Jauch Edward C, Huang David Y, Gardner Allison J, Blum Julie L
Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC, USA.
Department of Neurology, Division of Stroke and Vascular Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
Open Access Emerg Med. 2018 May 16;10:53-59. doi: 10.2147/OAEM.S160269. eCollection 2018.
The timely evaluation and initiation of treatment for acute ischemic stroke (AIS) is critical to optimal patient outcomes. However, clinical practice often falls short of guideline-established goals. Hospitals in rural regions of the USA, and notably those in the Stroke Belt, are particularly challenged to meet timing goals since the vast majority of primary stroke centers (PSCs) are concentrated in urban academic institutions.
Between May 2015 and May 2017, emergency department (ED) teams from 5 non-PSC hospitals in the Stroke Belt participated in a quality improvement (QI) initiative. The intervention included a baseline practice assessment survey, repeat audit-and-feedback cycles with patient data on AIS treatment timing, personalized Continuing Medical Education/Continuing Education-certified grand rounds sessions at each participating site with expert study faculty, targeted reinforcement of best practices, and follow-up to evaluate the benefits and limitations of the intervention.
At the start of the initiative, clinical staff from participating EDs overestimated the proportion of patients with AIS who received alteplase within the guideline-recommended 60-minute door-to-needle window at their facility. At the end of the 6-month intervention period, significantly more patients were treated with alteplase within 60 minutes of ED arrival compared to baseline across the entire sample (1.9% of patients at baseline vs. 5.2% at 6 months; < 0.01). Similarly, there was a trend toward a decrease in the percentage of patients whose alteplase treatment was initiated more than 60 minutes after their arrival at the ED (67.3% at baseline vs. 22.2% at 6 months).
Structured QI interventions that engage ED care teams to reflect on processes related to AIS diagnosis and treatment and deploy repeat audit-and-feedback cycles with real-time patient data have the potential to support an increase in the number of patients who receive alteplase within the guideline-recommended timeframe of 60 minutes from hospital arrival.
急性缺血性卒中（AIS）的及时评估和治疗启动对于患者获得最佳预后至关重要。然而，临床实践往往未达到指南设定的目标。美国农村地区的医院，尤其是卒中带地区的医院，在实现时间目标方面面临特别大的挑战，因为绝大多数初级卒中中心（PSC）都集中在城市学术机构。
2015年5月至2017年5月期间，卒中带地区5家非PSC医院的急诊科（ED）团队参与了一项质量改进（QI）计划。干预措施包括基线实践评估调查、使用AIS治疗时间的患者数据进行重复审核与反馈循环、在每个参与地点与专家研究人员共同开展经继续医学教育/继续教育认证的个性化大查房、针对性强化最佳实践，以及随访以评估干预措施的益处和局限性。
在该计划启动时，参与急诊科的临床工作人员高估了在其机构内指南推荐的60分钟门到针时间窗内接受阿替普酶治疗的AIS患者比例。在6个月的干预期结束时，与整个样本的基线相比，显著更多的患者在抵达急诊科后60分钟内接受了阿替普酶治疗（基线时为1.9%的患者，6个月时为5.2%；P<0.01）。同样，在抵达急诊科后60分钟以上才开始使用阿替普酶治疗的患者百分比有下降趋势（基线时为67.3%，6个月时为22.2%）。
让急诊科护理团队参与反思与AIS诊断和治疗相关的流程，并使用实时患者数据进行重复审核与反馈循环的结构化QI干预措施，有可能支持增加在从医院抵达起60分钟的指南推荐时间范围内接受阿替普酶治疗的患者数量。
