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| DC 欄位 | 值 | 語言 |
|---|---|---|
| dc.contributor.advisor | 賴美淑 | |
| dc.contributor.author | Wen-Chu Chiang | en |
| dc.contributor.author | 江文莒 | zh_TW |
| dc.date.accessioned | 2021-06-16T08:30:31Z | - |
| dc.date.available | 2014-02-25 | |
| dc.date.copyright | 2014-02-25 | |
| dc.date.issued | 2013 | |
| dc.date.submitted | 2013-12-27 | |
| dc.identifier.citation | 1. Nichol G, Thomas E, Callaway CW, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 2008;300:1423-31.
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| dc.identifier.uri | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/58778 | - |
| dc.description.abstract | 社區中猝死病患之急救，是世界各地緊急醫療救護與公共衛生領域共同的重要課題。對於這些到院前心跳停止 (out-of-hospital cardiac arrest) 的病患，如果沒有及時獲得旁觀者提供基礎救命術 (basic life support) 的協助，包括施予心肺復甦術 (cardiopulmonary resuscitation; CPR) 及使用自動體外去顫器 (automated external defibrillator; AED) 急救，將很難有長期存活的機會。然而，在如此重要的課題上，目前應用在我國社區中基礎救命術的建議大部分仍是直接採納來自北美或歐洲國家的報告。長期以來，本土研究付之闕如。
其實我國緊急醫療救護系統的組成與西方國家並不相同，此外文獻回顧亦顯示我國的社區中猝死病患其重要的流行病學特徵與西方國家有相當的差異，例如較低的可去顫心律 (shockable rhythm) 以及有接受旁觀者心肺復甦術的比率。因此，我們針對基礎救命術在我國心跳停止病患社區層面之議題，進行了關於下列三個主題的系列研究： (1) 旁觀者心肺復甦術的可近性，(2) 不同方式的基礎救命術的效益性，與 (3) 現場終止急救原則之適用性。 第一個研究採橫斷式設計 (cross-sectional design) 以檢視社會因素 (social determinants) 和接受旁觀者心肺復甦的機會的相關性。在此所指之社會因素係以該年度平均房價與平均家戶所得作為該社區社會經濟狀況 (socioeconomic status) 的代表。第二個研究是以隨機對照試驗 (randomized control trial) 檢驗兩種不同方式的基礎救命術：「先胸外按壓」與「先心律分析」，在低可電擊心律社區猝死病患急救的效果。第三個研究採世代研究設計 (cohort study) 以檢視源自於北美、組合多項現場基礎救命術相關變項的「終止急救」(termination-of-resuscitation; TOR) 原則，在我國社區中是否仍能準確預測社區猝死病患的存活、以及增加緊急醫療救護系統的效率。 研究結果有三項重要發現。第一，居住在本研究所定義之台北市較低社會經濟社區之民眾，發生院外猝死時較少接受旁觀者心肺復甦術，而且存活預後較差。提高當地民眾對猝死病患的辨識度及接受簡單急救訓練的比率可能有助提昇旁觀者心肺復甦術。提高線上派遣員對報案電話中猝死病患的辨識度也是一重要可行的方法。第二，針對社區猝死病患，現場急救人員先進行十循環CPR或先進行AED分析，其穩定心跳恢復率與長期存活率並無差異，但在穩定心跳恢復的病患中存活出院的比例以先接受十循環CPR方式者較高。考量我國社區猝死病患急救相關流行病學，先進行十循環CPR應為可行之道。第三，歐美發展並驗證成為目前急救指引所稱的「通用TOR原則」在台北市資料庫驗證時雖能有效減少不必要的醫院後送，但並無法達到與國外一樣的高準確性，無論在各種病患與施救者的組合下，都會有大於百分之一的機會將可長期存活的病患誤判成無法存活者。 本系列研究的結果，將目前關於基本救命術在社區層面之醫學實證與我國目前現況接軌，能作為日後公共衛生及緊急醫療相關領域政策制定時的重要參考。 | zh_TW |
| dc.description.abstract | Out-of-hospital cardiac arrest (OHCA) is a public health problem of paramount importance all over the world. Many lives and life-years were lost because prompt basic life support (BLS), including bystander cardiopulmonary resuscitation (CPR) and defibrillation, is not provided in the community. Besides, currently most of the recommendation in BLS applied in our community was adopted from the western countries. Characteristics of OHCAs and composition of emergency medical service (EMS) in Taipei were different from the western sites. Therefore, we conducted a series of studies in three important issues with the knowledge gaps, including (1) the accessibility of bystander-initiated CPR, (2) effectiveness of different BLS pattern, and (3) the screening of salvageable patients for hospital transport.
