1、,优化流程缩 短 DNT,武汉市第一医院神经内科 2016年4月16日,静脉溶栓2015DNT时间控制不良预后因素优化流程问题及改进相关研究,目录,静脉溶栓2015,144%,105%,市一医院,静脉溶栓2015,静脉溶栓、桥接治疗、血管内治疗,10人,70人,5人,7人,市一医院,静脉溶栓2015,DNT60min 11例分析，均符合DNT6步骤最佳时间内,DNT时间控制,DNT 80min 9例分析 ，多在检验环节耽误,DNT时间控制,9-12月平均缩短DNT25min，目前DNT为65min,DNT时间控制,死亡人数分布,不良预后因素,发病时间越长NIHSS评分越高年龄越大 患者预后越差
2、,大面积脑梗塞脑疝感染：4人大面积脑梗塞脑出血消化道出血：1人大面积脑梗塞、去骨瓣：1人 溶栓后心梗：1人,优化流程,急性卒中绿色通道路径图,优化流程,急性缺血性脑卒中静脉溶栓治疗方案,急性缺血性脑卒中血管内治疗方案,优化流程,急诊医生职责：首诊、评估、化验、陪送、做完头部CT后开具住院送至NICU.NICU医生职责：门口接诊、再次评估、与家属或患者谈话签字、开具手写处方、询问病史、看急诊化验结果NICU护士职责：转移病人至床位、建立输液通道、复查血糖、给予监护、根据医生手写处方配制r-tPA、抽血、给药NICU医生职责：调整血压、观察病情变化、联系血管内治疗、送患者至介入室NICU医生职责：
3、完善病历、开具医嘱、备皮、导尿等等,优化流程,问题及改进,总结分析DNT达标及延误原因，改进流程,在排除相关病史用药史后，AIS静脉溶栓前不等待血小板和凝血功能指标联合其他优化措施，可显著缩短DNT，不增加slCH和7d内的死亡风险。,减少检验延误,杨璐萌 程忻 凌倚峰 等. 急性缺血性卒中静脉溶栓前是否需等待血小板计数和凝血功能指标 ，中华神经科杂志2014，47（7）：464-468,Gottesman RF，Ah J，Wityk RJ，et a1Predicting abnormalcoagulation in ischemic stroke：reducing delay in rtPA
4、 useJNeurology，2006，67：16651667,问题及改进,通过询问病史如血小板减少、肝肾功能异常、服用抗凝药等，可以早期判断患者是否可能存在血小板降低或凝血功能异常的情况。Gottesman等指出预测PT、部分凝血活酶时间(PTT)是否正常的关键在于明确3个问题：(1)是否正在使用华法林治疗?(2)是否正在使用肝素或低分子量肝素治疗?(3)是否进行血液透析治疗?如果回答都是否定的，那么该方法预测PT、PTT正常的敏感度100，特异度946。,减少检验延误,杨璐萌 程忻 凌倚峰 等. 急性缺血性卒中静脉溶栓前是否需等待血小板计数和凝血功能指标 ，中华神经科杂志2014，47（7
5、）：464-468,Gottesman RF，Ah J，Wityk RJ，et a1Predicting abnormalcoagulation in ischemic stroke：reducing delay in rtPA useJNeurology，2006，67：16651667,问题及改进,减少患者入院后延误：急诊医生陪同减少电梯延误：提前通知电梯等候减少病房延误：门口平车上评估、查体后谈话（静脉、桥接）签字，病人安顿、监护好后即可开始给药治疗NIHSS评分6分以上备皮、导尿、通知介入小组每月召开总结会，反馈DNT时间、讨论改进办法,问题及改进,Patients should re
6、ceive 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 to 1, (b) acute ischemic stroke receiving intravenous r-tPA within 4.5 hours of onset according to guidelines from professional me
7、dical societies, (c) causative occlusion of the internal carotid artery or proximal MCA (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,桥接治疗的纳入标准,AHA/ASA Guideline：2015 AHA/ASA Focused Update of the 2
8、013 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,问题及改进,Saver JL. Stroke. 2006 Jan;37(1):263-6.,相关研究,分,小时,天,炎症,梗死周围去极化,兴奋性中毒,细胞凋亡,时间,影响,The benefits of intraveno
9、us tPA in acute ischemic stroke are highly time-dependent.Because of the importance of rapid treatment, AHA/ASA guidelines recommend 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 wer
10、e meeting this goal.To address this shortfall, 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 Times in Acute Ischemic Stroke: Principa
11、l Results from the Target: Stroke Initiative. ISC 2014, LB12,相关研究,Improving Door-to-Needle Times in Acute Ischemic Stroke: Principal Results from the Target: Stroke Initiative. ISC 2014, LB12,相关研究,Improving Door-to-Needle Times in Acute Ischemic Stroke: Principal Results from the Target: Stroke Init
