呂雅麗 李建華
[摘要]目的 探討基層醫(yī)院完善綠色通道及溶栓流程對(duì)急性缺血性腦卒中患者靜脈溶栓后神經(jīng)功能的影響。方法 選取我院2014年7月20日~2016年7月20日收治的260例發(fā)病-就診≤4.5 h的急性缺血性腦卒中患者作為研究對(duì)象,按照綠色通道完善情況分為對(duì)照組(130例)與觀察組(130例)。對(duì)照組采用常規(guī)綠色通道及溶栓流程,觀察組采用完善的綠色通道及溶栓流程。比較兩組的溶栓率、院內(nèi)時(shí)間(DNT)、發(fā)病-治療時(shí)間、溶栓后神經(jīng)功能(NIHSS)評(píng)分。結(jié)果 觀察組的總體溶栓率為7.10%,高于對(duì)照組的4.53%,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);觀察組患者的靜脈溶栓率為70.77%,高于對(duì)照組的51.54%,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。觀察組溶栓患者的DNT為(62.49±22.18)min,短于對(duì)照組的(87.31±35.23)min,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);觀察組溶栓患者的發(fā)病-治療時(shí)間為(144.50±40.30)min,短于對(duì)照組的(194.43±61.02)min,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);觀察組患者溶栓后7 d的NIHSS評(píng)分低于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(t=3.086,P<0.05)。結(jié)論 完善針對(duì)急性缺血性腦卒中患者的綠色通道和溶栓流程有助于把握溶栓治療的時(shí)間,縮短DNT,繼而縮短發(fā)病-治療的時(shí)間。盡早行靜脈溶栓治療可促進(jìn)患者神經(jīng)功能的早期恢復(fù),提高患者生存質(zhì)量;更重要的是同時(shí)提高溶栓率,使更多的患者在溶栓中獲益。
[關(guān)鍵詞]綠色通道;溶栓流程;急性缺血性腦卒中;靜脈溶栓率;入院至溶栓時(shí)間;神經(jīng)功能
[中圖分類號(hào)] R743.3 [文獻(xiàn)標(biāo)識(shí)碼] A [文章編號(hào)] 1674-4721(2019)5(a)-0068-04
Influence of optimization of the green channel and thrombolytic process in primary hospital on the neurological function of the patients with thrombolytic therapy in acute ischemic stroke
LV Ya-li LI Jian-hua
Department of Neurology, the First Hospital of Fangshang District in Beijing City, Beijing 102400, China
[Abstract] Objective To explore the influence of optimization of the green channel and thrombolytic process in primary hospital on the neurological function of the patients with thrombolytic therapy in acute ischemic stroke. Methods A total of 260 acute cerebral ischemic stroke patients with onset-treatment ≤4.5 h treated from 20 July 2014 to 20 July 2016 in our hospital were selected and divided into the control group and observation group according to the improvement of green channel, 130 cases in each group. The control group received conventional green channel and thrombolysis process, and the observation group received optimization of the green channel and thrombolytic process. The thrombolysis rate, door-to needle time (DNT), onset-treatment time, and post-disintegration neurological function (NIHSS) scores were compared between the two groups. Results The overall thrombolytic rate of the observation group was 7.10%, which was higher than 4.53% of the control group, and the difference had statistical significance (P<0.05). The intravenous thrombolysis rate in the observation group was 70.77%, which was higher than 51.54% in the control group, and the difference was statistically significant (P<0.05). The DNT of thrombolytic patients in the observation group was (62.49±22.18) min, which was shorter than (87.31±35.23) min of the control group, and the difference was statistically significant (P<0.05). The onset-treatment time of thrombolytic patients in the observation group was (144.50±40.30) min, which was shorter than (194.43±61.02) min in the control group, and the difference was statistically significant (P<0.05). The NIHSS score of the observation group at 7 days after thrombolysis was lower than that of the control group, and the difference was statistically significant (t=3.086, P<0.05). Conclusion Optimization of the green channel and thrombolytic process for patients with acute ischemic stroke is helpful to control thrombolytic treatment time, and shorten DNT and onset-treatment time. Earlier intravenous thrombolytic treatment can promote recovery of neurological function and improve quality of life in patients. More importantly, optimization of the green channel and thrombolytic process can increase the thrombolytic rate to save lives.
