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系統識別號 U0026-2306201721114000
論文名稱(中文) 影響急性心肌梗塞病人治療關鍵績效指標因素之研究
論文名稱(英文) A study of the factors influencing the key performance indicators in the treatment of patients with acute ST elevation myocardial infarction
校院名稱 成功大學
系所名稱(中) 高階管理碩士在職專班(EMBA)
系所名稱(英) Executive Master of Business Administration (EMBA)
學年度 105
學期 2
出版年 106
研究生(中文) 詹世鴻
研究生(英文) Shih-Hung Chan
學號 R07044848
學位類別 碩士
語文別 中文
論文頁數 81頁
口試委員 指導教授-呂執中
口試委員-彭泉
口試委員-翁家瑞
口試委員-謝佩璇
中文關鍵字 急性心肌梗塞  經皮冠狀動脈介入性治療  病人到達醫院急診到血管打通的時間  病人之從急診就診到心電圖完成的時間  檢傷分類 
英文關鍵字 Acute ST elevation myocardial infarction  Percutaneous coronary intervention  Door-to-balloon time  Door-to-electrocardiogram time  Triage 
學科別分類
中文摘要 急性心肌梗塞主要是肇因於供應心臟血流之冠狀動脈發生阻塞或供血不足的現象,是一個致死性極高的急症,約有三分之一的急性心肌梗塞患者在到醫院前即已死亡。縱使到達醫院求診,病患仍有5%~60%之死亡率。
急性心肌梗塞可分為ST波段上升型心肌梗塞及非ST波段上升型心肌梗塞,ST波段上升型心肌梗塞的治療包括保守藥物治療、血栓溶解劑及經皮冠狀動脈介入性治療;三者之中,經皮冠狀動脈介入性治療的治療效果較好,出血性併發症也較少。因此,經皮冠狀動脈介入性治療目前是國際間對於治療ST波段上升型心肌梗塞的建議治療方式。近年來,經皮冠狀動脈介入性治療的廣為施行已使ST波段上升型心肌梗塞患者死亡率逐漸下降。
急性心肌梗塞在治療上的一個重要概念是愈早使阻塞的冠狀動脈血流重建,病人的治療效果愈好。因此,國際學會對於以經皮冠狀動脈介入性治療ST波段上升型心肌梗塞的治療方法宣示一個重要指標,那就是所謂的「病人到達醫院急診到血管打通的時間」,通常以Door-to-balloon time (D2B time)來衡量。美國心臟醫學會建議D2B time最好小於90分鐘,這對病人的預後有幫助。影響D2B time的因素很多,包括病人就醫過程、病人本身狀況、醫師的診斷和治療過程以及整個醫療流程皆有相關;在不同國家、社會形態、區域及醫院間,影響D2B time的因素不盡相同。
本研究是一個回溯性世代研究,蒐錄自2013年1月1日至2016年12月31日因急性ST波段上升型心肌梗塞至南台灣某醫學中心就診的病人。經統計分析後發現,當急診檢傷分類為心臟血管系統問題及病人是由外部醫院轉入時,D2B time有較短的趨勢。當病人是在大夜班時到急診求診、病人是在星期六到急診求診、或病人之從急診就診到心電圖完成的時間較長時,D2B time會有較長的現象。這樣的結果代表著下列管理意涵;第一,病人從急診就診到心電圖完成的時間對於急性ST波段上升型心肌梗塞診斷及治療是重要的,完成的時間愈短,D2B time也將縮短。第二,到院前心電圖對於急性ST波段上升型心肌梗塞診斷及治療是重要的,可以協助提早啟動經皮冠狀動脈介入性治療團隊,D2B time可以縮短。第三,整體醫療團隊的專業訓練及建立可被即時啟動及運作的經皮冠狀動脈介入性治療團隊在急性ST波段上升型心肌梗塞病人的治療是重要的,正確判斷病人具有心臟血管系統問題及加速經皮冠狀動脈介入性治療團隊運作流程可以縮短D2B time。藉由這三方面的管理,D2B time可以縮短,急性ST波段上升型心肌梗塞病人的預後可望被改善。
英文摘要 Acute ST elevation myocardial infarction is mainly caused by occlusion of the coronary artery. It is associated with high mortality and is one of the leading causes of mortality all over the world. Nowadays, percutaneous coronary intervention is the treatment of choice for acute ST elevation myocardial infarction, which efficiently lowers the patient mortality. The most important treatment concept of acute ST elevation myocardial infarction is to re-perfuse the occluded coronary artery as soon as possible. The prognosis of patients is improved by shortening the door-to-balloon time. Almost all the acute ST elevation myocardial infarction patients are treated with percutaneous coronary intervention in our study medical center, located in South Taiwan. Internal analysis reveals a great variation in the door-to-balloon time. The objective of this study is to find out the factors associated with this variation. From 1st January 2013 to 31st December 2016, patients with acute ST elevation myocardial infarction treated with percutaneous coronary intervention are enrolled. The associations of variables with door-to-balloon time are checked by relevant statistical methods. We find that the door-to-balloon time is less if the triage for patient is a cardiovascular system disease or if the patients are transferred from outside hospitals. By contrast, the door-to-balloon time is greater if the door-to-electrocardiogram time is greater or if the patients come to hospital at off-hours. In conclusion, shortening the door-to-electrocardiogram time and facilitating the rapid activation of percutaneous coronary intervention team, especially at off-hours, may be the ways to shorten the door-to-balloon time in this medical center.
論文目次 第一章 緒論 1