12、iative. ISC 2014, LB12,Target: Stroke 10 Key Best Practice Strategies,1.Hospital pre-notification by Emergency 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 suppo
13、rt, stroke-specific 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 testing) if indicated7.Pre-mixing tPAmedication ahead of time
14、 for high likelihood candidates8.Rapid access to intravenous tPAin the ED/brain imaging area9.Team-based approach10.Rapid data feedback to stroke team on each patients DTN time and other performance data,相关研究,Target: CustomizableImplementation Tools,Patient time-trackersGuideline based algorithmstPA
15、 checklistStandardized order setsDosing chartsClinical pathwaysEvidence-based protocolsEMS toolsPatient educational materialsOther tools,相关研究,Fonarow GC, et al. JAMA. 2014 Apr 23-30;311(16):1632-40.,一项来自美国Target：Stroke项目共304家医院5460例接受tPA治疗患者的研究，旨在评估医院策略和缩短DNT时间的相关性,在11项缩短DNT的医院策略中，快速分诊并通知卒中小组(平均缩短8.
16、1分钟)，卒中小组集合(缩短4.3分钟)以及急诊储备tPA(缩短3.5分钟)是最有效的三种方法。,快速分诊并通知卒中小组,卒中小组集合,急诊储备tPA,缩短8.1min,缩短4.3min,缩短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 Improve Speed of Tissue-Type Plasminogen Activator Treatment in Acute Ischemic troke.Stroke. 2014;45:1387-139
17、5,相关研究,共71,169例接受rt-PA的患者，其中项目开展前为27,319例，开展后为43,850例DNT60min患者比例在项目开展前为29.6%，项目开展后增加到53.3%。开展前后的年增加率为1.36%vs.6.20%，P0.001,临床预后指标得到改善！,DNT60分比例(%),Fonarow GC, et al. JAMA. 2014 Apr 23-30;311(16):1632-40.,相关研究,一项来自美国Target：Stroke项目共304家医院5460例接受tPA治疗患者的研究，旨在评估医院策略和缩短DNT时间的相关性。,虽然单一治疗策略的作用效力可能较小，但这些策略
18、联合起来能使DNT节约14分钟。由于美国Get With The Guidelines-Stroke项目中DNT的平均时间为72分钟，因此，缩短14分钟将使大多数患者达到60分钟的治疗目标，从而挽救数以千计患者的残疾命运。,+,1种策略,+,10种策略,1.3分钟,14分钟,P=0.011,相关研究,Xian Y, et al. Strategies Used by Hospitals to Improve Speed of Tissue-Type Plasminogen Activator Treatment in Acute Ischemic troke.Stroke. 2014;45:1
19、387-1395,While there have been concerns that attempting to achieve shorter DTN times may lead to rushed assessments, inappropriate patient selection, dosing errors, and greater likelihood of complications, our findings suggest that more rapid reperfusion therapy in acute ischemic stroke is not only
20、feasible, but can be achieved with actual reductions in complications and improved 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,相关研究,入院到溶栓治疗时间60分
21、钟,到达急诊的疑似卒中患者,医师初始评估（包括病史，实验室检查，NIHSS评分）,通知卒中治疗小组（包括神经病学专家）,CT扫描完成,读CT及实验室检查报告完成,符合溶栓指征患者给予阿替普酶静脉溶栓,Bock BF. Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke; December 12-13,1996. http:/www.ninds.nih.gov/news_and_events/proceedings/stroke_proceedings/bock.htm,简化流程， “决胜60分”,thanks！,
