卒中门诊引导的卒中院内救治模式的评价和院内延迟因素的分析

Evaluation of Stroke Outpatient-Guided Stroke Hospital Treatment Model and Analysis of In-Hospital Delay Factors

摘要: 目的：评价卒中门诊引导的卒中院内救治模式在急性缺血性卒中院内救治过程的效果并分析院内救治延迟的因素。方法：以2021年4月兰州大学第一医院卒中门诊成立为时间分水岭，将2019年12月至2022年2月的227例静脉溶栓病人分别分为对照组及观察组，对照组采用传统急诊流程救治；观察组成立卒中门诊，在专科人员全程引导下救治。比较两组组患者院内救治各流程的时间及患者的预后和不良事件的发生情况、分析院内救治各环节的延误因素。结果：共纳入227例，对照组153例，观察组74例。两组患者人口学特征及临床资料的差异均无统计学意义(P > 0.05)；观察组在脑血管医生接诊及影像学完成等环节明显优于对照组。另外与对照组相比，患者就诊至溶栓时间(Door-to-needel time, DNT)中位数由54 min逐渐缩短至44 min (Z = −2.937, P = 0.000)，且观察组有较高的DNT ≤ 60 min比例(X2 = −7.384, P = 0.007)和DNT ≤ 45 min的比例(X2 = −5.835, P = 0.016)，差异具有统计学意义；观察组有着较低的入院至动脉穿刺的时间(Door-to-puncture time, DPT)和较高的DPT ≤ 90 min比率；差异无统计学意义；观察组在治疗后即刻NIHSS评分、治疗24 h后NIHSS评分较对照组低；症状性颅脑出血发生比率由原来的24%下降到5% (X2 = 4.265, P = 0.038)、肺炎发生比率由原来的35.3%下降到18.8% (X2 = 6.898, P = 0.009)，差异有统计学意义；对卒中院内救治的环节进行拆分，分析卒中院内救治延迟的因素，发现除了就诊至脑血管医生接诊、CT平扫完成至交代时间、交代完成至签血管内知情同意书、导管室至穿刺成功等子环节，其他环节均有延误。结论：卒中门诊引导的卒中院内救治模式能明显缩短院内救治时间，对急性缺血性卒中的院内救治模式的构建及其他绿色通道疾病的救治有较高的指导意义，但是对于有延迟的环节仍要加强优化，尽可能缩短卒中患者院内救治的时间。

Abstract: Objective: To evaluate the effect of stroke outpatient-guided in-hospital treatment model in acute ischemic stroke and analyze the factors of hospital treatment delay. Methods: With the establish-ment of the Stroke Clinic of the First Hospital of Lanzhou University in April 2021 as the time wa-tershed, 227 patients with intravenous thrombolysis from December 2019 to February 2022 were divided into the control group and the observation group. The stroke clinic was established and treated under the guidance of specialists. The time of each process of in-hospital treatment, the prognosis of patients and the occurrence of adverse events were compared between the two groups, and the delay factors of in-hospital treatment were analyzed. Results: A total of 227 cases were in-cluded, including 153 cases in the control group and 74 cases in the observation group. There was no significant difference in demographic characteristics and clinical data between the two groups (P > 0.05), but the cerebrovascular doctor reception and imaging completion in the observation group were significantly better than those in the control group. In addition, the door-to-needel time (DNT) was gradually shortened from 54 min to 44 min (Z = 11.838, P = 0.001). And the observation group had a higher ratio of DNT ≤ 60 min (X2 = 13.09, P = 0.001) and DNT ≤ 45 minutes (X2 = −5.835, P = 0.016), the difference was statistically significant. In the observation group, the door-to-puncture time (DPT) was lower and the ratio of DPT ≤ 90 min was higher, and the difference was not statistically significant. The NIHSS score immediately after treatment and NIHSS score 24 hours after treatment in the observation group were lower than those in the control group. The incidence rate of symptomatic craniocerebral hemorrhage decreased from 24% to 5%, and the incidence of pneumonia decreased from 35.3% to 18.8%. The difference was statistically significant. The treatment links in the stroke level people’s court were divided, and the factors of delay in stroke hospital treatment were analyzed. It was found that except for the sub-links from seeing a doctor to the cerebrovascular doctor, from the completion of the CT scan to the confession time, from the completion of the confession to the signing of the intravascular informed consent form, and from the catheterization room to the success of the puncture, there were delays in other links. Conclusion: The in-hospital treatment mode guided by stroke clinic can obviously shorten the time of in-hospital treatment, and has high guiding significance for the construction of the in-hospital treatment model of acute ischemic stroke and the treatment of other green channel diseases. However, it is necessary to strengthen and optimize the delayed links to shorten the time of inhospital treatment of stroke patients as much as possible.