Responsive image
博碩士論文 etd-0613122-094256 詳細資訊
Title page for etd-0613122-094256
論文名稱
Title
中風全人照護提升之探討-以高雄榮總為例
Study on Stroke Holistic Care Promotion - Using Kaohsiung Veteran General Hospital As an Example
系所名稱
Department
畢業學年期
Year, semester
語文別
Language
學位類別
Degree
頁數
Number of pages
61
研究生
Author
指導教授
Advisor
召集委員
Convenor
口試委員
Advisory Committee
口試日期
Date of Exam
2022-05-10
繳交日期
Date of Submission
2022-07-13
關鍵字
Keywords
中風、全人照護、急性後期照護、醫療照護失效模式及效應分析、創新智能資訊系統
Stroke, Holistic care, Healthcare failure mode and effect analysis, Innovative intelligent information system, Post-Acute care
統計
Statistics
本論文已被瀏覽 212 次,被下載 150
The thesis/dissertation has been browsed 212 times, has been downloaded 150 times.
中文摘要
腦中風的高死亡率及高殘障率造成家庭社會的沉重負擔,為提升中風照護品質,自2003年全世界興起Get With The Guidelines Program (GWTG)風潮,健保署也於2014年推動「急性後期照護計畫,Post-Acute Care,簡稱PAC」,使病人功能回復達到最佳化。高雄榮民總醫院由12個跨部科專家,組成中風全人團隊,採用「醫療照護失效模式及效應分析」 「Healthcare Failure Mode & Effects Analysis,簡稱HFMEA」手法,檢視高雄榮總急性腦中風照護流程,針對住院照護、全人評估、全人會議及全人照護等四項流程進行危害分析,找出中風照護流程中系統問題,共發現7個失效模式及69項失效原因。我們擬訂四項對策,包括「建立急性腦中風個案管理系統」、「改善急性腦中風病人住院全人評估作業」、「改善急性腦中風病人召開全人會議作業」、「改善急性腦中風病人跨領域全人照護品質」,經由研究過程中團隊精心執行上述四項對策,運用首創之創新作法,來進一步提升腦中風跨領域全人照護品質。本研究分析三個時期相關資料,包括研究進行前期(從2014年1月1日至2016年3月31日) 、研究進行期(從2016年4月1日至2020年12月31日)、研究後蹤期(從2021年1月1日至2021年12月31日),共計5,899位中風病人資料。本研究設定兩個主目標及四個次目標來提升腦中風全人照護。主目標1「急性腦中風PAC下轉率」目標設定15%,由研究進行前的12.3%,提升至研究進行中的17.0%,更進步至研究後追蹤的22.9%,超越預設目標值15%,進步率達到86%(P<0.001),本院腦中風PAC下轉率連續3年榮獲全國第一名。主目標2「急性腦中風符合PAC適應症下轉率」,標竿學習美國62.6%的比率,由研究進行前的42.7%,提升至研究進行中的62.6%,更進步至研究後追蹤的77.1%,超越預設挑戰美國62.6%的目標值,進步率達到81%(P<0.001)。
Abstract
The high mortality and disability rate of stroke causes a heavy burden on society. In order to improve the quality of stroke care, Get With The Guidelines Program (GWTG) trend rise since 2003 and the Taiwan National Health Insurance Administration launched the "Post-Acute Care Program, referred to as PAC", to maximize functional recovery of stroke patients. We organize a stroke holistic team of expertise from 12 clinical units. We use the "Healthcare Failure Mode & Effects Analysis" (HFMEA) method, to examine the current stroke care process, focusing on f inpatient care, holistic assessment, holistic meeting and holistic care. A total of 7 failure modes and 69 failure causes were identified. Four solutions, including "Establish an acute stroke case management system ", "Improve the holistic assessment of stroke patients", "Improve the operation of stroke holistic conferences" and "Improve the Quality of multidisciplinary holistic stroke care" were formulated and implemented comprehensively. The statistical analysis was carried out in the pre-study period (from January 2014 to March 2016), the study period (from April 2016 to December 2020), and the post-study follow-up period (from January 2021 to December 2021), a total of 5,899 stroke patients. The main goal 1, "the PAC transfer rate of stroke", was set at 15%, which increased from 12.3% before the study, to 17.0% during the study, and further improved to 22.9% after the study, exceeding the preset target value 15%, and the improvement rate was 86% (P<0.001). The main goal 2, "The PAC transfer rate of stroke patients fit with PAC indications", was set at 62.6%, has increased from 42.7% before the study, to 62.6% during the study, and further improved to 77.1% after the study, surpass the preset target of 62.6%, and the improvement rate was 81% (P<0.001).
