建議

以下將提出對本研究對研究結果建議與經濟評估後對於中央健保署、緊急醫療政 策的建議以及未來研究者之建議。

一、研究結果建議

本研究結果到院前心電圖系統實施後對於ST 波段上升型心肌梗塞病人的醫療品 質影響具有統計上顯著的是縮短到院後緊急心導管手術 (D2B time)，迅速讓心肌血管 重新再灌流，目前國內多數醫院均已建立院內急診搶救心肌梗病人之標準作業流程，

以達到縮短到院後到心肌再灌流之時間Door-to-Ballon (D2B) time <90 分鐘的標準。若 病人由救護車上救護人員送至急診，帶院內做心電圖才診斷出心肌梗塞，再啟動導管 手術準備程序，則需花費一段時間，亦可能因醫院無法實施導管手術而須將病人轉 院，所造成更長的搶救延遲。根據本研究結果到院前心電圖系統可有效縮短 D2B 時 間達 39 分鐘，並可提高 D2B 時間<90 分鐘的達成率 22%，先不論心肌梗塞病人送至 無導管醫院的轉送延誤。若在救護車上實施到院前心電圖後即可判斷病人疑似心肌梗 塞就可增加搶救的時間與效益。根據系統性文獻探討使用到院前心電圖系統之病人可 降低32%的死亡率，並可縮短住院與心臟相關併發症的比例。(Ducas et al., 2016)Ducas et al., 2016)。另外根據最新美國心臟學院 (ACC) /美國心臟學會 (AHA)指引建議將治 療心肌梗塞的黃金搶救時間，修正成建議自接觸第一位醫療人員(First medical contact) 後的90 分鐘內接受血管重新灌流手術，也就是 First medical contact-to-ballon (簡稱 FMC2B time)小於 90 分鐘。在歐洲心臟醫學會(ESC)的 STEMI 治療指引(Ibanez et al., 2018)中說明第一位醫療接觸人員是緊急醫療救護員(EMS)在到院前檢查出疑似 STEMI 病人，將病人直接送往有導管室的醫院進行治療，將可降低20 分鐘的時間，病人到院 後血管再灌流(Wire crossing)的時間標準在 60 分鐘內，若將心肌梗塞治療品質指標增加

到一位醫療人員到心血管再灌流時間(FMC2B)的時間小於 90 分鐘，到院前心電圖系統 對ST 上升型心肌梗塞搶救將更具有的效益上的提升。

二、經濟評估後的政策建議 對於中央健康保險署的建議

本研究結果顯示，高雄市消防局實施到院前心電圖可縮短D2B 時間並提高 D2B 小於90 分鐘達成率，有利於病人預後情況與降低住院死亡率的趨勢，對於醫療費用的 健保申報點數與實際支付費亦有降低趨勢，由於目前健保支付院內心電圖檢查費用，

每張150 點，但對於到院前心電圖系統所判讀的心電圖健保並無支付費用，目前已醫 師自願捐助方式進行，建議中央健保署可將線上判讀心電圖費用內入點值支付範圍預 計每年增加預算約405,628 元，但每年可減少人命損失預估 14.2 人，此投入可應鼓勵 急重症醫院加入到院前心電圖後送機制，降低病人因急診或轉診等待造成就醫延遲，

而喪失心肌梗塞黃金治療時機。

緊急醫療政策建議

本研究結果顯示，透過救護技術員實施到院前心電圖，早期判斷疑似急性心肌塞 病人，後送病人至有導管治療醫院，不僅可縮短病人到醫院後D2B 時間，在緊急醫療 救護法規定下，院前救護技術員必須將病人送至最近最適當之醫院，但配套方面是加 強消防隊救護人員對病人的檢傷能力，但救護人員面對重大傷病的病人之檢傷分類，

面臨過度檢傷及檢傷不足之間取得平衡 (Nathen 2003;Rivara 2008)。若透過到院前心電 圖可協助現場救護技術人員檢傷判斷，對於嚴重的心肌梗塞病人可以及早檢傷發現，

並送往最適的心肌梗塞急救醫院，將可提高急性心肌梗塞搶救的醫療品質，亦可減少 心肌梗塞死亡或嚴重傷害所造成的社會經濟上的損失。此外在民眾方面對於心肌梗塞 症狀發生後使用緊急醫療系統就醫的比例有限，若能增加宣導衛教提高民眾對胸痛胸

悶的警覺性，利用緊急醫療系統救醫避免救醫延遲，將可擴大心肌梗塞搶救效益。

建議緊急醫療主管機關推展到緊急醫療院前心電圖系統以提升緊急救護員在現場 檢傷能力，並各地衛生主管機關與消防主管機關共同合作推動民眾衛教工作。以目前 在高雄市已有國內整合醫療與消防機關推動的實際案例，做為其他縣市推動或中央主 管機關推動之參考。

另外建議中央主管機關可成立專責單位，包含24 小時值班之專科醫師人力對全 國緊急醫療提供到院前心電圖判讀服務，安排到院前心電圖設備與心電圖判讀的專科 醫師人力，並可指揮緊急救護人員與急重症醫院就醫安排，把握急性心肌梗塞病人的 黃金搶救時間。

三、對於未來研究者建議

本研究因為到院前心電圖初期人數較少與目前研究資料來源為單一家醫學中心，

研究對象有所限制。建議未來研究者可以擴大研究範圍至全高雄市收治心肌梗塞治療 的醫院，對於長期存活請況進行更全面的調查研究。且本研究忽略間接成本與病人之 生活品質方面探討，未來可進行成本效用分析，將更能反映到院前心電圖實施後對社 會所帶來的影響與價值。

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網頁資料

高雄市政府消防局辦理「守護心跳聲」專案執行成果統計

https://www.fdkc.gov.tw/Fileupload/statistics_report/66/201710021441270.pdf 高雄榮民總醫院全球心肌梗塞照護網

https://www2.vghks.gov.tw/GAMINWeb/new.html 救心第一 高市救護車設無線傳輸心電圖系統 http://www.epochtimes.com/b5/14/12/31/n4331300.htm

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