改进急诊流程,提高急性卒中静脉溶栓的成效  

Optimization of emergency procedures to improve the efficiency of thrombolytic therapy of acute stroke

作　　者：凌倚峰[1] 程忻[1] 方堃[1] 胡祖鹏[2] 董强[1] 

机构地区：[1]复旦大学附属华山医院神经内科,上海200040 [2]复旦大学附属华山医院急诊科,上海200040

出　　处：《实用医院临床杂志》2013年第3期17-21,共5页Practical Journal of Clinical Medicine

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。Objective Efficacy of thrombolytic therapy for ischemic stroke decreases with time elapsed from symptom onset. We hope that through our optimized emergency thrombolytic procedures could reduce in-hospital delays. Methods A series of inter- ventions to reduce treatment delays were implemented since July 2011. In-hospital delays were analyzed as annual median DNT in mi- nutes and the rate of DNT 〈 60 minutes. Results A total of 2,564 patients with cerebral infarction were admitted between January 2008 and December 2012,113 patients received intravenous thrombolytic therapy. The median age was 68 year-old （interquartile range IQR 57 -74）. Male percentage was 64. 6%. The baseline median National Institutes of Health Stroke Scale （NIHSS） score was 10 （IQR 6-14）. Percentage of thrombolytic use was increased from 1.9% to 9. 2% （P 〈 0. 001 ）. Median DNT was reduced from 100 minutes （ IQR 86 ~ 112） to 74 minutes （ IQR 55 99） （ P 〈 0. 001 ）. Rate of DNT 〈 60 minutes was increased from 6.5% to 34. 1% （P = O. 003 ）. Conclusions Achieving DNT 〈 60 minutes for the majority of thrombolytic therapy candidates is still our goal. Further simplifying the thrombolytie procedures to treat the patients faster will help us to achieve this goal in the future.

关 键 词：急性卒中 到院至rt-PA溶栓治疗时间 溶栓治疗 

分 类 号：R743.3[医药卫生—神经病学与精神病学]