第一節 研究背景與問題 1
第二節 研究動機 2
第三節 研究目的 2
第四節 研究範圍 3



第二章 文獻探討 4

第一節 冠狀動脈疾病 4
第二節 急性心肌梗塞 5
第三節 經皮冠狀動脈介入性治療 6
第四節 急性ST波段上升型心肌梗塞的治療 7
第五節 經皮冠狀動脈介入性治療之Door_to_balloon time對治療效果的影響 8
第六節 影響經皮冠狀動脈介入性治療之Door_to_balloon time之可能因素 9
第七節 台灣急診檢傷系統 10



第三章 研究方法 12

第一節 急性心肌梗塞患者就醫流程 12
第二節 觀念性架構 12
第三節 研究假說 14
第四節 變數操作性定義與衡量 15
第五節 資料蒐集 16
第六節 資料分析方法 17



第四章 資料分析 20

第一節 Door_to_balloon time 分析 20
第二節 統計管制圖分析 22
第三節 研究群體描述性統計 25
第四節 病人構面因素與Door_to_balloon time相關性分析 26
1. Door_to_balloon time與性別 26
2. Door_to_balloon time與年齡 26
3. Door_to_balloon time 與休克 26
第五節 到院方式與時間構面和Door_to_balloon time分析 27
1. Door_to_balloon time與到院方式 27
2. Door_to_balloon time與到院班別 28
3. Door_to_balloon time與到院日 29
第六節 急診檢傷分級構面與Door_to_balloon time分析 30
1. Door_to_balloon time與檢傷分級 30
2. Door_to_balloon time與檢傷系統分類 31
第七節 醫師構面與Door_to_balloon time分析 32
1. Door_to_balloon time與當班心臟科醫師 32
2. Door_to_balloon time與當班急診科醫師 33
第八節 Door_to_balloon time與Door_to_EKG time 相關性分析 34
第九節 Door_to_balloon time多因子分析 37
第十節 Door_to_balloon time與Door_to_EKG time及檢傷分級關聯性之再探討 40
1. Door_to_EKG time及檢傷分級關聯性 40
2. Door_to_balloon time與Door_to_EKG time及檢傷分級之關 聯性分析 41
第十一節 Door_to_balloon time與Door_to_EKG time及到院班別關聯 性之再探討 44
1. Door_to_EKG time及到院班別關聯性 44
2. Door_to_balloon time與Door_to_EKG time及到院班別之關聯性分析 44
第十二節 Door_to_balloon time與Door_to_EKG time及檢傷分類系統關聯性之再探討 47
1. Door_to_EKG time及檢傷分類系統關聯性 47
2. Door_to_balloon time與Door_to_EKG time及檢傷分類系統之關聯性分析 47
第十三節 Door_to_EKG time及休克關聯性之探討 50
第十四節 假說檢定結果小結 51
第十五節 討論 53



第五章 結論與建議 56

第一節 研究結論 56
第二節 管理與實務意涵 57
第三節 研究限制 59
第四節 後續研究的建議 59



參考文獻 61
壹、期刊論文 61
貳、網路資源 68



附件 69
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貳、網路資源
http://ctsurgerypatients.org/adult-heart-disease/coronary-artery-disease
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