急性缺血性卒中院内救治流程优化实践与评价

发布时间：2018-07-26 15:37

【摘要】：目的:通过文献与相关专业网站回顾国内外急性缺血性卒中院内救治现状和救治流程管理研究进展,并以流程管理理论为指导,构建急性缺血性卒中院内救治流程优化方案,并对方案进行临床验证评价实施效果,为缩短急性缺血性卒中院内救治时间,提高院内救治效率提供依据。方法:采用文献研究、现场观察以及质性访谈研究方法,总结分析急性缺血性卒中院内救治流程现状和可优化环节。课题组参照国际急性缺血性卒中救治相关指南,以前期研究结果为基础构建急性缺血性卒中院内救治流程优化草案,并通过专家会议法对草案进行论证,最终形成急性缺血性卒中院内救治流程优化方案。将急性缺血性卒中救治流程优化方案进行类实验临床验证,比较流程优化前后两组患者院内救治时间和救治效果,以评价急性缺血性卒中院内救治流程优化的可行性和实用性。结果:1、文献回顾研究发现国内急性缺血性卒中院内救治流程管理聚焦于静脉溶栓流程,且救治时间与国外先进水平相比差距较大。2、现场观察数据分析显示院内救治流程各环节耗时不均衡,医务人员专业技术仍有待提高,急性缺血性卒中患者和家属医疗决策延迟。深入访谈12名急性缺血性卒中院内救治医务人员对救治流程优化的建议,提炼出5个主题:目前救治流程仍有改进空间;患者和家属医疗决策延迟;对配置卒中护士的需求;对信息化平台支持的需求;对多学科合作密切性加强的需求。3、在前期现况研究的基础上,初步构建急性缺血性卒中院内救治流程优化草案,包括配置卒中急救护士、前移静脉溶栓地点至CT室、开展多元化病情告知方式、建设卒中救治流程管理信息平台等,并经过专家会议论证可行性和科学性最终形成急性缺血性卒中院内救治流程优化方案。4、将院内救治流程优化方案进行类实验临床验证,评价流程优化实施效果。结果显示:干预组57例患者就诊至静脉溶栓时间中位数27.5min,就诊至股动脉穿刺时间中位数51min,较对照组69例患者就诊至静脉溶栓时间中位数41min,就诊至股动脉穿刺时间中位数78min显著减少,差异均有统计学意义(P0.05)。流程环节中就诊至专科医生接诊时间中位数1min、就诊至开始CT时间中位数13min、开始CT至静脉溶栓用药时间中位数17min、静脉溶栓用药至股动脉穿刺时间中位数24min均较优化前减少,且差异均有统计学意义(P0.05)。两组患者治疗前、治疗后24h和治疗后一周NIHSS评分无统计学差异(P0.05),但进一步分析显示两组治疗后一周与治疗后24小时差值的差异以及治疗后24h与治疗前NIHSS评分差值的差异均具有统计意义(P0.05),表明流程优化后急性缺血性卒中患者治疗24h、治疗后一周救治效果优于流程优化前。结论:1、急性缺血性卒中院内救治流程优化后有效缩短了院内救治时间,就诊至静脉溶栓用药、就诊至股动脉穿刺、就诊至开始CT、开始CT至静脉溶栓用药、静脉溶栓用药至股动脉穿刺时间均较优化前减少,差异均具有统计学意义(P0.05)。2、急性缺血性卒中院内救治流程优化后能够改善患者良好预后,提高救治效果。3、将静脉溶栓地点前移至CT室,极大简化了院内救治流程,进一步缩短开始CT至静脉溶栓用药时间,使院内救治时间与国际先进水平接轨。4、卒中急救护士早期全程参与静脉溶栓流程,有效缩短就诊至静脉溶栓用药时间,提高院内救治效率。
[Abstract]:Objective: To review the current status of treatment and treatment process management of acute ischemic stroke at home and abroad by literature and related professional websites, and to construct an optimization scheme for acute ischemic stroke hospital treatment process with the guidance of process management theory, and to carry out clinical evaluation of the scheme in order to shorten the acute ischemic stroke. Methods: literature study, field observation and qualitative interview study methods were used to summarize and analyze the status and optimization of hospital treatment process in acute ischemic stroke. The draft of hospital treatment process of acute ischemic stroke was optimized, and the draft was proved by expert meeting method. Finally, the optimization scheme of hospital treatment process in acute ischemic stroke was formed. The optimization scheme of acute ischemic stroke treatment process was tested by class experiment, and the treatment time and rescue of two groups of patients were compared before and after the flow optimization. The treatment effect was used to evaluate the feasibility and practicability of the optimization of the hospital treatment process in acute ischemic stroke. Results: 1. The literature review found that the treatment process management of acute ischemic stroke in China focused on the venous thrombolytic flow, and the treatment time was larger than the foreign advanced level of.2. The field observation data analysis showed that the hospital rescue was saved in the hospital. Each link of the treatment process is not balanced, the medical personnel's professional technology still needs to be improved, the acute ischemic stroke patients and their family members' medical decision is delayed. 