Keywords: Stroke, Holistic care, Healthcare failure mode and effect analysis, Innovative intelligent information system, Post-Acute care
目次 Table of Contents
論文審定書 i
致謝 ii
摘 要 iii
Abstract iv
目錄 v
圖次 vii
表次 viii
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 3
第二章 文獻探討 5
第一節 中風現況及照護發展 5
第二節 指引遵從準則計畫 5
第三節 急性後期照護計畫-腦血管疾病 8
第四節 醫療照護失效模式與效應分析 10
第三章 研究方法 12
第一節 成立腦中風全人照護團隊 12
第二節 主題選定 13
第三節 研究架構與繪製流程圖 14
第四節 數據收集 16
第五節 執行危害分析 19
第六節 對策擬定 22
第七節 對策實施與檢討 24
第四章 研究結果 28
第一節 研究進行期及研究後追蹤期數據收集 28
第二節 有形成果(主目標) 28
第三節 有形成果(次目標) 31
第四節 無形成果(雷達圖) 35
第五節 創新手法與標竿學習 36
第六節 經濟效益 41
第五章 結論與建議 42
第一節 結論 42
第二節 檢討與建議 44
參考文獻 46
參考文獻 References
Adams, R., Acker, J., Alberts, M., Andrews, L., Atkinson, R., Fenelon, K., Furlan, A., Girgus, M., Horton, K., Hughes, R., Koroshetz, W., Latchaw, R., Magnis, E., Mayberg, M., Pancioli, A., Robertson, R. M., Shephard, T., Smith, R., Smith, S. C., Jr., Smith, S., Stranne, S. K., Kenton, E. J., 3rd, Bashe, G., Chavez, A., Goldstein, L., Hodosh, R., Keitel, C., Kelly-Hayes, M., Leonard, A., Morgenstern, L., & Wood, J. O. (2002). Recommendations for improving the quality of care through stroke centers and systems: an examination of stroke center identification options: multidisciplinary consensus recommendations from the Advisory Working Group on Stroke Center Identification Options of the American Stroke Association. Stroke, 33(1), e1-7.
Burke, R. E., Juarez-Colunga, E., Levy, C., Prochazka, A. V., Coleman, E. A., & Ginde, A. A. (2015). Patient and Hospitalization Characteristics Associated With Increased Postacute Care Facility Discharges From US Hospitals. Med Care, 53(6), 492-500. https://doi.org/10.1097/mlr.0000000000000359
Bushnell, C. D., Zimmer, L. O., Pan, W., Olson, D. M., Zhao, X., Meteleva, T., Schwamm, L., Ovbiagele, B., Williams, L., Labresh, K. A., & Peterson, E. D. (2010). Persistence with stroke prevention medications 3 months after hospitalization. Arch Neurol, 67(12), 1456-1463.
https://doi.org/10.1001/archneurol.2010.190
Chiu, C. C., Wang, J. J., Hung, C. M., Lin, H. F., Hsien, H. H., Hung, K. W., Chiu, H. C., Jennifer Yeh, S. C., & Shi, H. Y. (2021). Impact of Multidisciplinary Stroke Post-Acute Care on Cost and Functional Status: A Prospective Study Based on Propensity Score Matching. Brain Sci, 11(2).
