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腦中風病患入院後檢查所費時間及其診斷正確性之評估:介入性分析

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行政院國家科學委員會專題研究計畫成果報告

NSC Project Reports

計畫編號:NSC90-2314-B002-265

執行期間:90 年 8 月 1 日至 91 年 7 月 31 日

計畫主持人:呂建榮醫師

執行機構及單位名稱: 台大醫院神經部

共同主持人:葉炳強教授

執行機構及單位名稱: 台大醫院神經部

計畫參與人員:鄭建興 醫師

執行機構及單位名稱: 台大醫院神經部

一、中文摘要 本研究包括兩大部分:一部份是針對 一般大眾的教育,另一方面則是針對院內 醫療的評估。關於第一部份,我們台大醫 院神經部與台灣腦中風學會及台北科技大 學一起合作,已製作出一片衛教光碟及一 份衛教單張。並已於 91 年 6 月 22 日於國 父紀念館所舉辦之園遊會場分發給參加的 民眾。現場並回收問卷 263 份。關於第二 部份,則是承續以前的研究,目的在了解 中風病人在送達醫院之後,接受一系列的 檢查所要花費的時間,特別是對於完成頭 部電腦斷層檢查及完成抽血檢查所需的時 間作觀察。關於第二部份,我們共收集 167 位病人。登錄病人之基本資料、各項危險 因素、中風發生時之症狀、到院時間、所 安排的檢查,及完成各項檢查所花費之時 間;之後再分析是否有什麼因素會影響患 者入院之後,在檢查方面所花費的時間。 結果發現:以肢體無力來表現的病人,到 院後做完電腦斷層掃描所花費的時間是 86 (範圍 31-378)分鐘,在星期一至星期五的 平常日所需要花費的時間分別是 71 (範圍 31117) , 69 (範圍 31156), 139(範圍 37 -378), 187(範圍 36-338), 61(範圍 38-84)分 鐘,而於星期六、日等例假日所需花費的 時間是 44 (範圍 35-53)分鐘;到院後做完 抽血檢查的時間需要 125 (範圍 57-259)分 鐘,在星期一至星期五的平常日所需要花 費的時間分別是 155 (範圍 71-259) , 111 (範圍 57-192), 132 (範圍 103-177), 165 (範 圍 159-170), 114 (範圍 71-184)分鐘,而於 星期六、日等例假日所需花費的時間是 112 (範圍 103-130)分鐘。以暈眩來表現的病 人,到院後做完電腦斷層掃描所花費的時 間是 157 (範圍 53-378)分鐘,在星期一至 星期五的平常日所需要花費的時間分別是 139 (範圍 53-303) , 154 (範圍 86-267), 378 (範圍 378), 129 (範圍 98-159), 56 (範圍 56) 分鐘,而於星期六、日等例假日所需花費 的時間是 83 (範圍 83)分鐘;到院後做完 抽血檢查的時間需要 144 (範圍 64-313)分 鐘,在星期一至星期五的平常日所需要花 費的時間分別是 168 (範圍 74-313) , 166 (範圍 110-252), 128 (範圍 76-183), 85 (範圍 64-106), 184 (範圍 184)分鐘,而於星期六、 日等例假日所需花費的時間是 202 (範圍 202)分鐘。意即,患者以暈眩或肢體無力 來表現者,入院之後所花費的時間有差 異;而平常日或例假日入院時,於例假日 送達急診室的病人花在檢查方面的時間則 無明顯差異。

English Abstr act

Backgr ound and pur pose:

Cerebrovascular disease (CVD) remains a serious cause of physical disability and death in Taiwan. Thus we think it is important to educate the public to know what are the risk factors of stroke and how they can prevent stroke. Therefore the first part of this study is to make some material for public education, including the CD-R and print. The second purpose of this study is to know the time spent in examination in National Taiwan University Hospital. As we know, acute stroke therapy has been no more nihilism since the success in thrombolytic therapy was reported. It has also been generally accepted that a prerequisite for successful acute stroke intervention with thrombolysis or

neuroprotection is that the time from stroke onset to initiation of treatment must be kept to a minimum. We have studied the time

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from stroke ictus to arrival at hospital and now therefore we would like to explore the factors associated with in-hospital delay.

