78%/32.08%, 28.75%/0%, and 20.83%/38.89% respectively. Conclusions: Comparing with previous studies or quality indicator sets, designed for entire hospital admission, only rate of electrocardiogram within 10 minutes of presentation was mentioned before in the category of evaluating indicator. Almost all studies or indicator sets emphasized the early administration of Aspirin and β-blocker and timely PCI after arrival. Clopidogrel and Glycoprotein IIb/IIIa inhibitor administration rate were the new developed indicators in our study. Both of study hospitals should improve the performances of evaluating indicators and β-blocker administration rate. The performance of timely PCI after arrival was ideal in one of the study hospitals.