运用品管圈和丰田生产方式缩短急性脑梗死静脉溶栓门-针时间
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摘要
目的探讨运用品管圈(QCC)和丰田生产方式(TPS)缩短急性脑梗死患者静脉溶栓门-针时间(DNT)的效果。方法收集2012年7月～2015年6月重组组织型纤溶酶原激活剂(rt-PA)静脉溶栓的急性脑梗死患者138例为对照组,2015年7月～2018年6月启用QCC和TPS改善溶栓流程后rt-PA静脉溶栓的急性脑梗死患者370例为试验组,比较两组患者DNT时间及DNT≤60 min比例。并将所有纳入患者按DNT≤60 min与DNT>60 min分为院内非延误组和延误组进行分析,比较两组患者溶栓前和溶栓后24 h、14 d的NIHSS评分及溶栓后90 d的mRS评分的差异。结果使用QCC及TPS的方法有效优化了溶栓流程,使急性脑梗死静脉溶栓患者DNT由81 min缩短为59 min(P=0.002),DNT≤60 min的比例从20.3%提高至62.7%(P<0.001),预后良好(90 d的mRS评分0～2分)比例从23.2%提高至71.1%(P<0.001);与延误组相比,非延误组患者溶栓后24 h、14 d的NIHSS评分显著降低(P<0.05),预后良好比例显著提高(P<0.05),即非延误组预后较好。结论使用QCC及TPS的方法可有效缩短门-针时间,使患者能尽早实施静脉溶栓治疗,从而有效减轻神经功能损伤,改善患者预后,具有较高的临床应用价值。
Objective To investigate the effect of quality control circle(QCC) and Toyota production system(TPS) on shortening the door-to-needle time(DNT) of intravenous thrombolysis in patients with acute cerebral infarction. Methods A total of 138 patients with acute cerebral infarction who underwent intravenous thrombolysis with recombinant tissue plasminogen activator(rt-PA) from July 2012 to June 2015 were enrolled as controls. And 370 patients with acute cerebral infarction with rt-PA intravenous thrombolysis after using QCC and TPS to improve the thrombolytic process from July 2015 to June 2018 were included in the experimental group. The DNT time and DNT ≤60 min ratio were compared between the two groups. All included patients were divided into in-hospital non-delayed group and delayed group according to DNT≤60 min and DNT>60 min. The NIHSS score before thrombolysis and at 24 h and 14 d after thrombolysis, and the difference in m RS scores at 90 d after thrombolysis between the two groups were compared. Results The use of QCC and TPS effectively optimized the thrombolytic process. The DNT of patients with acute cerebral infarction was shortened from 81 min to 59 min(P=0.002), and the proportion of DNT≤60 min increased from 20.3% to62.7%(P< 0.001), and the proportion of good prognosis(0-2 points for 90 d mRS score) increased from 23.2% to 71.1%(P<0.001). Compared with that in the delayed group, the NIHSS score of the non-delayed group was significantly lower at 24 h and 14 d after thrombolysis(P<0.05), and the prognosis ratio in the non-delayed group was significantly improved(P<0.05), that was, the prognosis of the non-delayed group was better. Conclusion The use of QCC and TPS can effectively shorten the door-needle time, so that patients can implement intravenous thrombolytic therapy as soon as possible, thus effectively reducing nerve function damage and improving patient prognosis. It has high clinical application value.
Objective To investigate the effect of quality control circle(QCC) and Toyota production system(TPS) on shortening the door-to-needle time(DNT) of intravenous thrombolysis in patients with acute cerebral infarction. Methods A total of 138 patients with acute cerebral infarction who underwent intravenous thrombolysis with recombinant tissue plasminogen activator(rt-PA) from July 2012 to June 2015 were enrolled as controls. And 370 patients with acute cerebral infarction with rt-PA intravenous thrombolysis after using QCC and TPS to improve the thrombolytic process from July 2015 to June 2018 were included in the experimental group. The DNT time and DNT ≤60 min ratio were compared between the two groups. All included patients were divided into in-hospital non-delayed group and delayed group according to DNT≤60 min and DNT>60 min. The NIHSS score before thrombolysis and at 24 h and 14 d after thrombolysis, and the difference in m RS scores at 90 d after thrombolysis between the two groups were compared. Results The use of QCC and TPS effectively optimized the thrombolytic process. The DNT of patients with acute cerebral infarction was shortened from 81 min to 59 min(P=0.002), and the proportion of DNT≤60 min increased from 20.3% to62.7%(P< 0.001), and the proportion of good prognosis(0-2 points for 90 d mRS score) increased from 23.2% to 71.1%(P<0.001). Compared with that in the delayed group, the NIHSS score of the non-delayed group was significantly lower at 24 h and 14 d after thrombolysis(P<0.05), and the prognosis ratio in the non-delayed group was significantly improved(P<0.05), that was, the prognosis of the non-delayed group was better. Conclusion The use of QCC and TPS can effectively shorten the door-needle time, so that patients can implement intravenous thrombolytic therapy as soon as possible, thus effectively reducing nerve function damage and improving patient prognosis. It has high clinical application value.
引文
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[15]刘庭芳.我国医院品管圈活动综述[J].中国医院,2015,(7):1-3.
[16]Meretoja A,Strbian D,Mustanoja S,et al.Reducing inhospital delay to 20 minutes in stroke thrombolysis[J].Neurology,2012,79(4):306-313.
[17]Ford AL,Williams JA,Spencer M,et al.Reducing doorto-needle times using Toyota’s lean manufacturing principles and value stream analysis[J].Stroke,2012,(12):3395-3398.
