優(yōu)化流程縮短dnt

1、,,,優(yōu)化流程縮 短 DNT,武漢市第一醫(yī)院神經(jīng)內(nèi)科 2016年4月16日,,,,靜脈溶栓2015DNT時間控制不良預后因素優(yōu)化流程問題及改進相關(guān)研究,目錄,靜脈溶栓2015,,,,144%,105%,市一醫(yī)院,靜脈溶栓2015,靜脈溶栓、橋接治療、血管內(nèi)治療,10人,70人,5人,7人,市一醫(yī)院,靜脈溶栓2015,DNT≦60min 11例分析，均符合DNT6步驟最佳時間內(nèi),DNT時間控制,DNT ≧80min

2、9例分析 ，多在檢驗環(huán)節(jié)耽誤,DNT時間控制,9-12月平均縮短DNT25min，目前DNT為65min,,DNT時間控制,死亡人數(shù)分布,不良預后因素,發(fā)病時間越長NIHSS評分越高年齡越大 患者預后越差,大面積腦梗塞腦疝感染：4人大面積腦梗塞腦出血消化道出血：1人大面積腦梗塞、去骨瓣：1人 溶栓后心梗：1人,,,,優(yōu)化流程,急性卒中綠色通道路徑圖,,,,優(yōu)化流程,急性缺血性腦卒中靜脈溶栓治療方案,,,,,,急性缺血性腦

3、卒中血管內(nèi)治療方案,優(yōu)化流程,,,急診醫(yī)生職責：首診、評估、化驗、陪送、做完頭部CT后開具住院送至NICU.NICU醫(yī)生職責：門口接診、再次評估、與家屬或患者談話簽字、開具手寫處方、詢問病史、看急診化驗結(jié)果NICU護士職責：轉(zhuǎn)移病人至床位、建立輸液通道、復查血糖、給予監(jiān)護、根據(jù)醫(yī)生手寫處方配制r-tPA、抽血、給藥NICU醫(yī)生職責：調(diào)整血壓、觀察病情變化、聯(lián)系血管內(nèi)治療、送患者至介入室NICU醫(yī)生職責：完善病歷、開具醫(yī)囑、備皮、

4、導尿等等,優(yōu)化流程,①,③,,,問題及改進,①,③,總結(jié)分析DNT達標及延誤原因，改進流程,在排除相關(guān)病史用藥史后，AIS靜脈溶栓前不等待血小板和凝血功能指標聯(lián)合其他優(yōu)化措施，可顯著縮短DNT，不增加slCH和7d內(nèi)的死亡風險。,減少檢驗延誤,楊璐萌 程忻 凌倚峰 等. 急性缺血性卒中靜脈溶栓前是否需等待血小板計數(shù)和凝血功能指標 ，中華神經(jīng)科雜志2014，47（7）：464-468,Gottesman RF，Ah J，Wityk RJ，

5、et a1．Predicting abnormalcoagulation in ischemic stroke：reducing delay in rt—PA use[J]．Neurology，2006，67：1665—1667．,問題及改進,通過詢問病史如血小板減少、肝腎功能異常、服用抗凝藥等，可以早期判斷患者是否可能存在血小板降低或凝血功能異常的情況。Gottesman等指出預測PT、部分凝血活酶時間(PTT)是否正常的關(guān)鍵在于明

6、確3個問題：(1)是否正在使用華法林治療?(2)是否正在使用肝素或低分子量肝素治療?(3)是否進行血液透析治療?如果回答都是否定的，那么該方法預測PT、PTT正常的敏感度100％，特異度94．6％。,減少檢驗延誤,楊璐萌 程忻 凌倚峰 等. 急性缺血性卒中靜脈溶栓前是否需等待血小板計數(shù)和凝血功能指標 ，中華神經(jīng)科雜志2014，47（7）：464-468,Gottesman RF，Ah J，Wityk RJ，et a1．Predic

7、ting abnormalcoagulation in ischemic stroke：reducing delay in rt—PA use[J]．Neurology，2006，67：1665—1667．,問題及改進,,,減少患者入院后延誤：急診醫(yī)生陪同減少電梯延誤：提前通知電梯等候減少病房延誤：門口平車上評估、查體后談話（靜脈、橋接）簽字，病人安頓、監(jiān)護好后即可開始給藥治療NIHSS評分6分以上備皮、導尿、通知介入小組每月召

8、開總結(jié)會，反饋DNT時間、討論改進辦法,問題及改進,①,③,Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria (Class I; Level of Evidence A). (New recommendation): (a) prestroke mRS score 0 t

9、o 1, (b) acute ischemic stroke receiving intravenous r-tPA within 4.5 hours of onset according to guidelines from professional medical societies, (c) causative occlusion of the internal carotid artery or proximal MCA (

10、M1), (d) age ≥18 years, (e) NIHSS score of ≥6, (f) ASPECTS of ≥6, and (g) treatment can be initiated (groin puncture) within 6 hours of symptom onset,,,橋接治療的納入標準,①,③,AHA/ASA Guideline：2015 AHA/ASA Focused Update of t

11、he 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment. Downloaded from http://stroke.ahajournals.org/ at Pfizer DIS on July 2, 2015,問題及改進,,Saver JL. Stroke. 2

