急性缺血性脑卒中治疗基准数据的改进研究

Ongoing impronement in acute ischemic stroke therapy

目的尽管组织纤溶酶原激动剂(tPA)静脉溶栓治疗和血管内取栓治疗(EVT)是急性缺血性脑卒中(AIS)的有效治疗手段;但在临床实践中,启动上述治疗时间往往有延误。作者检验了美国单个高级卒中中心的质控数据,以期报道其在急性卒中处理的持续性质控基准数据改进情况。方法本研究纳入2013年1月-2018年12月美国单个高级卒中中心连续性的缺血性脑卒中患者。根据美国心脏协会(AHA)的卒中代码和2015年实施的简明改进协议对脑卒中患者进行管理。人口统计学和临床数据来自遵照指南(GWTG)-卒中登记处和电子病历。按照入院和实施质控改进举措的日期将患者分为3组。使用线性回归模型和Jonckheere-Terpstra检验分析质控指标,质控指标包括静脉tPA溶栓治疗和EVT率、入院-溶栓开始(DTN)时间和入院-动脉穿刺(DTP)时间。结果本研究共纳入1369例发病24h内的卒中患者,2013-2014年、2015-2016年和2017-2018年的静脉tPA溶栓率分别为20%、30%和22%;EVT率分别为9%、14%和15%。根据Jonckheere-Terpstra检验,DTN时间的中位数(57、45、39 min;P<0.001)和DTP时间中位数(172、130、114 min;P=0.009)在以上3个时间段内得到连续性的改善;2017年1月-2018年12月,80%的患者DTN时间≤60 min,63%的患者DTN时间≤45 min。结论遵循AHA指南和简明改进协议后,AIS的静脉溶栓/EVT率和治疗启动时间得到了不断改进。

Objective Although the intravenous tissue plasminogen activator(tPA)and endovascular therapy(EVT)are the standard managements of acute ischemic stroke(AIS),the initiation of the acute managements were delayed.We examined the evolution of stroke care,to report the ongoing quality improvement at our stroke center.Methods Consecutive patients with AIS from 2013 to 2018 were studied.Patients were managed using Code Stroke algorithm per concurrent AHA guidelines and a simple quality improvement protocol implemented in 2015.Demographics and clinical data were collected from Get-With-The-Guideline(GWTG)-Stroke registry and electronic medical records.Patients were divided into 3 groups per admission dates.Quality measures,including rates of intravenous tPA and endovascular thrombectomy(EVT),DTN time,door-to-puncture(DTP)and time were analyzed.Results Of the 1369 eligible patients presenting within 24 hours of symptom onset or wakeup stroke,the rate of intravenous tPA was 20%,30%and 22%,respectively,in 2013-2014,2015-2016,and 2017-2018.In contrast,EVT rate was 9%,14%and 15%,respectively.There was significant ongoing improvement in the median DTN time(57,45,39 minutes)and DTP time(172,130,114 minutes)during the 3 time periods,with DTN time 60 and 45 minutes in 80%and 63%patients,respectively,in 2017-2018.Conclusion The implementation of concurrent AHA guidelines and simple quality improvement initiatives are associated with excellent rates of acute stroke treatment and ongoing improvement in door to treatment times.