第五章 討 論
第二節 建議
一、對醫院管理者的建議
（一）內科系疾病由於變異較大制訂臨床路徑的並不多，本研究的 順利完成顯示推動內科系疾病的臨床路徑是可行的，經本研 究發現內科疾病臨床路徑之設置確實有助於醫療成本降低、
醫療品質提高，應可推廣至其他的內科疾病。
（二 ）評估路徑的指標不應只有一般性指標， 應有其路徑特定
（path-specific）的臨床指標(clinical indicators)以作 為後續定期的醫療照護結果監控和報告的依據。
（三）臨床路徑之評估需有特定的臨床指標隨時監測，如能以資訊 系統的輔助將有助於臨床路徑之推行，結合實證醫學即時化 的更新臨床路徑內容，以提供更高品質的醫療照護。
二、對後續研究者的建議
（一）本研究由於時間的限制，收案量稍嫌不足，應可在增加收案 量，以有較高的檢力，來偵測成本相關變項的效應。
（二） 腦中風病房研究顯示對中風病人有較佳的療效，臨床路徑亦 有助於提高病患身體功能，在兩者之關係上可以進一步探討。
（三） 醫療人員間的差異對於成效是否有影響？教育訓練是否足 以解決？
參考文獻
中文部分
中央健康保險局（1996）。衛生署健保字第 85018933 號公告修正--全民健康保 險重大傷病一覽表。台北：中央健康保險局。
台灣腦中風學會 Guideline。Http://www.stroke.org.tw/。
尹祚芊 (1999)。從公共衛生觀點論臨床路徑之袈構模式與推展策略。榮總護
楊樹昌，蘇喜（1995）臨床路徑（Clinical Paths）介紹；醫院；28（5）；20-31。
董正玫(1998)。臨床路徑對醫療成本及住院天數的影響— 以某區域醫院之闌尾切 除術為例。國立陽明大學醫務管理研究所碩士論文。
蔡淑芳（1998）。肺炎手術病患臨床路徑之建立。榮總護理，15（4），419-426。
廖美南（1997）。應用個案管理於控制腦中風病患成本效益之成效。台北醫學院 護理研究所碩士論文。
廖美南、盧美秀(1997)。臨床路徑之建構。護理雜誌 44:29-33。
廖美南、盧美秀（2000）。應用個案管理於控制腦中風病患成本效益之成效探討。
英文部分
Antoinette, T. (1998). Caregiving , staff for stroke rehabilitation. Provider, 6, 67-68.
Arriaga MA, Gorum M, Kennedy A. Clinical pathways in acoustic tumor management. Laryngoscope 1997;107:602-6.
Blegen, M.A., Peiter, R.C., Goode, C.J., ＆ Murphy, R.P. (1995)Outcomes of hospital-based Manned care ： A multivariate analysis of cost and quality.
Managed Care, 86（5）, 809-814.
Bonita R, Scragg R, Stewart A, Jackson R, Baeglehole R. cigarette smoking and risk of premature stroke in men and women. BMJ.1986;293:6-8.
Bowen, J., & Yaste, C. (1994). Effect of a stroke protocol on hospital cost of stroke patient’s. Neurology, 44(10), 1961-1964.
Brown, M.J.(2000).Stroke management: beginning. Outcomes Management for Nursing Practice.4(1),34-38.
Cochran, J. (1994). Family Caregivers of the Fail Elderly Burdens and Health. Nurse Practitioner, 19(5), 5-6.
Coffey, R.T. (1992)An Introduction to Critical Paths. Quality Management in Health Care.
DeWoody, S., & Price, J. (1994). A systems approachs to multidimentional article paths. Nursing Management, 25(11), 47-51.
Donabedian A. Explorations in quality assessment and monitoring vol.II: the
Criteria and standards of quality. Chapter 1 health administration press.
University of Michigan,1982.
Donabedian A. et al. Quality, Cost and Health :An integrative Model. Medcare 20(10):975-992,1982.