Methods: This study actually was

separated into two parts. In the first part, we cooperated with the Taiwan Stroke Society, and three students at National Taipei Technology University, using Flash 5 software, to make a CD-ROM for public education. We had made 300 CD-ROMs that had been freely sent to some Taipei citizens on 22 June 2002.

The second half of this study was performed between August 2000 and July 2002 at National Taiwan University Hospital (NTUH). The following data need special inquiry, including (1) the time of the onset of stroke,(2) the time when the patient arrived at the hospital,(3) the time spent in taking history and performing neurological examination,(4) the time spent in

consultation of neurologist,(5) the time spent in collecting laboratory results and (6) the time when the result of brain CT is obtained. In addition to time recording, the

sociodemographic data, clinical

manifestations, laboratory examinations, and head CT/MRI findings are all recorded. The following data will be analyzed to determine the factors of in-hospital delay including age, sex, time of onset, symptoms of onset, clinical course and association with medical disease.

Results: We had made 300 CD-ROMs that

had been freely sent to some Taipei citizens on 22 June 2002. Two hundreds and

sixty-three questionnaires were filled out, which can be used as an observation of public attitude toward cerebrovascular diseases and stroke.

In the second part of this study, we collected 167 patients who were sent to our emergency room, and their data were analyzed to see which factors would

significantly increase their in-hospital delay. In patients who presented as weakness, the average time spent in head CT was 86 (range 31-378) minutes, and from Monday to Friday were 71 (range 31-117), 69 (range31-156), 139(range 37 - 378), 187(range 36-338), 61(range 38 - 84) minutes respectively, and

44 (range 35-53)minutes on Saturday and Sunday. The average time spent in

completing the biochemical examination was 125 (range 57-259) minutes, and from

Monday to Friday were 155 (range 71-259), 111 (range 57-192), 132 (range 103-177), 165 (range 59-170), 114 (range 71-184) minutes respectively, and 112 minutes on Saturday and Sunday. In patients who presented as vertigo, the average time spent in head CT was 157 (range 53-378) minutes, and from Monday to Friday were 139 (range 53-303), 154 (range 86-267), 378 (range 378), 129 (range 98-159), 56 (range 56) minutes respectively, and 83 (range 83) minutes on Saturday and Sunday. The average time spent in completing the biochemical examination was 144 (range 64-313) minutes,and from Monday to Friday were 168 (range 74-313) , 166 (range 110 – 252 ), 128 (range 76-183), 85 (range 64-106), 184 (range 184) minutes respectively, and 202 (range 202) minutes on Saturday and Sunday.

Conclusions: According the preliminary

results, we found the time spent in

examination was of no significant difference between the patients who were sent to our emergency room on different weekday. However, there was difference between patients with different symptoms. Patient with vertigo would spend much more time in completing the imaging and biochemical examinations than patients with weakness.

Key wor ds: emergency room, in-hospital

dalay, acute stroke, vertigo

Subjects and Methods

This prospective study was performed at a medical center, National Taiwan University Hospital (NTUH) that is a 2,000-beds tertiary medical center located in the southern part of Taipei municipality, primarily serving the emergent medical network of the 6 nearby administrative districts. Due to the

geographic location and convenient transportation system in Greater Taipei (Taipei City and surrounding Taipei County), NTUH is also the referral center for nearby cities of Taipei County.

This study actually was separated into two parts. In the first part, we cooperated with the

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Taiwan Stroke Society, and three students at National Taipei Technology University, using Flash 5 software, to make a CD-ROM for public education.

