Nee P A, Gray A J, Martin M A
Stockport Infirmary, UK.
Qual Health Care. 1994 Mar;3(1):29-33. doi: 10.1136/qshc.3.1.29.
Early thrombolytic therapy after acute myocardial infarction is important in reducing mortality. To evaluate a system for reducing in-hospital delays to thrombolysis pain to needle and door to needle times to thrombolysis were audited in a major accident and emergency (A and E) department of a district general hospital and its coronary care unit (CCU), situated about 5 km away. Baseline performance over six months was assessed retrospectively from notes of 43 consecutive patients (group 1) transferred to the CCU before receiving thrombolysis. Subsequently, selected patients (23) were allowed to receive thrombolysis in the A and E department before transfer to the CCU. The agent was administered by medical staff in the department after receiving oral confirmation of myocardial infarction from the admitting medical officer in the CCU on receipt of fax transmission of the electrocardiogram. A second prospective audit during six months from the start of the new procedure established time intervals in 23 patients eligible to receive thrombolysis in the A and E department (group 2b) and 30 ineligible patients who received thrombolysis in the CCU (group 2a). The groups did not differ significantly in case mix, pre-hospital delay, or transfer time to the CCU. In group 2b door to needle time and pain to needle time were reduced significantly (geometric mean 38 min v 121 min (group 2a) and 128 min (group 1); 141 min v 237 min (group 2a) and 242 min (group 1) respectively, both p < 0.0001). The incidence of adverse effects was not significantly different. Nine deaths occurred (six in group 1, three in group 2b), an in-hospital mortality of 9.9%. Thrombolysis can be safely instituted in the A and E department in selected patients, significantly reducing delay to treatment.
急性心肌梗死后早期溶栓治疗对于降低死亡率至关重要。为评估一个减少院内溶栓延迟的系统，在一家区综合医院的主要事故与急救（A&E）科室及其距离约5公里的冠心病监护病房（CCU），对溶栓的疼痛至穿刺时间和门至穿刺时间进行了审核。从43例连续患者（第1组）接受溶栓前转至CCU的病历中回顾性评估了六个月的基线表现。随后，挑选出的患者（23例）在转至CCU之前在A&E科室接受溶栓治疗。在收到CCU住院医生通过心电图传真传来的心肌梗死口头确认后，由该科室的医务人员给予溶栓药物。从新流程开始后的六个月内进行了第二次前瞻性审核，确定了23例符合条件在A&E科室接受溶栓治疗的患者（第2b组）和30例在CCU接受溶栓治疗的不符合条件患者（第2a组）的时间间隔。两组在病例组合、院前延迟或转至CCU的时间方面无显著差异。在第2b组中，门至穿刺时间和疼痛至穿刺时间显著缩短（几何均数分别为38分钟对121分钟（第2a组）和128分钟（第1组）；141分钟对237分钟（第2a组）和242分钟（第1组），p均<0.0001）。不良反应发生率无显著差异。发生了9例死亡（第1组6例，第2b组3例），院内死亡率为9.9%。对于挑选出的患者，可在A&E科室安全地进行溶栓治疗，显著减少治疗延迟。
