农村脑卒中服务评估：协调员和路径的实施是否改善了农村医院的护理？

Evaluation of rural stroke services: does implementation of coordinators and pathways improve care in rural hospitals?

机构信息

From the Translational Public Health Unit, Stroke and Ageing Research Centre, Department of Medicine, Southern Clinical School, Monash University, Clayton, Australia (D.A.C., T.P., M.K.); Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia (D.A.C., T.P., M.K.); Stroke Services New South Wales, New South Wales Agency for Clinical Innovation, New South Wales, Australia (M.L.); Wagga Wagga Base Hospital, Wagga Wagga, New South Wales, Australia (K.M.); Hunter Stroke Service, Hunter New England Area Health, Rankin Park Centre, New South Wales, Australia (M.P.); Centre for Brain and Mental Health Research, University of Newcastle and Hunter Medical Research Institute, New Lambton, New South Wales, Australia (C.L.); and John Hunter Hospital, Newcastle, New South Wales, Australia (C.L.).

出版信息

Stroke. 2013 Oct;44(10):2848-53. doi: 10.1161/STROKEAHA.113.001258. Epub 2013 Aug 15.

DOI:10.1161/STROKEAHA.113.001258

PMID:23950561

Abstract

BACKGROUND AND PURPOSE

The quality of hospital care for stroke varies, particularly in rural areas. In 2007, funding to improve stroke care became available as part of the Rural Stroke Project (RSP) in New South Wales (Australia). The RSP included the employment of clinical coordinators to establish stroke units or pathways and protocols, and more clinical staff. We aimed to describe the effectiveness of RSP in improving stroke care and patient outcomes.

METHODS

A historical control cohort design was used. Clinical practice and outcomes at 8 hospitals were compared using 2 medical record reviews of 100 consecutive ischemic or intracerebral hemorrhage patients ≥12 months before RSP and 3 to 6 months after RSP was implemented. Descriptive statistics and multivariable analyses of patient outcomes are presented.

SAMPLE

pre-RSP n=750; mean age 74 (SD, 13) years; women 50% and post-RSP n=730; mean age 74 (SD, 13) years; women 46%. Many improvements in stroke care were found after RSP: access to stroke units (pre 0%; post 58%, P<0.001); use of aspirin within 24 hours of ischemic stroke (pre 59%; post 71%, P<0.001); use of care plans (pre 15%; post 63%, P<0.001); and allied health assessments within 48 hours (pre 65%; post 82% P<0.001). After implementation of the RSP, patients directly admitted to an RSP hospital were 89% more likely to be discharged home (adjusted odds ratio, 1.89; 95% confidence interval, 1.34-2.66).

CONCLUSIONS

Investment in clinical coordinators who implemented organizational change, together with increased clinician resources, effectively improved stroke care in rural hospitals, resulting in more patients being discharged home.

摘要

背景与目的

医院对卒中的治疗质量存在差异，尤其是在农村地区。2007 年，作为新南威尔士州（澳大利亚）农村卒中项目（RSP）的一部分，为改善卒中治疗提供了资金。RSP 包括雇用临床协调员来建立卒中单元或路径以及制定方案，并增加更多的临床人员。我们旨在描述 RSP 在改善卒中治疗和患者结局方面的效果。

方法

采用历史对照队列设计。通过对 RSP 实施前 12 个月和实施后 3 至 6 个月的 100 例连续缺血性或颅内出血患者的 2 次病历回顾，比较 8 家医院的临床实践和结局。呈现患者结局的描述性统计和多变量分析。

样本

RSP 前 n=750；平均年龄 74（SD，13）岁；女性占 50%；RSP 后 n=730；平均年龄 74（SD，13）岁；女性占 46%。RSP 后发现卒中治疗有许多改善：卒中单元的获得（RSP 前 0%；RSP 后 58%，P<0.001）；缺血性卒中后 24 小时内使用阿司匹林（RSP 前 59%；RSP 后 71%，P<0.001）；使用护理计划（RSP 前 15%；RSP 后 63%，P<0.001）；48 小时内进行联合健康评估（RSP 前 65%；RSP 后 82%，P<0.001）。实施 RSP 后，直接被 RSP 医院收治的患者出院回家的可能性高 89%（调整优势比，1.89；95%置信区间，1.34-2.66）。