12、006 Jan;37(1):263-6.,相關(guān)研究,,分,小時,天,炎癥,梗死周圍去極化,,,,興奮性中毒,細胞凋亡,時間,影響,The benefits of intravenous tPA in acute ischemic stroke are highly time-dependent.Because of the importance of rapid treatment, AHA/ASA guidelines recomm

13、end a door-to-needle (DTN) time of ≤60 minutes.Yet prior studies suggested fewer than 30% of intravenous tPA treated acute ischemic stroke patients in the United States were meeting this goal.To address this shortfall,

14、 Target: Stroke, a national initiative organized by the AHA/ASA, was launched in January 2010 to increase the proportion of stroke patients with DTN times ≤60 minutes (initial goal of ≥ 50%).,Improving Door-to-Needle Tim

15、es in Acute Ischemic Stroke: Principal Results from the Target: Stroke Initiative. ISC 2014, LB12,相關(guān)研究,Improving Door-to-Needle Times in Acute Ischemic Stroke: Principal Results from the Target: Stroke Initiative. ISC 20

16、14, LB12,相關(guān)研究,Improving Door-to-Needle Times in Acute Ischemic Stroke: Principal Results from the Target: Stroke Initiative. ISC 2014, LB12,Target: Stroke 10 Key Best Practice Strategies,1.Hospital pre-notification by Em

17、ergency Medical Services2.Rapid triage protocol and stroke team notification3.Single call/paging activation system for entire stroke team4.Use of a stroke toolkit containing clinical decision support, stroke-specific

18、order sets, guidelines, hospital-specific algorithms, critical pathways, NIH Stroke Scale and other stroke tools5.Rapid acquisition and interpretation of brain imaging6.Rapid Laboratory Testing (including point-of-care

19、 testing) if indicated7.Pre-mixing tPAmedication ahead of time for high likelihood candidates8.Rapid access to intravenous tPAin the ED/brain imaging area9.Team-based approach10.Rapid data feedback to stroke team on

20、each patient’s DTN time and other performance data,相關(guān)研究,Target: CustomizableImplementation Tools,Patient time-trackersGuideline based algorithmstPA checklistStandardized order setsDosing chartsClinical pathwaysEvi

21、dence-based protocolsEMS toolsPatient educational materialsOther tools,相關(guān)研究,Fonarow GC, et al. JAMA. 2014 Apr 23-30;311(16):1632-40.,,一項來自美國Target：Stroke項目共304家醫(yī)院5460例接受tPA治療患者的研究，旨在評估醫(yī)院策略和縮短DNT時間的相關(guān)性,在11項縮短DNT的醫(yī)院策略中，

22、快速分診并通知卒中小組(平均縮短8.1分鐘)，卒中小組集合(縮短4.3分鐘)以及急診儲備tPA(縮短3.5分鐘)是最有效的三種方法。,,,,快速分診并通知卒中小組,卒中小組集合,急診儲備tPA,縮短8.1min,縮短4.3min,縮短3.5min,62%使用率P=0.03,63%使用率P=0.018,69%使用率P=0.008,Xian Y, et al. Strategies Used by Hospitals to

23、 Improve Speed of Tissue-Type Plasminogen Activator Treatment in Acute Ischemic troke.Stroke. 2014;45:1387-1395,相關(guān)研究,,共71,169例接受rt-PA的患者，其中項目開展前為27,319例，開展后為43,850例DNT≤60min患者比例在項目開展前為29.6%，項目開展后增加到53.3%。開展前后的年增加率為1.36%

24、vs.6.20%，P＜0.001,臨床預后指標得到改善！,DNT≤60分比例(%),Fonarow GC, et al. JAMA. 2014 Apr 23-30;311(16):1632-40.,相關(guān)研究,一項來自美國Target：Stroke項目共304家醫(yī)院5460例接受tPA治療患者的研究，旨在評估醫(yī)院策略和縮短DNT時間的相關(guān)性。,雖然單一治療策略的作用效力可能較小，但這些策略聯(lián)合起來能使DNT節(jié)約14分鐘。由于美國Get W

25、ith The Guidelines-Stroke項目中DNT的平均時間為72分鐘，因此，縮短14分鐘將使大多數(shù)患者達到60分鐘的治療目標，從而挽救數(shù)以千計患者的殘疾命運。,+,1種策略,+,10種策略,,,1.3分鐘,,14分鐘,,P=0.011,相關(guān)研究,Xian Y, et al. Strategies Used by Hospitals to Improve Speed of Tissue-Type Plasminogen Ac

26、tivator Treatment in Acute Ischemic troke.Stroke. 2014;45:1387-1395,While there have been concerns that attempting to achieve shorter DTN times may lead to rushed assessments, inappropriate patient selection, dosing erro

27、rs, and greater likelihood of complications, our findings suggest that more rapid reperfusion therapy in acute ischemic stroke is not only feasible, but can be achieved with actual reductions in complications and improve

28、d outcomes.These findings further reinforce the importance and substantial clinical benefits of more rapid administration of intravenous tPA.,Fonarow GC et al. JAMA. 2014;311(16):1632-1640.,Conclusions,相關(guān)研究,入院到溶栓治療時間≤60

29、分鐘,到達急診的疑似卒中患者,醫(yī)師初始評估（包括病史，實驗室檢查，NIHSS評分）,通知卒中治療小組（包括神經(jīng)病學專家）,CT掃描完成,讀CT及實驗室檢查報告完成,符合溶栓指征患者給予阿替普酶靜脈溶栓,Bock BF. Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke; December 12-13,1996