In the second stage of this study, patients with acute stroke that are sent to the

emergency room of NTUH were recruited into this study. The criteria for stroke and TIA diagnosis have been described in details elsewhere according to WHO definition. Stroke was classified into the following categories: cerebral infarction, cerebral hemorrhage and subarachnoid hemorrhage. Cerebral infarction was classified into 5 subtypes: large artery atherosclerosis, lacunae, cardioembolism, other less common

determined causes, and undetermined cause according to the diagnostic criteria modified from TOAST classification. The following data need special inquiry, including (1) the time of the onset of stroke, (2) the time when the patient arrived at the hospital, (3) the time spent in taking history and performing

neurological examination, (4) the time spent in consultation of neurologist, (5) the time spent in collecting laboratory results and (6) the time when the result of brain CT is obtained. In addition to time recording, the sociodemographic data, clinical

manifestations, laboratory examinations, and head CT/MRI findings are all recorded. The following data will be analyzed to determine the factors of in-hospital delay including age, sex, time of onset, symptoms of onset, clinical course and association with medical disease.

Results

We had made 300 CD-ROMs that had been freely sent to some Taipei citizens on 22 June 2002. Two hundreds and sixty-three questionnaires were filled out, which can be used as an observation of public attitude toward cerebrovascular diseases and stroke.

In the second part of this study, we collected 167 patients who were sent to our emergency room, and their data were analyzed to see which factors would

significantly increase their in-hospital delay. In patients who presented as weakness, the average time spent in head CT was 86 (range

31-378) minutes, and from Monday to Friday were 71 (range 31-117), 69 (range31-156), 139(range 37 - 378), 187(range 36-338), 61(range 38 - 84) minutes respectively, and 44 (range 35-53) minutes on Saturday and Sunday. The average time spent in

completing the biochemical examination was 125 (range 57-259) minutes, and from

Monday to Friday were 155 (range 71-259), 111 (range 57-192), 132 (range 103-177), 165 (range 59-170), 114 (range 71-184) minutes respectively, and 112 minutes on Saturday and Sunday. In patients who presented as vertigo, the average time spent in head CT was 157 (range 53-378) minutes, and from Monday to Friday were 139 (range 53-303), 154 (range 86-267), 378 (range 378), 129 (range 98-159), 56 (range 56) minutes respectively, and 83 (range 83) minutes on Saturday and Sunday. The average time spent in completing the biochemical examination was 144 (range 64-313) minutes,and from Monday to Friday were 168 (range 74-313) , 166 (range 110 – 252 ), 128 (range 76-183), 85 (range 64-106), 184 (range 184) minutes respectively, and 202 (range 202) minutes on Saturday and Sunday.

Discussion

Cerebrovascular disease (CVD) remains a serious cause of physical disability and death in Taiwan. At present, stroke is the second leading cause of death. Acute stroke therapy has been no more nihilism since the success in thrombolytic therapy was reported. It has also been generally accepted that a prerequisite for successful acute stroke intervention with thrombolysis or

neuroprotection is that the time from stroke onset to initiation of treatment must be kept to a minimum. We have studied the time from stroke ictus to arrival at hospital and thus in this study we would like to explore the factors associated with in-hospital delay.

In patients who presented as weakness, the time spent in head CT was less than that spent in completing biochemical

examinations. This finding was out of our expectation. However, from Sunday to Saturday, we found no significant difference between the patients who were sent to our

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emergency room on different weekday. Although the variation of time spent in head CT was greater than that spent in

biochemical tests.

In patients presented as vertigo, the time spent in finishing head CT was as twice much as the time of those patients presented with weakness. Alike weakness, we found no significant difference between the patients who were sent to our emergency room on different weekday. The time spent in biochemical tests had no significant

difference between the patients with vertigo and weakness.

