比較加護病房使用The Full Outline of UnResponsiveness Scale及Glasgow Coma Scale監測病人意識狀態之一致性及預測預後的能力

Abstract

研究背景 意識狀態評估是臨床醫療人員的核心臨床技能，目前臨床最常用的意識評估量表是格拉斯哥昏迷指數(Glasgow Coma Scale, GCS)，但因使用GCS評估對於語言反應的測試有其缺陷，部分研究指出GCS有不一致的評量者一致性信度，因應GCS評估的不足，The Full Outline of UnResponsiveness Scale (The FOUR Scale)被發展出來，最初用於評估神經科加護病房病人的意識狀態，許多研究驗證The FOUR Scale有良好的信效度。 研究目的 比較於加護病房使用The FOUR Scale及GCS評估病人意識狀態之一致性及預測預後的能力。 研究方法 本研究採縱貫性重覆測量的研究設計，樣本來源為北市某醫學中心腦中風加護病房、神經外科加護病房、創傷加護病房，於病人入住加護病房24小時內，及入住加護病房第72小時，針對同一位病人，分別使用The FOUR Scale及GCS執行意識狀態測量，同時使用查閱病歷的方式，紀錄病人入加護病房時人口學資料、有無手術、手術術式、插管及使用呼吸器情形、腦中風量表(National Institute of Health Stroke Scale, NIHSS)分數、急性生理和慢性健康評分量表(Acute Physiology and Chronic Health Evaluation Ⅱ Score, APCHE Ⅱ Score)分數，並以查爾森共病症指標(Charlson Comorbidity Index, CCI)評估病人共病症情形。預後指標部分，將於病人入住加護病房後第30天，紀錄日常生活活動功能量表（巴氏量表，Barthel Index）、格拉斯哥預後量表(Glasgow Outcome Scale)、改良的Rankin量表(Modified Rankin Scale, m-RS)評估預後。使用統計軟體SPSS 16.0進行分析，包括：描述性統計、Kappa檢定、ROC曲線(ROC Curve)、羅吉斯回歸(Logistic Regression)、配對樣本t檢定(Paired t Test)等統計方法。本研究企圖了解The FOUR Scale及GCS量表在何種分類情況下有較好的一致性及預測預後的能力，以及兩個量表所花費的時間成本差異，期望未來可作為臨床醫療人員在選擇使用意識狀態評估量表時之參考。 研究結果 研究結果發現不同單位、是否診斷顱內出血、是否接受手術、不同急性生理和慢性健康評分量表(Acute Physiology and Chronic Health Evaluation Ⅱ Score, APCHE II Score)分類下的加護病房病人，其GCS及The FOUR Scale量表總分後分類結果具有一致性。使用ROC曲線法比較GCS及The FOUR Scale量表預測良好預後的能力，GCS的area under the curve (AUC)介於0.578~0.781，The FOUR Scale的AUC介於0.550~0.660，GCS相較The FOUR Scale有較佳預測力。多變項羅吉氏回歸分析發現預後顯著預測因子有：年齡、CCI量表總分、入加護病房72小時GCS分數。The FOUR Scale測試花費時間，顯著高於GCS測試花費時間。 結論與應用 GCS及The FOUR Scale測試之一致性皆很高，但以預測預後及測量時間成本而言，建議採用GCS作為加護病房意識狀態監測之量表。本研究發現共病較多個案，其預後較無共病個案差，建議護理教育未來在病人入院當下評估各種生理性指標時，可將個案共病之相關指標納入常規評估，提供預測個案預後之參考。

Background Consciousness assessment is an essential element for clinical medical staff. Glasgow Coma Scale (GCS) is the most widely used tool for the evaluation of consciousness. However, the use of GCS to assess language response has its defects. Some studies have pointed out that GCS has inconsistent inter rater consistency. In response to the shortcomings of GCS assessment, the Full Outline of UnResponsiveness Scale (The FOUR Scale) was developed, and has been found to be useful in the neurological intensive care unit. Many studies indicate the FOUR Scale has good reliability and validity. Aims To compare the consistency of the FOUR Scale and GCS in assessing the consciousness status of patients in the intensive care unit and their ability to predict outcomes. Methods This study is a longitudinal and repeated measurement research design. The study location are as follows: The stroke intensive care unit (ICU), neurosurgery ICU and trauma ICU of a medical center in Taipei City. The patients’ consciousness were assessed with GCS and the FOUR scale at two different times. The first evaluation is within 24 hours after admitted to ICU, and the second evaluation at 72 hours after admitted to ICU. At the same time, the researcher collected included demographic features of the patients, diagnosis, medical procedure, and the score of these scales (1) Charlson Comorbidity Index (CCI), (2) National Institute of Health Stroke Scale (NIHSS), and (3) Acute Physiology and Chronic Health Evaluation II Score (APCHE II Score). For the outcome indicators, the Barthel Index, Glasgow Outcome Scale, and modified Rankin Scale (m-RS) were recorded on the 30th day after the patient is admitted to the ICU. The statistical software SPSS 16.0 was used for analysis, including: descriptive statistics, Kappa test, ROC curve, logistic regression, and paired sample t test. This study attempts to understand under what classification conditions The FOUR Scale and GCS scale have better consistency and ability to predict outcomes. Hopefully, this can provide a reference for future clinical medical staff in selecting consciousness status assessment scales. Results The results showed that patients in different intensive care unit (ICU), whether they were diagnosed with intracranial hemorrhage, whether they underwent surgery, and different Acute Physiology and Chronic Health Evaluation II Score (APCHE II Score) categories, the FOUR Scale and GCS were highly consistent. Based on area under the curve (AUC), GCS was between 0.578 and 0.781, and the FOUR Scale was between 0.550 and 0.660, indicating that GCS had better predictive power than The FOUR Scale. Based on logistic regression analysis, the significant predictors of prognosis were age, total score of the CCI scale, and GCS score at 72 hours after admitted to the ICU. The time taken by GCS was shorter than that of the FOUR Scale, and there have statistically significant differences. Conclusions and implications The consistency of GCS and the FOUR Scale tests is high, but in terms of predicting prognosis and measurement time used, it is recommended to use GCS as the scale for monitoring consciousness status in the intensive care unit. This study found that patients with more comorbidities had a worse prognosis than patients without comorbidities. It is recommended that nursing education should include indicators of individual comorbidities in routine assessments when patients are admitted to the hospital in the future.