Dorsey, M. K., & Vaca, K. J. (1998). The Stroke patient and assessment ofcaregiver needs. Journal of Vascular Nursing, 16(3), 62-67.
Eaton,W.W. and Kessler,L.G.(1981). Rates of symptoms of depression in a national sample. American Journal of Epidemiology, 114(5),528-538.
Ford, A. B., Folmar, S. J., Salmon, R. B., Medalie, J. H., Roy, A. W., and Galazka, S.
S. (1988). Health and function in the old and very old. J Am Geriatr Soc, 36(3), 187-197.
Given, C. W., Collins, C. E., & Given, B. A. (1988). Sources of stress among families caring for relatives with Alzheimer’s disease. Nursing Clinic of North America, 23(1), 69-82.
Goode, C.J.(1995) Impact of a care map and case management on patient satisfaction and staff satisfaction, collaboration ,and autonomy. Nursing Economics.
13(6)337-348.
Grant, J. (1996). Home Care Problems Experienced by Stroke Survivors and The Stroke Family Caregiver. Journal of Family Nursing, 3(1), 36-56.
Han, B., & Haley, W. E. (1999). Family caregiving for patients with stroke review and analysis. Stroke, 30(7), 1478-1485.
Hulley S. B., Cummings S. R., Browner W.S., Grady D. Hearst Norman, Newman T.B. Designing Clinical Research. 2nd, Baltimore: Lippincott Williams &
Wilkins, 2001.
Holmboe ES, Meehan TP, Radford MJ, Wang Y, Marciniak TA, Krumholz HM (1999). Use of critical pathways to improve the care of patients with acute myocardial infarction. Am J Med.107:324-31
Ireson, C.L. (1997), Critical pathways: Effectiveness in achieving patient outcomes.
Journal of Nursing Care Quality;12(6):p.16-23.
Jacavone JB, Daniels RD, Tyner I (1999). CNS facilitation of a cardiac surgery clinical pathway program. Clinical Nurse Specialist.13;126-32.
Jeng, J. S., Lee, T. K., Chang, Y. C., Huang, Z. S., Ng, S. K., Chen, R. C., & Yip, P.
K. (1998). Subtypes and case- fatality rates of stroke: A hospital-based stroke registry in Taiwan. Journal of The Neurological Sciences, 156, 220-226.
June-Forkner,D.(1996), Clinical pathways bnenfits and liabilities. Nursing Management ; 27(11):p.35-37.
Kalka L, Eade J (1995). Role of stroke rehabilitation units in management severe disability after stroke. Stroke 26:2031-4.
Letizia, B. (1999). Ischemic stroke pathway relies on ED order sheets. RN, 62(10)
Lui, M. & Mackenzie, A. E. (1999). Chinese elderly patients’perceptions of their rehabilitation needs following a stroke. Journal of Advance Nursing, 30(2), 391-400.
McHorney CA, Ware JE, Rogers W, et al. The validity and relative precision of MOS short- and long-form health status scales and Dartmouth COOP charts: results from the Medical Outcomes Study. Med Care 1992;30S:MS253-MS265.
Muluk SC, Painter L, Sile S,et al (1997).Utility of clinical pathway and prospective case management to achivve cost and hospital stay reduction for aortic aneurysm surgery at a tertiary care hospital. Journal of Vascular Surgery.25:84-93.
Pearson, S.D (1995)：Critical pathway as a strategy for improving care : problem and potential.
Pierce, L., Rodrigues, Fisher, L., & Buettuer, M. (1995). Frequantly selected nursing diagnosis for the rehabilitation client with stroke. Rehabilitation Nursing, 20(3), 138-143.
Sisson, R. A. (1998). Life After a Stroke : Coping with Change. Rehabilitation Nursing, 23(4), 198-203.
Snedecor GW, Cochran WG. Statistical methods, 8thed.Aames, Iowa:Iowa State University Press, 1967.