According the preliminary results, we found the time spent in examination was of no significant difference between the patients who were sent to our emergency room on different weekday. However, there was difference between patients with different symptoms. Patient with vertigo would spend much more time in completing the imaging and biochemical examinations than patients with weakness.

記劃結果自評

Material for public education of stroke has been already done, and has been ready to go massive production when needed. We have achieved the first mission of this study, i.e. to introduce the correct concept of stroke to the public. According to our preliminary result of evaluation of in-hospital delay, it can hardly shorten the time spent in the same category of patient. However, in patients with different symptoms, the time varied widely. It means education for the emergency physician is necessary. The stroke unit at National Taiwan University Hospital will be up and running, we hope an intervention for

education to the stroke team will give benefit to care of stroke patients. This part of

mission is still going on.

Refer ences:

1. Hung TP: Cerebrovascular disease in the Taiwan Area: past, present and future. J Formos Med Assoc. 1993;92:S103-11.

[In Chinese; English abstract]

2. Chang CC, Chen CJ: Secular trend of mortality from cerebral infarct and

cerebral hemorrhage in Taiwan, 1974-1988. Stroke. 1993;24:212-8.

3. Jeng JS, Lee TK, Chang YC, et al:

Subtypes and case-fatality rates of stroke: a hospital-based stroke registry in Taiwan (SCAN-IV). J Neurol Sci.

1998;156:220-6.

4. Yip PK, Jeng JS, Lee TK, et al: Subtypes of ischemic stroke: A hospital-based stroke registry in Taiwan (SCAN-IV).

Stroke. 1997;28:2507-12.

5. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group: Tissue plasminogen activator for acute ischemic stroke. N Engl J Med.

1995;333:1581-7.

6. The European Ad Hoc Consensus Group: European strategies for early intervention in stroke. A report of an Ad Hoc

Consensus Group meeting. Cerebrovasc Dis. 1996;6:315-24.

7. Furlan A, Higashida R, Wechsler L, et al: Intra-arterial prourokinase for acute ischemic stroke. The PROACT II Study: a randomized controlled trial. JAMA 1999;282:2003-11.

8. Williams LS, Bruno A, Rouch D, et al: Stroke patients’ knowledge of stroke: influence on time to presentation. Stroke.

1997;28:912-5.

9. Cheung RTF, Li LSW, Mak W, et al: Knowledge of stroke in Hong Kong Chinese. Cerebrovasc Dis.

1999;9:119-23.

10. The National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Study Group: A systems approach to immediate evaluation and management of hyperacute stroke: experience at eight centers and implications for community practice and patient care. Stroke.

1997;28:1530-40.

11. Kothari RU, Brott T, Broderick JP, et al: Emergency physicians: accuracy in the diagnosis of stroke. Stroke.

1995:26:2238-41.

12. Jeng JS, Huang ZS, Chang YC, et al: Misdiagnosis of acute cerebrovasuclar disease: experience from a hospital-based stroke registry in Taiwan (SCAN-V).

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13. Stroke Unit Trialist’s Collaborators: Collaborative systematic review of randomized trials of organized inpatient (stroke unit) care after stroke. BMJ.

1997;314:1151-9.

14. Alberts MJ, Bertels C, Dawson DV: An analysis of time of presentation after stroke. JAMA. 1990;263:65-8.

15. Kay R, Woo J, Poon S: Hospital arrival time after onset of stoke. J Neurol Neurosurg Psychiatry. 1992;55:973-4.

16. Alberts MJ, Perry A, Dawson DV, et al: Effects of public and professional education on reducing the delay in presentation and referral of stroke patients. Stroke. 1992;23:352-6.

17. Harper GD, Harigh RA, Potter JF, et al: Factors delaying hospital admission after stroke in Leicestershire. Stroke.

1992;23:835-8.

18. Feldmann E, Gordon N, Brooks JM, et al: Factors associated with early presentation of acute stroke. Stroke. 1993;24:1805-10.

