[[alternative]]Development and Testing of Clinical Pathway for Ischemic Stroke Patients

[[abstract]]本研究旨在發展缺血性腦中風病人臨床路徑並測試其對住院天數、功能狀態、醫療費用、病人滿意度、醫護人員工作滿意度之影響和變異情形。研究分二階段進行，第一階段經由病歷回溯及以行動研究法發展缺血性腦中風病人之臨床路徑，第二階段為測試此臨床路徑之成效。研究採類實驗設計，針對缺血性腦中風之病患及醫護人員分別進行測試。於北區某醫學中心神經內科病房進行收案，先收集控制組50名，再以中風嚴重度配對方式收集實驗組50名；醫護人員樣本為30人。資料收集時間第一階段為89年9月至10月，第二階段為90年3月至90年5月。研究工具包括：病患基本資料表；美國國家衛生院中風量表；巴氏量表；臨床路徑變異記錄表；病患護理品質滿意度量表及中風病人認知評量表。醫護人員則以醫療人員工作滿意量表進行測試及比較。控制組採醫院常規照護；實驗組採所發展的臨床路徑進行。資料以SPSS 10.0套裝軟體進行建檔和統計分析。統計方法包括：平均值、標準差、百分比、t-檢定及共變數分析。 研究結果顯示：實施缺血性腦中風之臨床路徑可縮短住院天數，控制組為17.50天，實驗組之住院天數為8.9天；節省醫療費用，每人平均減少27919.58元；對身體活動功能之改善則無顯著差異，若控制NIHSS之影響後對於身體活動功能則成顯著差異；增加中風之認知；增加病患及家屬之滿意度；此外實施臨床路徑亦可增加醫護人員之滿意度。 結論：實施缺血性腦中風之臨床路徑，經控制入院時NIH中風量表之得分，住院天數少了7.57天。醫療費用經控制入院時NIH中風量表之得分，可節省26344.11元；扣除超長住院（≧30天）病患，其降幅可達39.94%。對於病患身體活動功能有顯著差異，而身體活動功能受疾病嚴重度及住院時間之影響。確可增加腦中風患者之認知程度。確可提升病患滿意度。確可增加醫護人員工作滿意度。[[abstract]]The purpose of this study is to develop a clinical pathway for ischemic patients and to test the effectiveness of the pathway to length of stay (LOS), functional status, medical cost, patient satisfaction, staff satisfaction, and record the clinical variation. This research was a two-stage process. The first stage was to develop a clinical pathway for ischemic stroke patients. Retrospective chart review method was used. The second stage was to test the effectiveness of the isehemic stroke pathway. The study is a quasi-experimental design. Subjects include ischemic stroke patients, medical and nursing staffs. The study was carried out in a neurological ward of a medical center in the Northern Taiwan. Data were collected from the control group of 50 patients first, then followed with a matched stroke severity of experimental group of 50 patients. Data collection for the first stage was from September 2000 to October 2000. The second stage of data collection was taken between March 2001 to May 2001. The research instruments include Patient’s Essential Data List, The National Institute of Health Stroke Scale (NIHSS), Barthel Index, Clinical Pathway Variance Record List, Patient Satisfaction with Nursing Care Questionnaire, and Stroke Knowledge Measurement for Patients. McCloskey/ Mueller Job Satisfaction was used for medical staff for testing and comparison. Control group received unit routine care. Experimental group received specific care as indicated within ischemic stroke clinical pathway. SPSS10.0 software was used for coding and datd analysis. Statistic methods included mean, standard deviation, percentile, independent sample t-test, and ANCOVA. The result shows that clinical pathway can effectively shorten LOS for ischemic stroke patients. Mean of LOS was 17.5 days for the control group, and 8.9 days for the experimental group. Utilization of the pathway decreased medical cost significantly, and reduced $27919.56 in NT per person. There was no significant difference on functional status. However there was a significant difference exist when the effect of NIHSS was under controlled. The pathway also improved the stroke knowledge and satisfaction of patients and families. Additionally, the pathway promoted job satisfaction of medical and nursing staffs. In conclusion, implementation of the clinical pathway for stroke patients, it reduced 7.57 days of hospital stay, and saved $26344.11 in NT. Excluding outlier of longer LOS patients (≧30 days), results indicated that the pathway could reduce cost up to 39.94%, improve functional status, knowledge and care satisfaction of patients and families. Furthermore, the pathway also promoted job satisfaction of medical and nursing staffs