https://doi.org/10.3390/brainsci11020161
De Luca, A., Giorgi Rossi, P., & Villa, G. F. (2013). The use of Cincinnati Prehospital Stroke Scale during telephone dispatch interview increases the accuracy in identifying stroke and transient ischemic attack symptoms. BMC Health Serv Res, 13, 513. https://doi.org/10.1186/1472-6963-13-513
Duncan, P. W., Bushnell, C., Sissine, M., Coleman, S., Lutz, B. J., Johnson, A. M., Radman, M., Pvru Bettger, J., Zorowitz, R. D., & Stein, J. (2021). Comprehensive Stroke Care and Outcomes: Time for a Paradigm Shift. Stroke, 52(1), 385-393. https://doi.org/10.1161/STROKEAHA.120.029678
Ekundayo, O. J., Saver, J. L., Fonarow, G. C., Schwamm, L. H., Xian, Y., Zhao, X., Hernandez, A. F., Peterson, E. D., & Cheng, E. M. (2013). Patterns of emergency medical services use and its association with timely stroke treatment: findings from Get With the Guidelines-Stroke. Circ Cardiovasc Qual Outcomes, 6(3), 262-269. https://doi.org/10.1161/circoutcomes.113.000089%
Feigin, V. L., Stark, B. A., Johnson, C. O., Roth, G. A., Bisignano, C., Abady, G. G., Abbasifard, M., Abbasi-Kangevari, M., Abd-Allah, F., Abedi, V., Abualhasan, A., Abu-Rmeileh, N. M. E., Abushouk, A. I., Adebayo, O. M., Agarwal, G., Agasthi, P., Ahinkorah, B. O., Ahmad, S., Ahmadi, S., Ahmed Salih, Y., Aji, B., Akbarpour, S., Akinyemi, R. O., Al Hamad, H.,…, Murray, C. J. L. (2021). Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet Neurology, 20(10), 795-820. https://doi.org/10.1016/s1474-4422(21)00252-0
Fonarow, G. C., Reeves, M. J., Smith, E. E., Saver, J. L., Zhao, X., Olson, D. W., Hernandez, A. F., Peterson, E. D., & Schwamm, L. H. (2010). Characteristics, performance measures, and in-hospital outcomes of the first one million stroke and transient ischemic attack admissions in get with the guidelines-stroke. Circ Cardiovasc Qual Outcomes, 3(3), 291-302.
https://doi.org/10.1161/circoutcomes.109.921858
Hinchey, J. A., Shephard, T., Furie, K., Smith, D., Wang, D., & Tonn, S. (2005). Formal dysphagia screening protocols prevent pneumonia. Stroke, 36(9), 1972-1976. https://doi.org/10.1161/01.STR.0000177529.86868.8d
Hsieh, C. Y., Lee, T. H., & Chang, K. C. (2014). A nationwide plan for postacute care of stroke in Taiwan. Int J Stroke, 9(1), E3. https://doi.org/10.1111/ijs.12232
Hsieh, C. Y., Tsao, W. C., Lin, R. T., & Chao, A. C. (2018). Three years of the nationwide post-acute stroke care program in Taiwan. J Chin Med Assoc, 81(1), 87-88. https://doi.org/10.1016/j.jcma.2017.09.003
Hsieh, F. I., Lien, L. M., Chen, S. T., Bai, C. H., Sun, M. C., Tseng, H. P., Chen, Y. W., Chen, C. H., Jeng, J. S., Tsai, S. Y., Lin, H. J., Liu, C. H., Lo, Y. K., Chen, H. J., Chiu, H. C., Lai, M. L., Lin, R. T., Sun, M. H., Yip, B. S., Chiou, H. Y., Hsu, C. Y., & Taiwan Stroke Registry, I. (2010). Get With the Guidelines-Stroke performance indicators: surveillance of stroke care in the Taiwan Stroke Registry: Get With the Guidelines-Stroke in Taiwan. Circulation, 122(11), 1116-1123. https://doi.org/10.1161/CIRCULATIONAHA.110.936526
Huang, H. C., Tsai, J. Y., Liu, T. C., Sheng, W. Y., Lin, T. C., Lin, C. W., Lee, I. H., & Chung, C. P. (2019). Functional recovery of stroke patients with postacute care: a retrospective study in a northern medical center. J Chin Med Assoc, 82(5), 424-427. https://doi.org/10.1097/JCMA.0000000000000076
