Kaiser Permanente Department of Emergency Medicine (San Rafael), CA 94901, USA.
Am J Emerg Med. 2012 Sep;30(7):1152-62. doi: 10.1016/j.ajem.2011.08.015. Epub 2011 Nov 17.
We examined the impact of primary stroke center (PSC) certification on emergency department (ED) use and outcomes within an integrated delivery system in which EDs underwent staggered certification.
A retrospective cohort study of 30,461 patients seen in 17 integrated delivery system EDs with a primary diagnosis of transient ischemic attack (TIA), intracranial hemorrhage, or ischemic stroke between 2005 and 2008 was conducted. We compared ED stroke patient visits across hospitals for (1) temporal trends and (2) pre- and post-PSC certification-using logistic and linear regression models to adjust for comorbidities, patient characteristics, and calendar time, to examine major outcomes (ED throughput time, hospital admission, radiographic imaging utilization and throughput, and mortality) across certification stages.
There were 15,687 precertification ED visits and 11,040 postcertification visits. Primary stroke center certification was associated with significant changes in care processes associated with PSC certification process, including (1) ED throughput for patients with intracranial hemorrhage (55 minutes faster), (2) increased utilization of cranial magnetic resonance imaging for patients with ischemic stroke (odds ratio, 1.88; 95% confidence interval, 1.36-2.60), and (3) decrease in time to radiographic imaging for most modalities, including cranial computed tomography done within 6 hours of ED arrival (TIA: 12 minutes faster, ischemic stroke: 11 minutes faster), magnetic resonance imaging for patients with ischemic stroke (197 minutes faster), and carotid Doppler sonography for TIA patients (138 minutes faster). There were no significant changes in survival.
Stroke center certification was associated with significant changes in ED admission and radiographic utilization patterns, without measurable improvements in survival.
我们考察了在一个采用分阶段认证模式的综合性医疗服务体系中，初级卒中中心（PSC）认证对急诊（ED）使用和结局的影响。
对 2005 年至 2008 年期间在一个综合性医疗服务体系的 17 个 ED 中因短暂性脑缺血发作（TIA）、颅内出血或缺血性卒中等主要诊断就诊的 30461 例患者进行了回顾性队列研究。我们比较了各医院的 ED 卒中患者就诊情况，（1）比较了各医院之间的时间趋势，（2）比较了认证前和认证后的情况——使用逻辑回归和线性回归模型来调整共病、患者特征和日历时间，以检验各认证阶段的主要结局（ED 周转时间、住院、影像学检查利用度和周转时间、死亡率）。
共纳入 15687 例认证前 ED 就诊和 11040 例认证后 ED 就诊。PSC 认证与与 PSC 认证过程相关的治疗流程的显著变化相关，包括（1）颅内出血患者的 ED 周转时间（快 55 分钟），（2）缺血性卒中患者的颅磁共振成像利用度增加（比值比，1.88；95%置信区间，1.36-2.60），以及（3）大多数检查方式的影像学检查时间缩短，包括 ED 到达后 6 小时内行颅 CT（TIA：快 12 分钟，缺血性卒中：快 11 分钟）、缺血性卒中患者的磁共振成像（快 197 分钟）以及 TIA 患者的颈动脉多普勒超声（快 138 分钟）。生存率无显著变化。
卒中中心认证与 ED 收治和影像学利用模式的显著变化相关，生存率无显著改善。