12 suggestions on the optimization of the medical treatment process in the hospital for acute ischemic stroke are discussed, and 5 themes are extracted: the patient and family doctor still have room for improvement. The demand for apoplexy nurses; demand for apoplexy nurses; demand for information platform support; demand for the close cooperation of multidisciplinary cooperation.3. On the basis of early current situation study, preliminary construction of acute ischemic stroke hospital treatment process optimization draft, including apoplexy emergency nurse, thrombolytic location of anterior vein to CT room, development According to the way of informing the condition of the disease, building the information platform of the stroke treatment process management and so on, and through the expert meeting to demonstrate the feasibility and scientificalness of the hospital, the optimization scheme of the hospital treatment process for acute ischemic stroke was finally formed.4, and the hospital treatment process optimization scheme was tested by the class experiment, and the effect of the process optimization was evaluated. The results showed that the intervention group was the intervention group. The median of 57 cases was 27.5min, the median time of the femoral artery puncture time was 51min, and the median of 69 patients in the control group was 41min, and the median 78min of the femoral artery puncture time was significantly reduced, the difference was statistically significant (P0.05). The median time of time was 1min, the median of CT time was 13min, the median time of CT to venous thrombolysis was 17min, the median of intravenous thrombolysis to the median of femoral artery puncture time was less than that before the optimization, and the difference was statistically significant (P0.05). Before treatment, there was no statistical difference between the two groups of 24h and the one week after treatment. The difference (P0.05), but further analysis showed that the difference of the difference between two groups after treatment and 24 hours after treatment and the difference between 24h and NIHSS score after treatment were statistically significant (P0.05), indicating that after the process optimization, the acute ischemic stroke patients were treated with 24h, and the treatment effect of one week after treatment was better than that before the process optimization. Conclusion: 1, urgent. After optimizing the hospital treatment process of sexual ischemic stroke, the hospital treatment time was effectively shortened, the treatment of intravenous thrombolytic therapy, the femoral artery puncture, the beginning of the CT, the CT to intravenous thrombolytic therapy, the intravenous thrombolytic therapy to femoral artery puncture time decreased, the difference was statistically significant (P0.05).2, acute ischemic stroke. After optimizing the treatment process of stroke hospital, the patient's good prognosis can be improved, the treatment effect is improved.3, the thrombolytic location of the vein is moved forward to the CT room, which greatly simplifies the hospital treatment process, further shortens the time of starting CT to intravenous thrombolysis, makes the hospital treatment time with the international advanced water level, and participates in the vein in the early stage of the stroke first aid nurse. The thrombolytic process can effectively shorten the time for treatment of intravenous thrombolysis and improve the efficiency of in-hospital treatment.
【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R743.3

【参考文献】