[18]Kim JT,Fonarow GC,Smith EE,et al.Treatment with tissue plasminogen activator in the golden hour and the shape of the 4.5-hour time-benefit curve in the National United States get with the guidelines-stroke population[J].Circulation,2017,135(2):128-139.
[19]Fonarow GC,Smith EE,Saver JL,et al.Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke:Patient characteristics,hospital factors,and outcomes associated with door-to-needle times within 60 minutes[J].Circulation,2011,123(7):750-758.
[20]覃珊,张仲,王学义,等.基于PDCA循环的质量改进方案缩短急性缺血性卒中患者就诊到溶栓时间[J].国际脑血管病杂志,2017,(4):331-337.
[21]Kamal N,Sheng S,Xian Y,et al.Delays in door-to-needle times and their impact on treatment time and outcomes in get with the Guidelines-Stroke[J].Stroke,2017,48(4):946-954.
[22]许盈盈,叶励超,蔡乾坤.缩短院内延迟对静脉溶栓治疗急性脑梗死患者MRS、NIHSS评分的影响分析[J].中外医学研究,2017,(36):34-35.
[2]Wang W,Jiang B,Sun H,et al.Prevalence,incidence,and mortality of stroke in China:Results from a Nationwide Population-Based Survey of 480687 Adults[J].Circulation,2017,135(8):759-771.
[3]Ojaghihaghighi S,Vahdati SS,Mikaeilpour A,et al.Comparison of neurological clinical manifestation in patients with hemorrhagic and ischemic stroke[J].World J Emerg Med,2017,8(1):34-38.
[4]Matsubara D,Kataoka K,Matsubara T,et al.Paradoxical brain embolism followed by percutaneous atrial septal closure:Stroke in a patient's thirties highlighting some issues surrounding brain stroke in an emergency setting[J].World J Emerg Med,2017,8(4):308-309.
[5]Wardlaw JM,Murray V,Berge E,et al.Recombinant tissue plasminogen activator for acute ischaemic stroke:An updated systematic review and meta-analysis[J].Lancet,2012,379(9834):2364-2372.
[6]El Khoury R,Jung R,Nanda A,et al.Overview of key factors in improving access to acute stroke care[J].Neurology,2012,79(13 Suppl 1):S26-34.
[7]中华医学会神经病学分会,中华医学会神经病学分会脑血管病学组.中国急性缺血性脑卒中诊治指南2018[J].中华神经科杂志,2018,(9):666-682.
[8]徐冬娟,李鸿飞,卢晓蓉,等.运用品管圈和丰田生产方式提高急性脑梗死患者静脉溶栓品质的研究[J].中华急诊医学杂志,2018,(6):685-688.
[9]Saver JL,Fonarow GC,Smith EE,et al.Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke[J].JAMA,2013,309(23):2480-2488.
[10]Meretoja A,Keshtkaran M,Saver JL,et al.Stroke thrombolysis:Save a minute,save a day[J].Stroke,2014,45(4):1053-1058.
[11]Wang Y,Liao X,Zhao X,et al.Using recombinant tissue plasminogen activator to treat acute ischemic stroke in China:Analysis of the results from the Chinese National Stroke Registry(CNSR)[J].Stroke,2011,42(6):1658-1664.
[12]Powers WJ,Rabinstein AA,Ackerson T,et al.2018 Guidelines for the early management of patients with acute ischemic stroke:A Guideline for healthcare professionals from the American Heart Association/American Stroke Association[J].Stroke,2018,49(3):e46-46e110.
[13]Yang J,Wang X,Yu JP,et al.Positive impact of the participation in the ENCHANTED trial in reducing Door-to-Needle time[J].Sci Rep,2017,7(1):14168.
[14]Huang Q,Zhang JZ,Xu WD,et al.Generalization of the right acute stroke promotive strategies in reducing delays of intravenous thrombolysis for acute ischemic stroke:Ameta-analysis[J].Medicine(Baltimore),2018,97(25):e11205.
[15]刘庭芳.我国医院品管圈活动综述[J].中国医院,2015,(7):1-3.
[16]Meretoja A,Strbian D,Mustanoja S,et al.Reducing inhospital delay to 20 minutes in stroke thrombolysis[J].Neurology,2012,79(4):306-313.
[17]Ford AL,Williams JA,Spencer M,et al.Reducing doorto-needle times using Toyota’s lean manufacturing principles and value stream analysis[J].Stroke,2012,(12):3395-3398.
[18]Kim JT,Fonarow GC,Smith EE,et al.Treatment with tissue plasminogen activator in the golden hour and the shape of the 4.5-hour time-benefit curve in the National United States get with the guidelines-stroke population[J].Circulation,2017,135(2):128-139.
[19]Fonarow GC,Smith EE,Saver JL,et al.Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke:Patient characteristics,hospital factors,and outcomes associated with door-to-needle times within 60 minutes[J].Circulation,2011,123(7):750-758.
[20]覃珊,张仲,王学义,等.基于PDCA循环的质量改进方案缩短急性缺血性卒中患者就诊到溶栓时间[J].国际脑血管病杂志,2017,(4):331-337.
[21]Kamal N,Sheng S,Xian Y,et al.Delays in door-to-needle times and their impact on treatment time and outcomes in get with the Guidelines-Stroke[J].Stroke,2017,48(4):946-954.
[22]许盈盈,叶励超,蔡乾坤.缩短院内延迟对静脉溶栓治疗急性脑梗死患者MRS、NIHSS评分的影响分析[J].中外医学研究,2017,(36):34-35.