Leong Bao Yu Geraldine, Ni Hui Min Joyce, Tiah Ling, Tan Camlyn
Emergency Medicine, Changi General Hospital, Singapore, SGP.
Performance Improvement, Changi General Hospital, Singapore, SGP.
Cureus. 2020 Dec 27;12(12):e12316. doi: 10.7759/cureus.12316.
Introduction Administering intravenous thrombolytic therapy within 60 minutes on arrival in any healthcare facility is challenging, especially when done by Emergency Medicine Physicians (EMP) via telemedicine in centres without onsite neurology cover. Prior quality improvement interventions have improved median Door-to-Needle (DTN) timings in our centre; however, it still falls short of the DTN target of 60 minutes. Methods Various quality improvement interventions were implemented over four months by a multi-disciplinary telestroke workgroup led by EMPs to improve DTN timings for patients presenting with acute ischaemic strokes. A retrospective observational study was conducted to review if these interventions resulted in an improvement in DTN timings while keeping the rates of stroke mimics given thrombolytic therapy, haemorrhagic conversions and 30-day mortality rates low. Results A total of 279 patients were evaluated. Median DTN timings significantly improved from 71.0 minutes pre-intervention to 62.0 minutes post-intervention (p=0.012). Correspondingly, the proportion of patients with DTN ≤ 60 minutes increased from 31.7% pre-intervention to 47.0% post-intervention, giving an odds ratio of 1.91 (95% CI 1.17 - 3.11, p=0.009). There were no significant differences found in the rates of stroke mimics, haemorrhagic conversions and 30-day mortality pre and post-intervention. Conclusion The implementation of EMP led to systemic quality improvement interventions is associated with improved DTN timings without compromising clinical quality outcome measures like haemorrhagic conversion rates and 30-day mortality rates. EMPs, with a broad knowledge base and familiarity, interacting with various specialities and co-ordinating care, are uniquely suited in this role to drive change. More work in the public health sector would also have to be done to improve the population's response to acute stroke symptoms.
引言 在任何医疗机构中，在患者到达后60分钟内进行静脉溶栓治疗都具有挑战性，尤其是当由急诊科医生（EMP）通过远程医疗在没有现场神经科支持的中心进行时。先前的质量改进干预措施已经改善了我们中心的中位门到针（DTN）时间；然而，它仍未达到60分钟的DTN目标。 方法 由EMP领导的多学科远程卒中工作组在四个月内实施了各种质量改进干预措施，以改善急性缺血性卒中患者的DTN时间。进行了一项回顾性观察研究，以审查这些干预措施是否导致DTN时间得到改善，同时使接受溶栓治疗的疑似卒中患者的比例、出血性转化和30天死亡率保持在低水平。 结果 共评估了279例患者。中位DTN时间从干预前的71.0分钟显著改善至干预后的62.0分钟（p = 0.012）。相应地，DTN≤60分钟的患者比例从干预前的31.7%增加到干预后的47.0%，优势比为1.91（95%CI 1.17 - 3.11，p = 0.009）。干预前后疑似卒中患者的比例、出血性转化和30天死亡率均无显著差异。 结论 由EMP主导的系统性质量改进干预措施的实施与DTN时间的改善相关，同时不影响出血转化率和30天死亡率等临床质量指标。EMP拥有广泛的知识基础且熟悉情况，与各个专业进行互动并协调护理，在推动变革方面特别适合担任这一角色。公共卫生部门还需要开展更多工作，以改善民众对急性卒中症状的反应。