Jauch, E. C., Saver, J. L., Adams, H. P., Jr., Bruno, A., Connors, J. J., Demaerschalk, B. M., Khatri, P., McMullan, P. W., Jr., Qureshi, A. I., Rosenfield, K., Scott, P. A., Summers, D. R., Wang, D. Z., Wintermark, M., & Yonas, H. (2013). Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 44(3), 870-947. https://doi.org/10.1161/STR.0b013e318284056a
Johnston, S. C., Mendis, S., & Mathers, C. D. (2009). Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modelling. Lancet Neurol, 8(4), 345-354. https://doi.org/10.1016/s1474-4422(09)70023-7
Kane, R. L., Lin, W. C., & Blewett, L. A. (2002). Geographic variation in the use of post-acute care. Health Serv Res, 37(3), 667-682. https://doi.org/10.1111/1475-6773.00043
Katan, M., & Luft, A. (2018). Global Burden of Stroke. Semin Neurol, 38(2), 208-211. https://doi.org/10.1055/s-0038-1649503
Keenan, C. R., & White, R. H. (2007). The effects of race/ethnicity and sex on the risk of venous thromboembolism. Curr Opin Pulm Med, 13(5), 377-383. https://doi.org/10.1097/MCP.0b013e3281eb8ef0
Kleindorfer, D. O., Towfighi, A., Chaturvedi, S., Cockroft, K. M., Gutierrez, J., Lombardi-Hill, D., Kamel, H., Kernan, W. N., Kittner, S. J., Leira, E. C., Lennon, O., Meschia, J. F., Nguyen, T. N., Pollak, P. M., Santangeli, P., Sharrief, A. Z., Smith, S. C., Jr., Turan, T. N., & Williams, L. S. (2021). 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke, 52(7), e364-e467.
https://doi.org/10.1161/STR.0000000000000375
LaBresh, K. A., Gliklich, R., Liljestrand, J., Peto, R., & Ellrodt, A. G. (2003). Using "get with the guidelines" to improve cardiovascular secondary prevention. Jt Comm J Qual Saf, 29(10), 539-550. https://doi.org/10.1016/s1549-3741(03)29064-x
Lai, C. L., Tsai, M. M., Luo, J. Y., Liao, W. C., Hsu, P. S., & Chen, H. Y. (2017). Post-acute care for stroke - a retrospective cohort study in Taiwan. Patient Prefer Adherence, 11, 1309-1315. https://doi.org/10.2147/ppa.S136041
Lee, H. C., Chang, K. C., Lan, C. F., Hong, C. T., Huang, Y. C., & Chang, M. L. (2008). Factors associated with prolonged hospital stay for acute stroke in Taiwan. Acta Neurol Taiwan, 17(1), 17-25.
McArthur, K. S., Quinn, T. J., Higgins, P., & Langhorne, P. (2011). Post-acute care and secondary prevention after ischaemic stroke. Bmj, 342, d2083.
https://doi.org/10.1136/bmj.d2083
McKevitt, C., Coshall, C., Tilling, K., & Wolfe, C. (2005). Are there inequalities in the provision of stroke care? Analysis of an inner-city stroke register. Stroke, 36(2), 315-320. https://doi.org/10.1161/01.Str.0000152332.32267.19
Ormseth, C. H., Sheth, K. N., Saver, J. L., Fonarow, G. C., & Schwamm, L. H. (2017). The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke Vasc Neurol, 2(2), 94-105. https://doi.org/10.1136/svn-2017-000092
Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., Brown, M., Demaerschalk, B. M., Hoh, B., Jauch, E. C., Kidwell, C. S., Leslie-Mazwi, T. M., Ovbiagele, B., Scott, P. A., Sheth, K. N., Southerland, A. M., Summers, D. V., & Tirschwell, D. L. (2019). Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke, 50(12), e344-e418. https://doi.org/10.1161/STR.0000000000000211
Prvu Bettger, J. A., Kaltenbach, L., Reeves, M. J., Smith, E. E., Fonarow, G. C., Schwamm, L. H., & Peterson, E. D. (2013). Assessing stroke patients for rehabilitation during the acute hospitalization: findings from the get with the guidelines-stroke program. Arch Phys Med Rehabil, 94(1), 38-45.
