改进急诊流程,提高急性卒中静脉溶栓的成效

被引：19

作者：

凌倚峰 ^{[1
]}

程忻 ^{[1
]}

方堃 ^{[1
]}

胡祖鹏 ^{[2
]}

董强 ^{[1
]}

机构：

[1] 复旦大学附属华山医院神经内科

[2] 复旦大学附属华山医院急诊科

来源：

实用医院临床杂志 | 2013年 / 10卷 / 03期

关键词：

急性卒中; 到院至rt-PA溶栓治疗时间; 溶栓治疗;

D O I：

暂无

中图分类号：

R743.3 [急性脑血管疾病（中风）];

学科分类号：

1002 ;

摘要：

目的静脉注射重组组织型纤溶酶原激活剂(recombinant tissue plasminogen activator,rtPA)是经循证医学证明缺血性卒中超早期最有效的治疗药物,rt-PA的疗效有时间依赖性,因此,我们尝试通过优化急诊流程来减少溶栓院内延误的时间。方法自2011年7月以来华山医院神经内科实施了一系列的措施,建立了急诊溶栓治疗的"华山模式",以减少延误治疗,评价急性卒中患者到院至rtPA为溶栓治疗时间(door-to-needle time,DNT)和DNT≤60分钟比例来分析华山医院静脉溶栓的院内延误情况。结果 2008年1月至2012年12月华山医院神经内科共收住2564例脑梗死患者,其中117例患者接受静脉溶栓治疗,其中4位先行多模式CT后溶栓,故剔除。113例溶栓患者年龄中位数68岁(四分位数范围:57～74岁),男性占64.6%,基线NIHSS卒中评分中位数10分(6～14分)。优化急诊溶栓流程后,溶栓比例逐年从1.9%增加至9.2%(P<0.001)。DNT中位数从100分钟(86～112分钟)缩短至74分钟(55～99分钟)(P<0.001),DNT≤60分钟比例从6.5%上升至34.1%(P=0.003),而患者的症状性脑出血率没有增加(9.7%vs.7.3%,P>0.05)。结论优化急诊流程后,使华山医院时间窗内脑梗死患者的溶栓比例明显提高,并且大幅度减少院内延误。希望通过进一步优化流程细节来达到DNT≤60分目标。

引用

页码：17 / 21

页数：5

共 8 条

[1] Does a code stroke' rapid access protocol decrease door-to-needle time for thrombolysis? [J].

Tai, Y. J. ;

Weir, L. ;

Hand, P. ;

Davis, S. ;

Yan, B. .

INTERNAL MEDICINE JOURNAL, 2012, 42 (12) :1316-1324

[2] Reducing Door-to-Needle Times Using Toyota's Lean Manufacturing Principles and Value Stream Analysis [J].

Ford, Andria L. ;

Williams, Jennifer A. ;

Spencer, Mary ;

McCammon, Craig ;

Khoury, Naim ;

Sampson, Tomoko R. ;

Panagos, Peter ;

Lee, Jin-Moo .

STROKE, 2012, 43 (12) :3395-+

[3] Reducing in-hospital delay to 20 minutes in stroke thrombolysis [J].

Meretoja, Atte ;

Strbian, Daniel ;

Mustanoja, Satu ;

Tatlisumak, Turgut ;

Lindsberg, Perttu J. ;

Kaste, Markku .

NEUROLOGY, 2012, 79 (04) :306-313

[4] Factors Associated With Prehospital Delays in the Presentation of Acute Stroke in Urban China [J].

Jin, Haiqiang ;

Zhu, Sainan ;

Wei, Jade W. ;

Wang, Jiguang ;

Liu, Ming ;

Wu, Yangfeng ;

Wong, Lawrence K. S. ;

Cheng, Yan ;

Xu, En ;

Yang, Qidong ;

Anderson, Craig S. ;

Huang, Yining .

STROKE, 2012, 43 (02) :362-370

[5]

The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke （the third international stroke trial[IST-3]）: a randomised controlled trial[J] . Sandercock Peter,Wardlaw Joanna M,Lindley Richard I,Dennis Martin,Cohen Geoff,Murray Gordon,Innes Karen,Venables Graham,Czlonkowska Anna,Kobayashi Adam,Ricci Stefano,Murray Veronica,Berge Eivind,Slot Karsten Bruins,Hankey Graeme J,Correia Manuel,Peeters Andre,Matz Karl,Lyrer Phillipp

[6]

Improving Door-to-Needle Times in Acute Ischemic Stroke: The Design and Rationale for the American Heart Association/American Stroke Association?s Target: Stroke Initiative[J] . Gregg C. Fonarow,Eric E. Smith,Jeffrey L. Saver,Mathew J. Reeves,Adrian F. Hernandez,Eric D. Peterson,Ralph L. Sacco,Lee H. Schwamm.Stroke . 2011 (10)

[7]

Timeliness of Tissue-Type Plasminogen Activator Therapy in Acute Ischemic Stroke: Patient Characteristics, Hospital Factors, and Outcomes Associated With Door-to-Needle Times Within 60 Minutes[J] . Gregg C. Fonarow,Eric E. Smith,Jeffrey L. Saver,Mathew J. Reeves,Deepak L. Bhatt,Maria V. Grau-Sepulveda,DaiWai M. Olson,Adrian F. Hernandez,Eric D. Peterson,Lee H. Schwamm.Circulation . 2011 (7)

[8]

Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials[J] . Kennedy R Lees,Erich Bluhmki,Rüdiger von Kummer,Thomas G Brott,Danilo Toni,James C Grotta,Gregory W Albers,Markku Kaste,John R Marler,Scott A Hamilton,Barbara C Tilley,Stephen M Davis,Geoffrey A Donnan,Werner Hacke.The Lancet . 2010 (9727)

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