1、優化流程縮 短 DNT 武漢市第一醫院神經內科 2016年4月16日靜脈溶栓2015DNT時間控制不良預后因素優化流程問題及改進相關研究目錄靜脈溶栓2015醫院（排名不分先后）例數DNT市一醫院8065省人民醫院5470陸軍總醫院2372天佑醫院2073市三醫院1275漢口醫院475長航、市四、市五、漢陽、武昌醫院11889一六一醫院885東西湖醫院695144%105%市一醫院年份201320142015靜脈rt-PA溶栓治療例數163980靜脈溶栓2015靜脈溶栓、橋接治療、血管內治療10人70人5人7人市一醫院靜脈溶栓2015DNT 80min 9例分析 ，多在檢驗環節耽誤DNT時間控制

2、月份（N=27）9月10月11月12月單月均DNT（min)90796371累月均DNT（min）90837365 9-12月平均縮短DNT25min，目前DNT為65minDNT時間控制優化流程急性卒中綠色通道路徑圖優化流程急性缺血性腦卒中靜脈溶栓治療方案 急性缺血性腦卒中血管內治療方案優化流程問題及改進總結分析DNT達標及延誤原因，改進流程在排除相關病史用藥史后，AIS靜脈溶栓前不等待血小板和凝血功能指標聯合其他優化措施，可顯著縮短DNT，不增加slCH和7d內的死亡風險。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和凝血功能指標 ，中華神經科雜志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問題及改進減少患者入院后延誤：急診醫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開總結會，反饋DNT時間、討論改進辦法問題及改進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 橋接治療的納入標準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問題及改進Saver JL. Stroke. 2006 Jan;37(1):263-6.大血管、幕上缺血性卒中神經回路損失的預估速度神經元丟失突觸丟失有髓纖維丟失加速老化每次卒中12億8.3萬億7140千米36年每小時1.2億8300億714千米3.6年每分鐘190萬140億

7、12千米3.1周每秒鐘32,0002.3億200米8.7小時相關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 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 相關研究Improving Door-to-Needle Times in Acute Ischemic Stroke: Principal Results from the Target: Stroke Initiative. ISC 2014, LB12相關研究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相關研究一項來自美國Target：S

13、troke項目共304家醫院5460例接受tPA治療患者的研究，旨在評估醫院策略和縮短DNT時間的相關性在11項縮短DNT的醫院策略中，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?？焖俜衷\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3.5min62%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相關研究共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DNT60min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%vs.6.20%，P0.001臨床預后指標得到改善！OutcomePre-Target: Stroke(n=27,319)Post-Target: Stroke(n=43,850)Difference Pre and PostP Val

15、ue院內死亡率9.93%8.25%-1.68%P值*出院回家37.6%42.7%+5.1%0.0001獨立行動能力42.2%45.4%+3.2%0.0001癥狀性出血5.68%4.68%-1.00%0.0001tPA相關并發癥6.68%5.50%-1.18%0.0001DNT60分比例(%) Fonarow GC, et al. JAMA. 2014 Apr 23-30;311(16):1632-40.相關研究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相關研究入院到溶栓治療時間60分鐘到達急診的疑似卒中患者醫師初始評估（包括病史，實驗