使用數位式模擬教具及影帶教學評估急診護理人員CPR品質之探討

Abstract

美國心臟學會根據近年來的實證醫學研究結果，公佈2010年版心肺復甦術(Cardiopulmonary Resuscitation，CPR)，並首次改變其急救流程，且一再強調高品質CPR(壓的夠深、壓的夠快、1:1壓放比率和不中斷)的重要性。急診室護理人員幾乎每天都需要用到這項技術，但國內各家醫院卻無固定標準來做技術評估及複習，而且也沒有使用客觀評估CPR執行的品質。 故此研究的目的在探討一、急診護理人員個人的基本屬性，包括性別、年齡、護理進階程度、工作年資、急診工作年資等，以及CPR知識等是否影響高品質CPR技術(包括壓的夠深、壓的夠快、1:1壓放比率及盡量減少中斷)的執行？二、高品質CPR技術的保留，是否隨者時間的增加而減少？三、使用影帶教學介入後，高品質CPR技術保留的成效。本研究採縱貫式、相關性，單組前後測試研究設計，探討急診室護理人員執行CPR技術的現況分析、CPR技術是否隨著時間而改變及影帶介入後的成效及相關因素探討。於北部某急診室臨床護理人員為主要研究對象。採立意取樣(purpose sampling)，每三個月收案一次，共四次收案。第一次為現況分析，第一次收案完成三個月及六個月後進行第二次及第三次收案，再隔三個月後進行影帶教學後，立即進行第四次收案，故此研究共計完成4次的測驗。而收案工具包括數位式模擬教具及電腦、基本資料及工作年資調查、CPR相關知識測驗20題以及CPR教學影帶等進行收案。資料收集完成後，使用描述性統計進行基本資料分析；推論性統計部分，則是使用卡方統計及邏輯迴歸分析進行護理人員執行高品質CPR技術的現況分析及影響CPR技術的相關因素的探討，再以廣義估計方程式分 析隨著時間的增加，CPR技能保留的狀況，及影帶教學介入的成效。 研究結果第一次現況分析共收案77人，第二次至第四次收案33人。整體護理人員在執行高品質CPR技術不理想，只有一人達到高品質CPR的技術，在現況分析中，影響高品質CPR的因素包括了性別、急診工作年資、總護理工作年和急救訓練次數等。此外，發現經過六過月後，CPR技能的保留會隨者時間的增加而流失，尤其是在壓放比值，從0.896降至0.808(p < 0.05)，而在壓胸深度上，雖然沒有統計上的意義，但從55.363 mm下降至54.211 mm (p = 0.209)，有下滑的趨勢。在影帶教學介入後，發現壓放比值通過率介入後比介入前增加了0.618(p < 0.05)，因此影帶教學介入的效果良好，而影響高品質CPR的因素為年齡、性別、N level、護理總工作年資、急診工作年資、和急救訓練次數。此研究限制因收案時間長，且需耗費大量體力，因此造成個案參予意願偏低，而造成個案數少，且所收集的個案只有北部某家醫院，故此研究結果較難推論到其他單位之護理人員。建議臨床定期的訓練和評核CPR技術，而複習和評核的時間建議是在學習CPR訓練6個月較為適當，以維持高品質CPR的執行。

The American Heart Association (AHA) published the 2010 AHA Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) based on evidence-based medical research findings in recent years, as well as changed its emergency rescue procedure for the first time. The Guidelines repeated emphasized the importance of high quality of CPR (high frequency and deep compression, 1:1 compression-release ratio and to continue uninterrupted). Although this is an essential technique of the emergency nursing staff and is almost practiced every day, currently in Taiwan, there are no rules for evaluation and review of CPR techniques, and the quality of CPR was not evaluated objectively as well. The purposes of this study were to (1) investigate the demographic characteristics and working experiences ( i.e., of the emergency nursing staff, including gender, age, nursing skill level, work experiences and emergency experiences) and CPR related knowledge influenced the quality CPR techniques implemented (including depth, frequency, 1:1 compression-release ratio and frequency of un-interruption); (2) to explore whether the retention of high quality CPR skill diminishes with time, and (3) to investigate the effectiveness of instructional video on the retention of high quality CPR skill. This longitudinal, correlation with pre- and post-test in one group study investigated the current status of CPR skills in emergency nursing staff, and further explore whether CPR skills change with time, and examine the effect of instructional video on the retention of high quality CPR skill. The eligible participants were clinical nursing staff members from an emergency ward at a teaching hospital in northern Taiwan. The purpose sampling was used to recruite the nurses and collected data every 3 months for four times. The data for the first time was used to explore the baseline status analysis; Before the day for collecting the fourth data, instructional video were applied and the fourth recruitment in order to examine the immediate effect of the video. Measurement for collecting outcomes included digital CPR simulator, the demographic and work experience survey, a 20-item CPR knowledge test and CPR instructional video. After the data was collected, descriptive statistics were used to analyze the baseline information. The evaluation of nursing staff performing high quality CPR techniques and factors affecting CPR skills were analyzed with inferential statistics such as chi-square analysis and logistic regression analysis. The retention of CPR skills with time and effectiveness of CPR instruction video were evaluated by generalized estimating equation. Totally, 77 nurses were completed the first survey, and 33 nurses were completed the four times of data collection. The results has shown that generally the high quality CPR implementation by the ursing staff was poor and only one nurse reached the high quality CPR. The factors associated with high quality CPR included gender, emergency work experiences, total nursing work experiences and frequency of CPR training. In addition, we found that the CPR skills were diminishing by time after 6 months, especially on compression-release ratio, which was decreased from 0.896 to 0.808(p < 0.05). For depth of chest compression, we found that it decreased from 55.363 mm to 54.211 mm (p = 0.209). Although it was statistically non-significant, we nevertheless noted a decreasing trend. After intervention with instructional video, we found that the compression-release ratio has increased by 0.618(p<0.05) after intervention, indicating good results from instructional video. The factors associated with high quality CPR were age, gender, N level, total nursing work experiences, emergency work experiences, and frequency of CPR training. Study limitations were with small sample size due to longer recruitment preiod for one year, physical strength involved and low willingness to participate. Moreover, since participants were recruited from only one hospital in northern Taiwan, the results could not be generalized to other institutions. It is recommended to have regular clinical training and evaluation of CPR skills in clinical settings and the re-evaluation period is recommended at very 6 months after CPR training in order to maintain high quality CPR.