急性腦中風急診病患縮短血栓溶解治療時間介入方案的評估研究

Evaluation of Intervention Program on Shortening the Door-to-needle Times in Emergency Department Patients with Acute Stroke

謝明儒(Ming-Ju Hsieh)

指導教授 ： 賴美淑

國立臺灣大學/公共衛生學院/流行病學與預防醫學研究所/碩士(2012年)

https://doi.org/10.6342/NTU.2012.00345

摘要

背景
近年來，腦中風為台灣十大死因的第三位，而缺血性腦中風約占所有腦中風的七成左右。血栓溶解劑被證明可改善急性缺血性腦中風病患的功能性預後，且中風症狀發生後越早施打血栓溶解劑效果越好。縮短病患到達急診後至接受血栓溶解治療的時間不僅可增加血栓溶解治療的效果，也可減少血栓溶解治療併發症產生的機會。某醫院已進行急性腦中風急診病患縮短血栓溶解治療時間之介入方案且進入成熟期。該介入方案自2010年8月1日開始進行分階段導入。本研究主要目的在評估該醫院之介入方案結果。另外亦尋求影響血栓溶解治療時間的影響因子。

材料與方法
本評估研究比較2010年1月1日至2010年7月31日之介入方案前期間及2011年3月1日至7月31日之介入方案後評估期間之變化。評估指標包括病患到達急診至開始接受血栓溶解劑的時間、到達急診至完成電腦斷層時間與接受血栓溶解治療的病患占急性缺血性腦中風病患的比例。研究個案之納入條件為：(1)研究期間內經急診到院，且到達急診離症狀發作時間≦3小時；(2)經影像檢查或神經科醫師診斷為急性缺血性腦中風的病患。排除條件為：(1)在醫院內發生的缺血性中風； (2)在其他醫院經由影像學檢查與醫師診斷為急性缺血性腦中風，為了接受血栓溶解治療而轉診前來本院。經訓練的中風登錄員以病歷回顧方式，回溯性地收集於該醫院急診部之腦中風及短暫缺血性中風病患的人口統計學資料與相關中風資訊，同時收集研究期間病患到院前救護資料。利用醫院之醫療資訊系統抓取於研究期間內，執行電腦斷層完成後，第一張電腦斷層片上傳電腦的時間與急診擁塞指標。

結果
在介入方案前期間和介入方案後評估期間分別有607位及554位於症狀發作10天內經急診入院的腦中風及短暫缺血性腦中風病患。在排除了腦內出血、蜘蛛膜下腔出血、短暫缺血性腦中風病患、在醫院內發生中風的病患、到達急診距離症狀發作時間超過3小時的病患，以及從外院轉來接受施打血栓溶解劑的病患後，介入方案前期間和介入方案後評估期間分別有106位及90位病患成為研究族群，而其中有57位病患接受血栓溶解劑。18位於介入方案前期間接受血栓溶解劑治療，而其他39位則於介入方案後評估時期接受血栓溶解劑治療。經由比較兩期間病患到達急診至開始接受血栓溶解治療的時間中發現，該時間間隔的中位數由原本的66.5分鐘縮減到53分鐘且有統計學上的意義﹙P=0.03﹚。到達急診至完成電腦斷層時間從介入方案前期間的42.5分鐘下降為11.6分鐘﹙P<0.01﹚。接受血栓溶解劑病患占所有缺血性腦中風病患比例從原本之4.19％上升到9.95％﹙P<0.01﹚。介入方案為唯一影響到達急診至開始接受血栓溶解劑的時間≦60分鐘目標的影響因子﹙P=0.03﹚，而年齡與到院前救護人員處置時間並無影響。

結論
本評估研究發現該介入方案可使病患到達急診至完成電腦斷層時間及開始接受血栓溶解治療的時間都顯著地縮短，達到美國心臟醫學會準則建議的目標；接受血栓溶解劑治療病患占急性缺血性腦中風病患的比例亦顯著增加。介入方案實行後，到院前救護處置時間長短卻無顯著改變。上述評估研究結果顯示此介入方案有效改善了急性腦中風病患的醫療照護品質。

關鍵字

中風 ； 栓溶治療 ； 組織與行政 ； 品質

並列摘要

Background
Recently, stroke is the third leading cause of death in Taiwan. About 70％ of stroke is ischemic stroke. Thrombolytic therapy has been proved to improve the functional outcome of the patients with acute ischemic stroke. In addition, It also has been shown that the sooner the stroke patients receiving thrombolytic therapy, the better the functional outcome. Door-to-needle time is defined as the time duration from patients arriving at emergency department (ED) to patients starting to receive thrombolytic therapy. Shortening the door-to-needle time not only increases the effects of thrombolytic therapy but also lowers the risk of complications induced by the therapy. One intervention program on shortening the door-to-needle times in ED patients with acute stroke has performed in the hospital and is under the period of maturity. The intervention program was launched step by step since August 1, 2010. The aim of our study is to evaluate the intervention program. We also want to search the factors affecting the door-to-needle time.

Material and Methods
Our study compared the condition of the evaluation period from March 1, 2011 to July 31, 2011 with those of the pre-intervention period from January 1, 2010 to July 31, 2010. The evaluation measures included the door-to-needle time, the time duration from patients arriving at ED to computed tomography being finished (door-to-CT time) and the percentage of patients with thrombolytic therapy among ischemic stroke patients. The inclusion criteria were as follows: (1) patients arriving at ED within 3 hours after symptoms onset (2) ischemic stroke patients diagnosed by neurologists or neuroimaging results. Patients with in-hospital stroke, or patients transferred from other hospitals for thrombolytic therapy were excluded. The trained stroke registrar collected the demographics and the in-hospital stroke data of the study group retrospectively. The pre-hospital data was collected at the same time. We also acquired the time of finishing computed tomography (CT) and ED overcrowding variables from the medical information system of the hospital.

Results
A total of 607 patients during the pre-intervention period and 554 patients during the evaluation period diagnosed as stroke and transient ischemic stroke visited ED within 10 days after symptoms onset. After excluding patients with intra-cerebral hemorrhage, subarachnoid hemorrhage, transient ischemic stroke, in-hospital stroke, patients arriving at ED more than 3 hours after stroke onset and patients transferred from other hospitals for thrombolytic therapy, there were 106 patients during the pre-intervention period and 90 patients during the evaluation period into our study group. Fifty-seven patients of our study group received thrombolytic therapy with 18 patients during the pre-intervention period. The median of door-to-needle time decreased from 66.5 minutes to 53 minutes significantly after intervention program was performed (p=0.03). The door-to-CT time decreased from 42.5 minutes to 11.6 minutes significantly (p<0.01). The percentage of patients with thrombolytic therapy among ischemic stroke patients increased from 4.19％ to 9.95％ (p<0.01). Intervention program was the only factor affecting the door-to-needle time≦60 minutes (p=0.03). No association was noted between age and the door-to-needle time≦60 minutes. The pre-hospital operation period was not different significantly (22.5 minutes vs. 24 minutes, p=0.43).

Conclusion
Our study revealed that the intervention program shortened the door-to-CT time and the door-to-needle time significantly. The intervention program achieved the goals of management time recommended by the American Heart Association guideline. In addition, the percentage of patients with thrombolytic therapy among ischemic stroke patients also increased significantly after intervention program was implemented. Nevertheless, the duration of pre-hospital operation period did not change. Our study showed that the intervention program effectively improved the quality of care in patients with acute stroke.

並列關鍵字

stroke ； thrombolytic therapy ； organization and administration ； quality

參考文獻

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