质量监督与持续改进对急性缺血性卒中患者早期救治效率的影响

发布时间：2018-02-02 11:14

本文关键词： 脑缺血卒中医师诊疗模式血栓溶解疗法流程血管内治疗　出处：《中国脑血管病杂志》2017年04期 　论文类型：期刊论文

【摘要】：目的分析质量监督与持续改进制度对优化急性缺血性卒中(AIS)患者院内诊疗流程的效果。方法回顾性连续纳入2013年9月至2016年5月第二军医大学附属长海医院接受静脉溶栓和(或)血管内治疗的AIS患者424例,按流程运行年度[第1年度(2013年9月至2014年8月)、第2年度(2014年9月至2015年8月)、第3年度(2015年9月至2016年5月)]进行分析。比较第1、2、3年度各治疗环节[抵达医院至影像学检查(DTI)、抵达医院至静脉穿刺(DTN)、影像学检查至静脉穿刺(ITN)、抵达医院至股动脉穿刺(DTP)、影像学检查至股动脉穿刺(ITP)]耗费时间及延误(DTN60 min、DTP90 min)率;以第1、2、3年度治疗环节耗费时间差异有统计学意义的时段(中位数值)为因变量,观察年度、治疗方式对延误的影响;分析不同年度静脉溶栓和血管内治疗的延误原因(客观原因/其他原因)构成比的差异。结果 (1)第1、2、3年度,DTI分别为23.0(11.0,42.0)、22.0(10.1,39.0)、13.0(6.0,27.0)min,DTN分别为50.0(30.0,77.1)、45.0(30.0,70.2)、36.0(24.0,57.0)min,DTI及DTN环节耗费时间逐年缩短,年度间差异均有统计学意义(均P0.01);DTP耗费时间有缩短趋势,但年度间差异无统计学意义(P=0.06);ITN及ITP环节耗费时间的差异均无统计学意义(均P0.05)。(2)第1、2、3年度,DTN延误率分别为33.3%(40/120)、20.7%(29/140)和8.1%(9/111),3个年度间差异均有统计学意义(χ~2=22.111,P0.01);DTP延误率差异均无统计学意义(P=0.08)。(3)多因素Logistic回归分析结果显示,以第1年度为参照,第3年度DTI发生延误的风险降低(OR=0.174,95%CI:0.101~0.298,P0.01),第2、3年度DTN发生延误的风险均降低(OR=0.564,95%CI:0.338~0.941;OR=0.180,95%CI:0.101~0.320;均P0.05);相对于单纯静脉溶栓,桥接治疗是DTI环节救治效率改善的保护因素(OR=0.530,95%CI:0.297~0.943,P=0.031);相对于桥接治疗,直接血管内治疗是DTP救治效率改善的保护因素(OR=0.427,95%CI:0.202~0.901,P=0.025);其余自变量对DTI、DTN和DTP环节是否造成延误无明显影响(均P0.05)。(4)在3个年度中,静脉溶栓发生延误以客观原因为主,其他原因所致的静脉溶栓延误构成比逐年下降,第3年度已无其他原因发生的延误(χ~2=10.402,P=0.004);血管内治疗方式延误原因的构成比差异无统计学意义(χ~2=3.622,P=0.164)。结论在现有流程和资源配置下,设定DTN目标时间并实行持续质量改进,有利于时间窗内AIS患者到院后影像学检查的进行和静脉溶栓的有效实施和持续优化。
[Abstract]:Objective to analyze the effect of quality supervision and continuous improvement system on the optimization of acute ischemic stroke (AIS). Effect of in-hospital procedures for diagnosis and treatment of patients. Methods intravenous thrombolysis and / or thrombolytic therapy were performed in the Changhai Hospital affiliated to the second military Medical University from September 2013 to May 2016. There were 424 cases of AIS treated by endovascular therapy. Running year by process. [Year 1 (September 2013-August 2014) and year 2 (September 2014-September 2014). Analysis was made in year 3 (September 2015-May 2016). [From the hospital to the imaging examination, to the hospital to the venipuncture, the imaging examination to the venipuncture and to the femoral artery puncture (DTP). Imaging examination to ITP (femoral artery puncture) was time-consuming and delayed DTN60 min to DTP 90 min) rate. The effect of treatment mode on delay was observed in the period (median value), which was statistically significant in the first year of the second trimester, and the effect of the treatment mode on the delay was observed. To analyze the difference of the composition ratio of the delayed reasons (objective cause / other cause) of venous thrombolysis and endovascular therapy in different year. Results 1) the DTI of the 1st second trimester was 23.0 / 11.0 respectively. The DTN of 42.0 ~ 22.0 ~ 10.1 ~ 39.0 ~ 13.0 ~ 6.0 ~ 27.0 / min DTN is 50.0 ~ 30.0 ~ 77.1 ~ (-1) respectively (P < 0.05). The time consuming of DTN and DTN was shortened year by year. The differences between years were statistically significant (all P 0.01); There was a tendency to shorten the time consuming of DTP, but there was no significant difference between years. The delay rate of ITN and ITP in the 1st year was 33.3 / 120, respectively. There were statistically significant differences between 20.729 / 140 and 8.1 / 9 / 111 (蠂 ~ (2 / 2) / 22.111 / P ~ (0.01)) among the three years (蠂 ~ (2 / 2) = 22.111 / P ~ (0.01)). The results of multivariate Logistic regression analysis showed that the delay rate of DTP was not significantly different from that in the first year. The risk of delay in DTI in the third year is reduced by 0.174 / 95 CI: 0.101 / 0.298 / P0.01a, No. 2. The risk of delay in DTN in 3 years was reduced by 0.564 / 95 CI: 0.338 / 0.941; Orang 0.180 and 95 CI: 0.101 0.320; P0.05; Compared with intravenous thrombolysis alone, bridging therapy was the protective factor to improve the efficiency of DTI treatment. Compared with bridging therapy, direct intravascular therapy was the protective factor for the improvement of DTP treatment efficiency. The other independent variables had no significant effect on the delay of DTN and DTP (all P0.05. 4) in three years, the main reason of delay in intravenous thrombolysis was the objective reason. The ratio of venous thrombolytic delay caused by other reasons decreased year by year, and there was no delay due to other reasons in the third year (蠂 ~ (2 / 2) 10.402 / P ~ (0.004)). There was no significant difference in the composition of the causes of delay in endovascular treatment (蠂 ~ 2 / 23.622 / P = 0.164). Conclusion under the present procedure and resource allocation, there is no significant difference in the composition of the causes of intravascular treatment delay (蠂 ~ (2)). Setting the target time of DTN and carrying out continuous quality improvement are beneficial to the post-hospital imaging examination of AIS patients in the time window and the effective implementation and continuous optimization of intravenous thrombolysis.
【作者单位】：第二军医大学附属长海医院神经外科;
【基金】：中国脑卒中高危人群干预适宜技术研究及推广项目(GN-2016R0002)
【分类号】：R743.3;R197.323
【正文快照】： 静脉使用重组组织型纤溶酶原激活剂和前循环大动脉闭塞的血管内治疗是急性缺血性卒中(acuteischemic stroke,AIS)早期的标准治疗措施,尽可能缩短救治时间是提高AIS救治效果、改善患者预后的关键[1]。院内诊疗是AIS早期救治的重要环节,尤其血管内治疗作为Ⅰa类推荐进入指南[2],

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