台灣教學醫院急性中風病人照護品質的提升–以A醫院為例

Abstract

中風是全球非傳染性疾病死因的第二位，也是成人疾病失能的主因。雖然在台灣中風死亡率逐年下降，但盛行率並未減少與人口老化，中風病人仍持續增加。急性中風，特別是急性缺血中風，近年的診斷與治療有突破性進展，新的腦部影像技術的進步提高中風病灶的確定，血管再開通治療包括靜脈血栓溶解與動脈血栓移除治療顯著改善中風病人的預後，但要達成良好治療成效有賴於急性中風病人能儘快抵達醫院與到院後高品質、有效率的急性中風診斷治療流程。支持此高品質的治療或持續分析改進流程有賴於完整的資料收集整理，中風登錄可以提供了解中風的類型、危險因子的分佈、治療的反應、功能預後等。本論文研究旨在探討下列問題：(1) 由1995至2018年的台大醫院腦中風登錄，分析中風型態、危險因子、死亡率等的年代變遷；(2) 急性中風病人院前流程改進，包括如何提高大眾對於急性中風的認知、如何提高緊急醫療服務（emergency medical services, EMS）對中風的辯識、院前通報、繞道轉送等；(3) 急性缺血中風病人的灌流治療，包括靜脈血栓溶解治療、動脈血栓移除治療，如何有效率進行病人到院後流程、提升急性缺血中風病人接受治療的比例與預後。 由1995至2018年的台大醫院腦中風登錄，於24年期間，中風類型、危險因子和治療選擇有明顯的年代變遷，心因性栓塞、心房顫動、與再灌流治療的比例顯著增加。急性缺血中風病人接受血栓溶解或血栓移除治療存在許多院前和到院後的障礙，克服這些障礙的策略需要急性中風團隊定期良好的溝通、追踪和修正流程，包括提高大眾對中風認知、提升院前的EMS啟動與院前通報、到院後急性中風流程的啟動與跨科部同時進行的效率。研究結果顯示有使用EMS的病人與中風嚴重度、意識改變和心房顫動顯著相關。利用EMS不僅可協助急性缺血中風病人較早到急診，也能有效促進血栓溶解治療進行、縮短中風發生至治療時間。EMS的院前通報可縮短中風病人較快接受斷層掃瞄檢查、增加血栓溶解治療機會。中風病人到院後急性中風流程的緊急啟動能顯著加速中風確診與提升治療效率。 結論為：(1)中風病人資料收集的完整性與評估處置品質有賴於走系統的中風登錄，由過去中風登錄顯示台灣過去1/4世紀中風類型、危險因子、治療、預後的年代變遷；(2) 應持續提升民眾對中風的認知，加強院前的EMS、改進院內急性中風治療照護體系；(3) 提升院前的中風緊急醫療服務，包括急救醫療人員的派遣、中風辨識、院前通告等，需要持續醫療教育與技能增進；(4) 改進醫院的急性中風治療體系，包括團隊形成、定期檢討流程、改進與修正作業流程、持續追蹤病人預後，需要不間斷的努力。

Stroke is the secondary leading cause of non-communicative disease worldwide, and is also the most leading cause of disability in adults. Although stroke mortality has been decreasing in recent 2-3 decades, the little changed prevalence of stroke and ageing population lead to gradual increase of stroke patients in Taiwan. Acute stroke, especially acute ischemic stroke, has made breakthroughs in the diagnosis and treatment. New brain imaging techniques have improved the determination of stroke lesions. Reperfusion therapy including intravenous thrombolysis and endovascular thrombectomy has significantly improved neurological function. To achieve good outcome depends on early presentation of acute stroke patients to the hospitals and a high-quality efficient acute stroke team. Hospital-based stroke registration is one of the clinical stroke research methods. Stroke registration can provide understanding of the type of stroke, the distribution of risk factors, treatment response, and functional outcome. This thesis aimed to investigate: (1) the secular trends of stroke types, risk factors, treatment, and outcome during the period of 1995-2018 from National Taiwan University Hospital (NTUH) Stroke Registry; (2) the quality of pre-hospital stroke management, including identification and pre-notification through emergency medical services (EMS); (3) the quality of of acute stroke care after hospital arrival. There were secular changes in stroke types, risk factors and treatment during a 24-year period from NTUH Stroke Registry. Significant increases in the rates of cardioembolism, atrial fibrillation, and percentage of reperfusion therapy were found. There are many pre-admission and post-admission barriers to the uterization of thrombolysis and/or thrombectomy for acute ischemic stroke patients. Strategies to overcome these barriers required well communication, tracking and adjustment of the pathway by the acute stroke team, include public awareness campaigns, prehospital triage by paramedics, hospital bypass protocols and prenotification systems, urgent stroke-unit admission, on-call multidisciplinary acute stroke teams, urgent neuroimaging protocols, risk-assessment tools to aid physicians when considering thrombolysis or thrombectomy. Our study results showed that patients having EMS utilization were significantly associated with higher stroke severity, altered consciousness, and the presence of atrial fibrillation. Utilization of EMS can not only help acute ischemic stroke patients in early presentation to the hospital, but also effectively facilitate thrombolytic therapy and shorten the onset-to-needle time. The accuracy of the new prehospital notification criteria for patients with potential acute stroke in the prehospital setting was good. Acute stroke patients with pre-notification had shorter door-to-CT time, and higher chance of receiving thrombolytic therapy. The stroke code protocol can significantly increase the percentage of acute ischemic stroke patients receiving thrombolysis and decreases door-to-needle time. In conclusion, there were significant secular changes of stroke type, risk factors, treatment and prognosis in the past 24 years in Taiwan. To improve acute stroke management requires raising the public’s stroke awareness, promoting pre-hospital EMS’s personnel dispatch, stroke identification, pre-notification, and enhancing in-hospital acute stroke management, including close communication, tracking and adjustment of the process by acute stroke team.