[Key words] Green channel; Thrombolytic process; Acute ischemic stroke; Intravenous thrombolysis rate; Time from admission to thrombolysis; Neurological function
在我國(guó),急性缺血性腦卒中是具有高患病率、高發(fā)病率和重大疾病負(fù)擔(dān)的最常見(jiàn)病種之一,隨著老年人口的增加,其發(fā)病率近年呈現(xiàn)持續(xù)上升趨勢(shì),對(duì)患者的生命健康和生活質(zhì)量造成了嚴(yán)重影響[1-3]。靜脈溶栓治療是目前臨床上用于治療缺血性腦卒中的最有效方法,最佳的溶栓治療時(shí)間是在發(fā)病后的4.5 h內(nèi),院內(nèi)時(shí)間(door-to-needle time,DNT)則在1 h,把握時(shí)間是搶救的關(guān)鍵[4-6]。按診斷流程對(duì)疑似腦卒中患者進(jìn)行快速診斷,盡可能在到達(dá)急診室后60 min內(nèi)完成腦CT等基本評(píng)估并開(kāi)始治療,縮短院前時(shí)間(onset-to-door time,ODT)和DNT是改進(jìn)腦卒中綠色通道的主要措施[7-9]。目前,國(guó)內(nèi)外多數(shù)醫(yī)院的DNT都在1 h以上,這嚴(yán)重影響了靜脈溶栓治療的效果,影響患者的預(yù)后[10-11]。我院結(jié)合實(shí)際情況完善綠色通道和溶栓流程,有效縮短了DNT,提高了救治效果,現(xiàn)報(bào)道如下。
1資料與方法
1.1一般資料
選取我院2014年7月20日~2016年7月20日收治的260例發(fā)病-就診≤4.5 h的急性缺血性腦卒中患者作為研究對(duì)象,按照綠色通道完善情況分為對(duì)照組(130例)與觀察組(130例)。對(duì)照組中,女40例,男90例;平均年齡(62.64±12.8)歲。觀察組中,女42例,男88例;平均年齡(63.50±11.39)歲。兩組的年齡、性別構(gòu)成等一般資料比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。納入標(biāo)準(zhǔn):①均符合《中國(guó)急性缺血性腦卒中診治指南》的診斷標(biāo)準(zhǔn)[7];②進(jìn)入缺血性腦卒中綠色通道且發(fā)病-就診時(shí)間≤4.5 h的患者;③住院時(shí)間≥7 d。排除標(biāo)準(zhǔn):①伴有嚴(yán)重精神疾病者或嚴(yán)重心、肺、肝、腎功能不全者;②發(fā)病-就診時(shí)間≥4.5 h;③住院時(shí)間≤7 d。本研究符合人體試驗(yàn)倫理學(xué)標(biāo)準(zhǔn),并得到醫(yī)學(xué)倫理委員會(huì)的批準(zhǔn)且患者及其家屬知情同意。
1.2方法
對(duì)照組采用完善前綠色通道及溶栓流程。觀察組患者采用完善后的綠色通道及溶栓流程,從患者急診就診到治療的每個(gè)流程中,接診患者的醫(yī)生及護(hù)士要同時(shí)填寫(xiě)時(shí)間表,具體措施如下。
1.2.1科室間合作 通過(guò)醫(yī)院主管院長(zhǎng)協(xié)調(diào),醫(yī)務(wù)科監(jiān)督,120救護(hù)車、急診室、神經(jīng)內(nèi)科、神經(jīng)外科、化驗(yàn)室、CT室、掛號(hào)室等多個(gè)部門(mén)密切協(xié)作,實(shí)現(xiàn)無(wú)縫銜接。檢查單上加蓋腦卒中專用綠色通道章,先檢查后付費(fèi)。