There were three studies included in the series. The first study is a cross-sectional design to assess the association between social determinant and chances of receiving bystander-initiated CPR for patients with cardiac arrest in community. We used the average of real estate price and hosehold income to surrogate the socioeconomic status (SES) of the community. The second study was a randomized control trial to determine the effectiveness of different patterns of BLS (compression first” (CF) versus “analyze first” (AF) strategies) in community of low prevalence of shockable rhythms. The third study was a cohort study to evaluate the applicability of rules for termination of resuscitation (TOR) and to determine whether BLS-TOR rules acceptable as the universal rule in a mixed-tire EMS as in Taipei. The first study revealed that patients who experienced an OHCA in low-SES areas of the city were less likely to receive bystander CPR, and demonstrated worse survival outcomes. The information could guide targeted community training to promote bystander CPR. In the second study, in Taipei City, a population with low rates of shockable rhythms and bystander CPR, there were no differences in sustained return of spontaneous circulation (ROSC) between compressions first vs. analyze first strategy. Considering the EMS operation situation, a period of CPR for up to 10 cycles by paramedic prior to rhythm analysis could be a feasible strategy in this Asian community. In the third study, ALS- and BLS-TOR rules performed well in decreasing unnecessary transport of OHCA patients, and BLS-TOR rule has better performance comparing to ALS TOR rule under all provider combinations in an area with a mixed-tier response EMS system. However, because greater than 1% of those lived would be misclassified as non-survivor by current TOR rules, implementation in this community or other areas with similar characteristics should be cautious. This series of studies provided informative knowledge to current scientific gaps, and would have implication for improving the basic life support for patients with cardiac arrest in our own community. | en |
| dc.description.provenance | Made available in DSpace on 2021-06-16T08:30:31Z (GMT). No. of bitstreams: 1 ntu-102-D94846001-1.pdf: 9804509 bytes, checksum: 8d8fa586f9c6b28475077df31f8e3651 (MD5) Previous issue date: 2013 | en |
| dc.description.tableofcontents | Abstract 7
Keywords 8 中文摘要 9 關鍵字 10 Abbreviations 11 1 Introduction 12 1.1 Cardiac arrest and basic life support (BLS) in community 12 1.2 Scientific focus on BLS in community level 13 Figure 1-1: Chain of Survival for patients with cardiac arrest 13 Figure 1-2: The pyramid of patients from cardiac arrest in community to survival to discharge 16 2 Literature Review: basic life support (BLS) in community 17 2.1 Accessibility of bystander-initiated CPR in community 17 2.1.1 Bystander CPR: individual barrier and neighborhood influence. 17 2.1.2 Disparity of bystander-initiated CPR among different neighborhoods. 17 2.1.3 Importance of identifying disparity of bystander CPR in a community. 18 Table 2-1: Major articles addressed association between bystander CPR and neighborhoods 19 2.2 Effectiveness of different patterns of BLS provided by EMTs in community 24 2.2.1 Patterns of BLS provided by EMTs in community. 24 2.2.2 Theory-based debate between compression first vs. analyzing first 24 2.2.3 Studies on compression first vs. analyzing first. 25 Table 2-2. Major articles addressed comparison of compression first versus analyzing first. 26 2.3 Applicability of termination-of-resuscitation rules for OHCAs in community level: factors associated with/without advanced therapies and composite criteria. 