https://doi.org/10.1016/j.apmr.2012.06.029
Reeves, M. J., Parker, C., Fonarow, G. C., Smith, E. E., & Schwamm, L. H. (2010). Development of stroke performance measures: definitions, methods, and current measures. Stroke, 41(7), 1573-1578.
https://doi.org/10.1161/strokeaha.109.577171
Schwamm, L., Fayad, P., Acker, J. E., 3rd, Duncan, P., Fonarow, G. C., Girgus, M., Goldstein, L. B., Gregory, T., Kelly-Hayes, M., Sacco, R. L., Saver, J. L., Segrest, W., Solis, P., & Yancy, C. W. (2010). Translating evidence into practice: a decade of efforts by the American Heart Association/American Stroke Association to reduce death and disability due to stroke: a presidential advisory from the American Heart Association/American Stroke Association. Stroke, 41(5), 1051-1065. https://doi.org/10.1161/STR.0b013e3181d2da7d
Schwamm, L. H., Fonarow, G. C., Reeves, M. J., Pan, W., Frankel, M. R., Smith, E. E., Ellrodt, G., Cannon, C. P., Liang, L., Peterson, E., & Labresh, K. A. (2009). Get With the Guidelines-Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack. Circulation,119(1),107-115.
https://doi.org/10.1161/CIRCULATIONAHA.108.783688
Schwamm, L. H., Pancioli, A., Acker, J. E., 3rd, Goldstein, L. B., Zorowitz, R. D., Shephard, T. J., Moyer, P., Gorman, M., Johnston, S. C., Duncan, P. W., Gorelick, P., Frank, J., Stranne, S. K., Smith, R., Federspiel, W., Horton, K. B., Magnis, E., Adams, R. J., & American Stroke Association's Task Force on the Development of Stroke, S. (2005). Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association's Task Force on the Development of Stroke Systems. Circulation, 111(8), 1078-1091. https://doi.org/10.1161/01.CIR.0000154252.62394.1E
Spath, P. L. (2003). Using failure mode and effects analysis to improve patient safety. Aorn j, 78(1), 16-37; quiz 41-14. https://doi.org/10.1016/s0001-2092(06)61343-4
Tseng, M. C., & Lin, H. J. (2009). Readmission after hospitalization for stroke in Taiwan: results from a national sample. J Neurol Sci, 284(1-2), 52-55. https://doi.org/10.1016/j.jns.2009.04.009
Wang, C. Y., Chen, Y. R., Hong, J. P., Chan, C. C., Chang, L. C., & Shi, H. Y. (2017). Rehabilitative post-acute care for stroke patients delivered by per-diem payment system in different hospitalization paths: A Taiwan pilot study. Int J Qual Health Care, 29(6), 779-784. https://doi.org/10.1093/intqhc/mzx102
Xian, Y., Xu, H., Lytle, B., Blevins, J., Peterson, E. D., Hernandez, A. F., Smith, E. E., Saver, J. L., Messé, S. R., Paulsen, M., Suter, R. E., Reeves, M. J., Jauch, E. C., Schwamm, L. H., & Fonarow, G. C. (2017). Use of Strategies to Improve Door-to-Needle Times With Tissue-Type Plasminogen Activator in Acute Ischemic Stroke in Clinical Practice: Findings from Target: Stroke. Circ Cardiovasc Qual Outcomes, 10(1). https://doi.org/10.1161/circoutcomes.116.003227

電子全文 Fulltext
本電子全文僅授權使用者為學術研究之目的,進行個人非營利性質之檢索、閱讀、列印。請遵守中華民國著作權法之相關規定,切勿任意重製、散佈、改作、轉貼、播送,以免觸法。
論文使用權限 Thesis access permission:校內校外完全公開 unrestricted
開放時間 Available:
校內 Campus: 已公開 available
校外 Off-campus: 已公開 available


紙本論文 Printed copies
紙本論文的公開資訊在102學年度以後相對較為完整。如果需要查詢101學年度以前的紙本論文公開資訊,請聯繫圖資處紙本論文服務櫃台。如有不便之處敬請見諒。
開放時間 available 已公開 available

QR Code