19. Barsan WG, Brott TG, Broderick JP, et al: Time of hospital presentation in patients with acute stroke. Arch Intern Med.

1993;153:2558- 61.

20. Biller J, Patrick JT, Shepard A, Adams HP Jr: Delay time between onset of ischemic stroke and hospital arrival. J Stroke Cerebrovasc Dis. 1993;3:228-30.

21. Anderson NE, Broad JB, Bonita R: Delays in hospital admission and investigation in acute stroke. BMJ.

1995;311:162.

22. Jørgensen HS, Nakayama H, Reith J, et al: Factors delaying hospital admission in acute stroke: the Copenhagen Stroke Study. Neurology. 1996;47:383-7.

23. Fogelholm R, Murros K, Rissanen A, et al: Factors delaying hospital admission after acute stroke. Stroke.

1996;27:398-400.

24.Lacy CR, Bueno M, Kostis JB: Stroke time registry for outcomes knowledge and epidemiology (S.T.R.O.K.E). J Stroke Cerebrovas Dis. 1997;6:470 (Abstract).

25. Smith MA, Doliszny KM, Shahar E, et al: Delayed hospital arrival for acute stroke: The Minnesota Stroke Survey. Ann Intern

Med. 1998;129:190-6.

26. Wester P, Rådberg J, Lundgren B, et al: Factors associated with delayed

admission to hospital and in-hospital delays in acute stroke and TIA. A prospective multicenter study. Stroke.

1999;30:40-8.

27. Yip PK, Jeng JS, Ng SK, et al: The stroke and cerebral atherosclerosis study of National Taiwan University Hospital (SCAN): background and methodology.

Acta Neurol Taiwan. 1997;6:300-8.

28. Hung TP, Lin LS, Su CL for the Stroke Study Group: Prospective survey and registry of stroke in Taiwan area: The fourth annual report. Taipei: Department

of Health, R.O.C. 1992. [In Chinese; English abstract]

29. Dornan WA, Stroink AR, Kattner KA, et al: A public education program is

associated with a dramatic decrease in hospital arrival time in patients with acute stroke. Stroke. 1999:30;232

(Abstract).

30. Dexter L. Morris, Wayne Rosamond, Kenneth Madden, Carol Schultz, and Scott Hamilton: Prehospital and Emergency Department Delays After Acute Stroke : The Genentech Stroke Presentation Survey. Stroke 2000 31: 2585-2590.

31. Emily B. Schroeder, Wayne D.

Rosamond, Dexter L. Morris, Kelly R. Evenson, and Albert R. Hinn:

Determinants of Use of Emergency Medical Services in a Population With Stroke Symptoms : The Second Delay in Accessing Stroke Healthcare (DASH II) Study. Stroke 2000 31: 2591-2596. 32. . Lin CS. Tsai J. Woo P. Chang H.

Prehospital delay and emergency department management of ischemic stroke patients in Taiwan, R.O.C..

Prehospital Emergency Care.1999: 3(3):194-200.

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行政院國家科學委員會補助專題研究計畫成果報告

※※※※※※※※※※※※※※※※※※※※※※※※※※

腦 中 風 病 患 發 病 後 到 院 及 入 院 後 各 項 檢 查 所 費 時 間 及

其診斷正確性之評估:介入性分析

(

Factor s Associated With Delayed Ar r ival Time and

In-Hospital Delays and the Accur acy of Diagnosis in Acute Str oke:

An Inter vention Study

)

※※※※※※※※※※※※※※※※※※※※※※※※※※

計畫類別:

x

個別型計畫

□整合型計畫

計畫編號:NSC90-2314-B002-265

執行期間:90 年 8 月 1 日至 91 年 7 月 31 日

計畫主持人:

呂建榮醫師

共同主持人:

葉炳強教授

計畫參與人員: 鄭建興醫師

執行單位:台大醫院神經部

91

10

31 日

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