精益管理在卒中中心脑梗死单病种费用控制中的应用研究

Application of lean management in cost control of cerebral infarction single disease in stroke center

目的探讨精益管理在卒中中心急性脑梗死(ACI)患者单病种费用控制中的作用。方法采用回顾性研究方法,选择浙江省台州市中心医院卒中中心行静脉溶栓的ACI患者为研究对象,将2016年7月至2017年9月采用传统管理流程的30例患者纳入对照组,将2017年10月至2018年12月采用精益管理的32例患者纳入精益组。对照组采用传统静脉溶栓流程,患者送入神经内科病房进行静脉溶栓;精益组应用精益管理"价值流"优化流程管理,成立卒中中心精益管理团队,建立卒中救治绿色通道,尽量消除等待时间,溶栓地点改为急诊科神经重症加强治疗病房(NICU)。比较两组患者静脉溶栓门-针时间(DNT)、入院至神经内科医生接诊时间(T1)、CT检查至送入神经内科病房或急诊科NICU时间(T2)、神经内科病房或急诊科NICU接诊至用药时间(T3)、DNT控制在40 min内患者比例,溶栓后7 d神经功能缺损恢复情况〔美国国立卫生研究院卒中量表(NIHSS)评分〕、日常生活能力评价(Barthel指数),以及住院时间、住院费用和患者满意度;同时记录患者脑梗死单病种过程质量主要、易漏指标执行率。结果与对照组比较,精益组患者DNT、T1、T2均明显缩短〔DNT(min):39.56±11.12比63.03±19.63,T1(min):16.23±6.79比33.48±12.63,T2(min):13.45±3.84比17.47±5.56,均P<0.01〕,T3略有缩短(min:9.88±1.95比10.95±2.69,P>0.05),DNT控制在40 min内的患者比例明显增加〔75.0%(24/32)比16.7%(5/30),P<0.01〕;同时7 d NIHSS评分明显下降(分:8.66±4.12比13.00±5.63,P<0.01),7 d Barthel指数显著升高(71.6±16.7比54.7±17.1,P<0.01),住院时间明显缩短(d:9.69±4.06比12.47±3.83,P<0.01),住院费用显著减少(元:16 338±5 481比19 470±5 495,P<0.05),患者满意度显著提高〔(91.38±2.69)%比(86.53±2.78)%,P<0.01〕。在溶栓药物应用前评估、吞咽困难评价及24 h内血管功能评价、ACI的健康教育、康复评价与实施等反映质量的主要、易漏指标的执行率方面,精益组均较对照组明显提高〔87.5%(28/32)比53.3%(16/30),96.9%(31/32)比73.3%(22/30),78.1%(25/32)比43.3%(13/30),100.0%(32/32)比76.7%(23/30),75.0%(24/32)比33.3%(10/30),均P<0.05〕。结论运用精益思想实现卒中中心流程标准化,有效利用医疗资源,可提高医疗质量,降低脑梗死单病种费用。

Objective To explore the effect of lean management on cost control of single disease in patients with acute cerebral infarction(ACI)in stroke center.Methods A retrospective study was conducted.The patients with ACI who underwent intravenous thrombolysis in the stroke center of Taizhou Central Hospital in Zhejiang Province were enrolled.Thirty patients adopted traditional management procedures from July 2016 to September 2017 were enrolled in the control group,and 32 patients received lean management from October 2017 to December 2018 were enrolled in the lean group.The patients in the control group were treated with traditional intravenous thrombolysis,and the patients were sent to the neurology ward for intravenous thrombolysis.The patients in the lean group applied lean management value stream to optimize process management,the lean management team of the stroke center was established,and the green channel for stroke treatment was established to eliminate the waiting time as far as possible.The location of thrombolysis was changed from neurology ward to the neurological intensive care unit(NICU)in emergency department.The patients in the two groups were compared in terms of intravenous thrombolytic door-to-needle time(DNT),admission time to the neurologist's visit time(T1),CT examination time to neurology ward or NICU admission time(T2),neurology ward/NICU visit time to medication time(T3),and the proportion of patients with DNT controlled within 40 minutes,recovery of neurological impairment 7 days after thrombolysis[national institutes of health stroke scale(NIHSS)score],activity of daily living assessment(Barthel index),length of hospital stay,cost of hospital stay and patient satisfaction.At the same time,the main process quality and the implementation rate of easily missed indexes of cerebral infarction single disease were recorded.Results Compared with the control group,DNT,T1 and T2 in the lean group were significantly shortened[DNT(minutes):39.56±11.12 vs.63.03±19.63,T1(minutes):16.23±6.79 vs.33.48±12.63,T2(minutes):13.45±3.84 vs.17.47±5.56,all P<0.01],T3 was slightly shortened(minutes:9.88±1.95 vs.10.95±2.69,P>0.05),and the proportion of DNT control within 40 minutes was significantly increased[75.0%(24/32)vs.16.7%(5/30),P<0.01],the 7-day NIHSS score was decreased significantly(8.66±4.12 vs.13.00±5.63,P<0.01),7-day Barthel index was increased significantly(71.6±16.7 vs.54.7±17.1,P<0.01),the length of hospital stay was significantly shortened(days:9.69±4.06 vs.12.47±3.83,P<0.01),the hospital costs were significantly reduced(Yuan:16 338±5 481 vs.19 470±5 495,P<0.05),the satisfaction of patients was improved significantly[(91.38±2.69)%vs.(86.53±2.78)%,P<0.01].In terms of the implementation rate of quality indicators such as pre-application evaluation of thrombolytic drugs,evaluation of dysphagia,and evaluation of vascular function,health education of ACI,rehabilitation evaluation and implementation within 24 hours,etc.,the lean group was significantly improved as compared with the control group[(87.5%(28/32)vs.53.3%(16/30),96.9%(31/32)vs.73.3%(22/30),78.1%(25/32)vs.43.3%(13/30),100.0%(32/32)vs.76.7%(23/30),75.0%(24/32)vs.33.3%(10/30),all P<0.05].Conclusion Lean thinking can realize the standardization of stroke center process,effectively utilize medical resources,improve medical quality and reduce the cost of cerebral infarction single disease.