优化流程缩短DNT课件

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医院（排名不分先后）例数DNT市一医院8065省人民医院5470陆军总医院2372天佑医院2073市三医院1275汉口医院475长航、市四、市五、汉阳、武昌医院11889一六一医院885东西湖医院695144%105%市一医院年份201320142015静脉rt-PA溶栓治疗例数163980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2015DNT 80min 9例分析 ，多在检验环节耽误DNT时间控制

2、月份（N=27）9月10月11月12月单月均DNT（min)90796371累月均DNT（min）90837365 9-12月平均缩短DNT25min，目前DNT为65minDNT时间控制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2

3、014，47（7）：464-468Gottesman 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

4、 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 to 1, (b) acute ischemic stroke receiving intravenous r-tPA within 4.5 hours of onset according to guidelines from professional

5、 medical 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

6、 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment. Downloaded from / at Pfizer DIS on July 2, 2015问题及改进Saver JL. Stroke. 2006 Jan;37(1):263-6.大血管、幕上缺血性卒中神经回路损失的预估速度神经元丢失突触丢失有髓纤维丢失加速老化每次卒中12亿8.3万亿7140千米36年每小时1.2亿8300亿714千米3.6年每分钟190万140亿

7、12千米3.1周每秒钟32,0002.3亿200米8.7小时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 intravenous 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 3

8、0% of intravenous tPA treated acute ischemic stroke patients in the United States were 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 (in

9、itial goal of 50%).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 Initiative. ISC 2014, LB12相关研究Improving Door-to-Need

10、le Times in Acute Ischemic Stroke: Principal Results from the Target: Stroke Initiative. ISC 2014, LB12Target: Stroke 10 Key Best Practice Strategies1.Hospital pre-notification by Emergency Medical Services2.Rapid triage protocol and stroke team notification3.Single call/paging activation system for

11、 entire stroke team4.Use of a stroke toolkit containing clinical decision support, 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 (includ

12、ing point-of-care 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 each patients DTN time and other performance data相关研究一项来自美国Target：S

13、troke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8.1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3.5min62%使用率P=0.0363%使用率P=0.01869%使用率P=0.008 Xian Y, et al. Strategies Used by Hospitals to Improve Speed of Tissue-Type Pla

14、sminogen Activator Treatment in Acute Ischemic troke.Stroke. 2014;45:1387-1395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！OutcomePre-Target: Stroke(n=27,319)Post-Target: Stroke(n=43,850)Difference Pre and PostP Val

15、ue院内死亡率9.93%8.25%-1.68%P值*出院回家37.6%42.7%+5.1%0.0001独立行动能力42.2%45.4%+3.2%0.0001症状性出血5.68%4.68%-1.00%0.0001tPA相关并发症6.68%5.50%-1.18%0.0001DNT60分比例(%) Fonarow GC, et al. JAMA. 2014 Apr 23-30;311(16):1632-40.相关研究While there have been concerns that attempting to achieve shorter DTN times may lead to rushe

16、d 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 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分钟到达急诊的疑似卒中患者医师初始评估（包括病史，实验