29 2.3.1 Survivals predict factors associated with/without advanced therapies in community level. 29 2.3.2 Composite criteria for survival prediction in community level: Termination of resuscitation (TOR) rules for various providers. 30 2.3.3 Studies on predictive values of ALS-TOR rules and BLS-TOR rules 31 Table 2-3. Major articles addressed predictive values of TOR rules. 32 2.4 Brief summary of literature review 35 2.4.1 Consensus on science: BLS in patients with OHCA 35 2.4.2 Recognition of knowledge gaps 35 3 Objectives 36 4 Materials and Methods 37 4.1 A cross-sectional study to assess the association between receiving bystander-initiated CPR and socioeconomic status among districts in Taipei. 37 4.1.1 Data source and study database 37 4.1.2 Study design, study setting, and study population. 37 4.1.3 Definition of study variables 38 4.1.4 Hypothesis 39 4.1.5 Statistical analysis 39 4.2 A clinical trial to examine effectiveness of BLS sequences on survival of OHCA: starting compression first versus applying AED first. 41 4.2.1 Hypothesis 41 4.2.2 Study design, study population, and study setting. 41 4.2.3 Randomization, blinding procedure, and inclusion/exclusion criteria 41 4.2.4 Definition of intervention and primary outcome, secondary outcomes, and post-hoc analyses 43 Figure 4-1: Diagram of compression first (CF; intervention group) vs. analyzing first (AF; control group) strategies 44 4.2.5 Data collection 45 4.2.6 Statistical analysis 45 4.3 A cohort study to examine the applicability of TOR rules by Utstein-style OHCA registry data in Taipei 47 4.3.1 Data source, study database, and study population. 47 4.3.2 Study design and study setting: predictive values of ALS-TOR rules and BLS-TOR rules in a mixed-tiered EMS 47 4.3.3 Definition of composite criteria, predictive values, and effect on EMS transport system of TOR rules 48 4.3.4 Hypothesis 51 4.3.5 Statistical analysis 51 5 Results and Brief Summary 52 5.1 Accessibility of bystander-initiated CPR in community 52 5.1.1 Description of independent variable: socioeconomic status 52 Table 5-1-1. Distribution of SES among 12 administrative districts during study period 53 5.1.2 Description of bystander-initiated CPR in study population 55 5.1.3 Analytic analysis of disparity of provision of bystander-initiated CPR in high-SES areas versus low-SES areas in Taipei City 56 Figure 5-1-2: Annual incidence of cardiac arrest (per 100,000) and rate of bystander-initiated CPR among 12 districts in Taipei City. 56 Figure 5-1-3: Bystander-initiated CPR rate (percentage and 95% CI) according to SES, age, and gender. 57 5.1.4 Dependent variables: bystander CPR and patient outcomes 58 Table 5-1-1: OHCAs with versus without bystander-initiated CPR 58 Table 5-1-2: OHCAs occurring in high-SES versus low-SES districts 59 Figure 5-1-4: Adjusted odds rations of receiving bystander-initiated CPR 60 Figure 5-1-5: Population density (per 100,000) and rate of bystander-initiated CPR among 12 districts in Taipei City. 61 5.1.5 Brief summary 62 5.2 Effectiveness of different patterns of BLS provided by EMTs in community 63 5.2.1 Enrollment and Patient Characteristics 63 Figure 5-2-1: Flow diagram of subject progress through the trial 63 Table 5-2-1: Pre-specified criteria for exclusion in randomized patients 64 Table 5-2-2: Baseline characteristics of patients enrolled in final analyses 65 5.2.2 Primary outcome, secondary outcomes, and post-hoc analyses 66 Table 5-2-3: Outcomes of Compression First s (CF) vs. Analyze First (AF) 66 Figure 5-2-2A: Unadjusted Odds Ratios for Sustained (> 2 hours) Return of Spontaneous Circulation (ROSC) 67 Figure 5-2-2B: Unadjusted Odds Ratios for survival to discharge 67 Figure 5-2-3A: Adjusted Odds Ratios for Sustained (> 2 hours) Return of Spontaneous Circulation (ROSC) 68 Figure 5-2-3B: Adjusted Odds Ratios for Survival to Discharge 68 Table 5-2-4: Demographic data of enrollees allocated in Team A, B, and C. 69 5.2.3 Brief summary 71 5.3 Factors associated with survival from OHCAs in community level and applicability of composite criteria (TOR rules) among various providers. 