Stroke Unit Trialists’ Collaboration: A systemic review of the randomized trials of organized inpatient (stroke unit) care after stroke. Br Med J 1997;314:1151
Spath, P. L. (1994). Clinical paths: An outcomes management tool. In P. L. Spath
Clinical Paths: Tools For Outcomes Management (pp. 1-24). Chicago: American Hospital Publishing, Inc.
Ware E.J and Sherbourne D.C., ” The MOS 36-Item Short-Form Health Survey(SF- 36) I. Conceptual framework and item selection.”, Medical Care, Vol. 30, NO. 6, June 1992.
Wentworth, D. A., & Atkinson, R. P. (1996). Implementation of an acute stroke program decreases hospitalization costs and length of stay. Stroke, 27(6), 1040-1043.
Werner RA, Kessler S (1996). Effectiveness of an intensive outpatient rehabilitation program for post acute stroke patients. Am J Phys Med Rehabil 75:114-20.
Westling, B., Norrving, B., & Thorngren, M. (1990). Survival following stroke: a prospective population-based study of 438 hospitalized cases with prediction according to subtype, severity and age. Acta Neurol Scand, 81, 457- 463.
Williams, A. (1994). What Bothers Caregivers of Stroke Victims ? Journal of Neuroscience Nursing, 26(3), 155-161.
Zander, (1992). Quantifying, managing and improving quality, The new Definition, 7(4), 2.
Zehr KJ, Dawson PB, Yang SC, Heitmiller RF(1998). Standardized clinical care pathways for major thoracic cases reduce hospital costs. Annals of Thoracic Surgery.66:914-9.
附錄表
附錄一 缺血性腦中風病患基本資料
附錄二 全面性照護之缺血性腦中風臨床路徑表(Clinical Pathway) 附錄三 美國國家衛生研究院中風量表（NIHSS）
附錄四 巴氏量表（Barthel Scale）
附錄五 雷式修正量表（MRS）
附錄六 生活功能獨立執行量表（FIM）
附錄七 中國人健康量表（CHQ-12）&憂鬱程度量表 附錄八 主要照護者評估量表
附錄九 教育訓練課程表
附錄一 缺血性腦中風病患基本資料
4□Hyperlipidemia 5□ （請註明）
□ □
附錄二 CVA clinical pathway Phase I 911008
□TPR.BP.GCS.Pupil size
□Head up300, □預防跌倒
□TPR.BP.GCS.Pupil size
□Head up300 □預防跌倒
□TPR.BP GCS. Pupil size
□Head up300 □預防跌倒
○NG Feeding
○Regular diet ○NPO
○NG Feeding
○DM Diet
○Low salt diet
○Low purine diet
○Low fat diet
○Regular diet ○NPO
○NG Feeding
○DM Diet
○Low salt diet 1 2 3
○Low purine diet 1 2 3
○Low fat diet 1 2 3
○Regular diet ○NPO
○NG Feeding
○DM Diet
□Brain CT/MRI
□Check (CBC/DC. BS BUN.
Cr. Na. K. GOT. GPT. PT.