1.2.2改善綠色通道流程 ①在急診診治過(guò)程中,對(duì)于發(fā)病4.5 h之內(nèi)疑似腦卒中患者,急診醫(yī)生快速識(shí)別并完成查體,開(kāi)具醫(yī)囑套餐(頭顱CT、快速血糖、血常規(guī)、肝腎功能、凝血四項(xiàng)、心電圖)并撥打溶栓二線電話,同時(shí)急診護(hù)士需要監(jiān)測(cè)生命體征、抽血建立靜脈通路、陪同患者CT檢查。神經(jīng)內(nèi)科溶栓二線到急診直接接診患者,快速神經(jīng)科查體并記錄美國(guó)國(guó)立衛(wèi)生研究院腦卒中量表(national institute of health stoke scale,NIHSS)評(píng)分,陪同到CT室完成頭顱CT檢查。②CT室腦卒中綠色通道章優(yōu)先檢查,神經(jīng)內(nèi)科二線和CT室醫(yī)生共同閱片,排除出血性腦卒中及其他影像學(xué)禁忌?;颊咴\斷為急性缺血性腦卒中則立即聯(lián)系溶栓床。③CT-腦卒中病房患者檢查結(jié)束后,神經(jīng)內(nèi)科溶栓二線帶領(lǐng)患者到腦卒中單元病房,在途中與家屬進(jìn)行溶栓溝通。④在腦卒中病房,對(duì)患者再次進(jìn)行溶栓前各項(xiàng)的評(píng)估,獲得知情同意書(shū)后,立即予以靜脈溶栓治療并對(duì)患者進(jìn)行各項(xiàng)指標(biāo)監(jiān)測(cè)。
1.2.3腦卒中靜脈溶栓相關(guān)知識(shí)培訓(xùn) 我院制作了缺血性腦卒中綠色通道視頻,發(fā)放宣傳手冊(cè)、院報(bào),開(kāi)辦腦卒中短期培訓(xùn)以提高醫(yī)生對(duì)缺血性腦卒中溶栓治療的重視及腦卒中患者識(shí)別度。對(duì)120醫(yī)生、急診醫(yī)生、護(hù)士進(jìn)行腦卒中快速識(shí)別及NIHSS評(píng)分培訓(xùn)。
1.2.4科室備藥及預(yù)留溶栓床 神經(jīng)內(nèi)科及急診科室內(nèi)預(yù)備阿替普酶,患者可以先用藥再繳費(fèi),神經(jīng)內(nèi)科預(yù)留溶栓床。
1.2.5流程質(zhì)控 院長(zhǎng)帶頭參加每月質(zhì)控會(huì)議,對(duì)存在的問(wèn)題及延誤及時(shí)采取措施進(jìn)行整改。
1.3觀察指標(biāo)及評(píng)價(jià)標(biāo)準(zhǔn)
觀察兩組患者的靜脈溶栓率、DNT、發(fā)病-治療時(shí)間、不同時(shí)間點(diǎn)的NIHSS評(píng)分(溶栓前、溶栓后2 h、溶栓后7 d)。采用NIHSS評(píng)分評(píng)估患者的神經(jīng)功能缺損程度,分值越高表示神經(jīng)功能缺損越嚴(yán)重。溶栓前采用NIHSS評(píng)分評(píng)估兩組患者的腦卒中嚴(yán)重程度,分別于溶栓治療后2 h、7 d評(píng)估兩組的治療效果,并進(jìn)行對(duì)比分析。
1.4統(tǒng)計(jì)學(xué)方法
采用SPSS 19.0統(tǒng)計(jì)學(xué)軟件進(jìn)行數(shù)據(jù)分析,計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,符合正態(tài)分布的計(jì)量資料兩兩比較采用t檢驗(yàn),非正態(tài)分布計(jì)量資料兩兩比較采用Mann-Whitney U秩和檢驗(yàn),計(jì)數(shù)資料以率(%)表示,采用χ2檢驗(yàn),以P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2結(jié)果
2.1兩組患者發(fā)病-急診≤4.5 h到院患者溶栓率的比較
觀察組4.5 h到院患者的溶栓率明顯高于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)(表1)。
2.2兩組DNT、DNT≤60 min達(dá)標(biāo)率、發(fā)病-治療時(shí)間的比較
觀察組溶栓患者的DNT短于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);觀察組的發(fā)病-治療時(shí)間短于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);觀察者的DNT≤60 min達(dá)標(biāo)率高于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)(表2)。
2.3兩組患者溶栓前后NIHSS評(píng)分的比較