73 5.3.1 Univariate analyses of survival predictors in community level in the study population. 73 Table 5-3-1: Univariate analyses of composite criteria in TOR rules by study population. 73 5.3.2 Demographic features of study population among various provider combinations. 74 Figure 5-3-1: Patient flow and study design. 74 Table 5-3-2: Demographic data of OHCAs responded by different EMS level 75 5.3.3 Predictive values and effect on EMS transport system of TOR rules 76 Table 5-3-3: Predictive values of ALS TOR and BLS TOR rules among various provider combinations. 76 Table 5-3-4: misclassification of cases with favorable neurologic outcome 78 Table 5-3-5: Effect on EMS transport system of ALS TOR and BLS TOR rules on EMS among various provider combinations. 79 5.3.4 Refinement of universal TOR rules by extra criteria 80 Table 5-3-6: additional criteria and changes of accuracy of TOR rules. 80 5.3.5 Brief summary 81 6 Conclusion and Discussion 83 6.1 Final conclusion 83 6.2 Strengths of the study 84 6.3 Limitations 85 6.4 Policy recommendations 87 6.4.1 Increase bystander-initiated CPR rate in our community 87 6.4.2 Enhancement of effectiveness of CPR plus AED in our community 89 6.4.3 Application of TOR rules in our community 90 6.5 Suggestions for further study 92 7 References 93 8 Appendix 102 8.1 Utstein’s style of registration for patients with out-of-hospital cardiac arrest 102 8.2 Study process and data collection of the randomized controlled trial examining compression first vs. analyzing first 129 8.3 Accepted papers 137 | |
| dc.language.iso | en | |
| dc.subject | 心肺復甦術 | zh_TW |
| dc.subject | 基礎救命術 | zh_TW |
| dc.subject | 緊急醫療救護 | zh_TW |
| dc.subject | 到院前心跳停止 | zh_TW |
| dc.subject | 社會經濟狀況 | zh_TW |
| dc.subject | 終止急救原則 | zh_TW |
| dc.subject | 自動體外去顫器 | zh_TW |
| dc.subject | Socioeconomic status (SES) | en |
| dc.subject | Out-of-hospital cardiac arrest (OHCA) | en |
| dc.subject | Emergency medical service (EMS) | en |
| dc.subject | Cardiopulmonary resuscitation (CPR) | en |
| dc.subject | Termination-of-resuscitation (TOR) rule | en |
| dc.subject | Automated external defibrillator (AED) | en |
| dc.subject | Bystander | en |
| dc.subject | Basic life support (BLS) | en |
| dc.title | 基礎救命術在心跳停止病患社區層面之研究：可近性、效用性及現場終止急救原則之適用性 | zh_TW |
| dc.title | Study on Basic Life Support for Cardiac Arrest in Community: Accessibility, Effectiveness, and Applicability of Termination-of-Resuscitation Rules | en |
| dc.type | Thesis | |
| dc.date.schoolyear | 102-1 | |
| dc.description.degree | 博士 | |
| dc.contributor.coadvisor | 馬惠明 | |
| dc.contributor.oralexamcommittee | 簡國龍,紀志賢,陳文鍾 | |
| dc.subject.keyword | 基礎救命術,心肺復甦術,自動體外去顫器,緊急醫療救護,到院前心跳停止,社會經濟狀況,終止急救原則, | zh_TW |
| dc.subject.keyword | Automated external defibrillator (AED),Basic life support (BLS),Bystander,Cardiopulmonary resuscitation (CPR),Emergency medical service (EMS),Out-of-hospital cardiac arrest (OHCA),Socioeconomic status (SES),Termination-of-resuscitation (TOR) rule, | en |
| dc.relation.page | 155 | |
| dc.rights.note | 有償授權 | |
| dc.date.accepted | 2013-12-30 | |
| dc.contributor.author-college | 公共衛生學院 | zh_TW |
| dc.contributor.author-dept | 流行病學與預防醫學研究所 | zh_TW |
| 顯示於系所單位： | 流行病學與預防醫學研究所 | |
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