PTT)
□LDL.TG. Cholesterol. Uric acid
□CCCD/TCCD ○MRI/MRA
□ U/A .S/A ○EEG
○Heart echo ○HbA1C (if DM)
○PT,PTT（if on anticoagulant）
○BS: AC/PC(if DM)
□追蹤異常檢驗值 problem list
□完成的檢驗 功能評估 □NIHSS □FIM, Rankin scale, BI □Depression score, CHQ12
藥物/治療 □Hemodilution
○Antiplatelet
○Anticoagulant
○other
Do not lower BP in ischemic stroke unless BP>220/120 mmHg
□Hemodilution ○Operation
○Antiplatelet ○Intubation
○Anticoagulant ○ICU
○Supportive ○NG
○other ○Foley Do not lower BP in ischemic stroke unless BP>220/120 mmHg
□Hemodilution ○Operation
○Antiplatelet ○Intubation
○Anticoagulant ○ICU
○Supportive ○NG
○other ○Foley Do not lower BP in ischemic stroke unless BP>220/120 mmHg
□Hemodilution ○Operation
○Antiplatele ○Intubation
○Anticoagulant ○ICU
○Supportive ○NG
○other ○Foley Do not lower BP in ischemic stroke unless BP>220/120 mmHg Variance □病人家屬因素
附錄二CVA clinical pathway 變異單
附錄三 美 國 國 家 衛 生 研 究 院 中 風 評 量 表 NIHSS
2：present forced deviation 完全凝視麻痺 2
視野正常 0
部分偏盲 1
完全偏盲 2
3.視野
1：partial hemianopia（1/4）
2：complete hemianopi
3：bilateral （blindness） 兩側偏盲 3
動作正常 0
輕微麻痺 1
局部麻痺 2
4.顏面麻痺
1：mild nasolabial fold shallow 2：central type
3：peripheral type 完全麻痺 3
hand 10 seconds , leg 5 seconds 1：drift 未碰到床
1：pinprick decrease but touch being；
if stupor or aphasia
2：not aware of being touch ；if conscious coma 嚴重喪失 2
無失語症 0
輕-中度失語症 1
嚴重失語 2
9.語言（包括 comprehension）
1：不流利但聽得懂
1：slurred speech 但可以理解 2：slurred speech 但難以理解
無法測試 9
11.疏忽/不注意（視覺、觸覺、聽覺、空間、人） 無疏忽 0
部分疏忽 1
完全疏忽 2
總 分
附錄四 巴 式 量 表 Barthel Index
附錄五
Modified Rankin Scale
Score Description
0 No symptoms at all
1 No significant disability despite symptoms; able to carry out all usual duties and activities
2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance
3 Moderate disability; requiring some help, but able to walk without assistance
4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance
5 Severe disability; bedridden, incontinent and requiring constant nursing care and attention
6 Dead
TOTAL (0–6):
附錄六 生 活 功 能 獨 立 執 行 測 量 表
FIM (Functional Independence Measure)
總分： 等級： 日期： 年 月 日 編號：
附錄七 中 國 人 健 康 量 表 CHQ-12
附錄七 憂 鬱 量 表
上一個禮拜中，您有沒有下面的情形和感覺？請問您是從來沒有、很少、
有時候、還是常常？
您會不會… .. 從未 很少
(1 天)
有時 (1-4 天)
常常 (5-7 天)
D1.不想吃東西、胃口不好 1 2 3 4
D2.覺得心情很不好 1 2 3 4
D3.覺得做事情很不順利 1 2 3 4
D4.睡不安穩 1 2 3 4
D5.覺得很快樂 1 2 3 4
D6.覺得很孤單、寂寞 1 2 3 4
D7.覺得人人都很不友善 (對您不 好)
1 2 3 4
D8.覺得日子過得很好很享受人生 1 2 3 4
D9.覺得很悲哀 1 2 3 4
D10.覺得別人不喜歡您 1 2 3 4
D11.提不起勁做任何事 1 2 3 4
附錄八
A2.從多久以前，您因為他身體有問題而開始照顧他？
4 3 2 1 0
C、 照顧者的社交生活
D、 照顧者資料 D1.Short Form 36
本調查目的在探討您對自己健康的看法。這些資訊將能幫助您記錄您的感
4.在過去四個禮拜內，您是否曾因為身體健康問題，而在工作上或其他日常活
妨礙到極點...5
D2.CHQ-12
D3.疾 病 史
E、 照顧者基本資料
附錄九 臨 床 路 徑 教 育 訓 練 課 程 表 1.服用 Coumadin 患者的注
意事項 1. 服用 Coumadin患者的注意
事項
2.高血壓,高血脂症,高膽固 醇症患者的日常生活須知 3. CVA clinical pathway
劉崇祥醫師 2002-10-02
14:00-15:00 16C 會議室