Bradley Elizabeth H, Nallamothu Brahmajee K, Curtis Jeptha P, Webster Tashonna R, Magid David J, Granger Christopher B, Moscucci Mauro, Krumholz Harlan M
Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, USA.
Crit Pathw Cardiol. 2007 Sep;6(3):91-7. doi: 10.1097/HPC.0b013e31812da7bc.
Despite the clinical importance of prompt percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction, many hospitals do not routinely achieve the guideline-recommended 90-minute door-to-balloon times. In this review, we evaluate existing evidence that identifies effective hospital strategies for reducing door-to-balloon time. We performed a computerized search of MEDLINE and Current Contents for studies conducted in the last 10 years of hospital efforts to improve door-to-balloon times. We excluded studies that had <10 patients, had nonspecific efforts, or, for quantitative studies, lacked statistical tests; each study was independently evaluated by 3 researchers. We found 13 studies that examined the relationship between hospital-based strategies and door-to-balloon times. Three examined national samples of hospitals using cross-sectional designs; 8 were conducted in a single or small number of hospitals using pre/post interventional or cross-sectional designs, and 2 were qualitative in design. Strategies with the strongest evidence include (1) activation of the catheterization laboratory using emergency medicine physicians rather than cardiologists, (2) effective use of prehospital electrocardiograms, (3) performance data monitoring/feedback. Reasonable evidence exists for establishing a single-call system for activating the catheterization laboratory, setting the expectation that the catheterization team be available 20-30 minutes after being paged, and having an organizational environment with strong senior management support and culture to foster changes directed at improving door-to-balloon time. In conclusion, although evidence of "what works" is based on observational studies rather than randomized trials, there is evidence on effective interventions to reduce door-to-balloon time.
尽管对于ST段抬高型心肌梗死患者而言，及时进行经皮冠状动脉介入治疗具有临床重要性，但许多医院并未常规达到指南推荐的90分钟门球时间。在本综述中，我们评估了现有证据，这些证据确定了降低门球时间的有效医院策略。我们对MEDLINE和《现刊目次》进行了计算机检索，以查找过去10年中关于医院为缩短门球时间所做努力的研究。我们排除了患者人数少于10人、措施不具体或对于定量研究缺乏统计检验的研究；每项研究由3名研究人员独立评估。我们发现了13项研究，这些研究探讨了基于医院的策略与门球时间之间的关系。3项研究使用横断面设计对全国医院样本进行了调查；8项研究在一家或少数几家医院进行，采用介入前/后或横断面设计，2项研究为定性设计。证据最充分的策略包括：（1）由急诊科医生而非心脏病专家启动导管室；（2）有效利用院前心电图；（3）绩效数据监测/反馈。对于建立用于启动导管室的一键呼叫系统、设定导管室团队在接到传呼后20 - 30分钟内可用的预期以及营造具有强大高级管理层支持和文化氛围以促进旨在缩短门球时间的变革的组织环境，存在合理证据。总之，尽管关于“有效措施”的证据基于观察性研究而非随机试验，但有证据表明存在可有效缩短门球时间的干预措施。
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