[TCT2007]美国心脏病学院动员医生行动起来减少就诊-介入时间

发布于:2007-10-26 09:52

Nationwide Initiatives Reducing Door-to-Balloon Times

　　减少就诊-介入时间受到各家医疗系统及全国性研究极大关注，并显示出了很好的效果，Mayo临床医院将就诊-介入时间从14分钟减至4分钟。

　　在Saint Marys医院，在过去的3年中，就诊-介入时间已从90分钟降为60分钟。“80%的患者其就诊-介入时间不超过90分钟，”该医院的内科副教授Henry H.Ting医生说。他及其同事评估了自2004年5月至2007年6月间402位患者的就诊-介入时间(图1)。

　　该院在正常工作时间的中位数就诊-介入时间为64分钟，非工作时间为74分钟，Ting说。他发现非工作时间时额外的时间通常耽误在导管室启动到患者到达导管室之前这段时间：正常工作时间其中位数时间为14分钟，而非工作时间时则为24分钟。

　　Mayo临床中心实施了“100-day”方案，该方案扩展了Mayo其它5家医院的最新程序并显著降低了就诊-介入时间。Ting说，Door-to-ECG时间已从平均14分钟降至4分钟。

　　该方案通过改变就诊-介入时间过程成功降低了就诊-介入时间，当患者因胸痛而入院时，由急诊科医师做心电图并进行评估，继之通知导管室并进行最终处理。该院省略了旧方案中通知导管室前由CCU医师进行评估及听取CCU医师报告这两个步骤。

　　D2B联盟及其使命—生命线

　　Yale 大学内科和流行病学教授Harlan Krumholz医生说，能够应用美国心脏学院发动的“D2B联盟”方案，多家医院已报道成功减少了就诊-介入时间，MUSC医科大学就是其中之一(图2)。

　　Krumholz是D2B联盟的循证研究评估小组成员之一。他报告说目前有900多家医院加入了D2B联盟；该联盟有包括美国心脏学会（AHA）在内的38个战略伙伴。

　　AHA在今年年初开展了他自己命名为“使命—生命线”的全国性运动。AHA前副主席Alice Jacobs博士于周日在TCT2007上报告了有关“使命—生命线”的执行情况及所取得的初步成功。

　　Jacobs引用了“1994-2004年间就诊-介入时间用时研究数据”资料。在此期间，就诊-介入时间为90分钟及以下的非转诊患者的数量从33.1%升至41%。而同样用时的接转患者的数量从3.9%升高到5.4%。

　　Jacobs认为，对于某些患者实现理想的就诊-介入时间存在一些限制。“50%以上的患者没有使用EMS，”她说，“而且，多数EMS系统不做12导心电图。其他限制还包括医院地区分布，农村地区转运明显延长，经济因素在患者接转方面的不利影响以及目前普遍较慢的接转时间”

　　AHA目前正在研究现行的STEMI治疗模式。

　　减少在导管室的时间延误

　　减少cath lab-to-balloon时间可改善操作及患者治疗结果，Jeptha P. Curtis博士说。减少延迟时间的可行策略是需要有高效的团队和及时的反馈。

　　Yale大学的讲师Curtis报告了对采用28种方案对365家医院进行网络调查所得的数据，其中数家医院与导室室内操作程序有关。

　　减少延迟的另一个战略在于导管室的准备时间，这包括非工作日保持手术台的24小时无菌状态，急诊室和CCU医生交叉培训。

　　网络调查显示，88%的受访者说导管室常规24小时备用(就诊-介入时间，105分钟)上，7%的受访者称未能做到这一点(就诊-介入时间，103分钟)，5%的受访者称导管室无相应制度(就诊-介入时间109分钟，整体P=0.49)。

　　大多数受访者(95%)称他们的团队未有这种急诊室与CCU交叉培训。进行了交叉培训的团队其就诊-介入时间较低(98分钟 vs 105分钟; P=0.22)。

Curtis提议：另一个改进方案是导管室工作人员接到呼叫后30分钟内到达—如果可能的话20分钟内到达。调查显示，56%的受访者称他们的队员通常在21-30分钟内有回应(就诊-介入时间，102分钟)。13%的受访者称其队员在传呼后20分钟内回应，引组就诊-介入时间最少，为97分钟(整体P < .05)。当急性MI患者到来前清洁导管室亦可减少时间延误。几乎所有快速回应的door-to- balloon时间也是最低的(104 min) ，但与未能快速回应(107 min)相比并没有差别。

　　(阜外心血管病医院宋会军高立建编译)

来源：医心网

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2007-10-26 12:36:02 by: marry88611

Nationwide Initiatives Reducing Door-to-Balloon Times   Mayo Clinic hospitals reduced door-to-ECG time from 14 minutes to 4 minutes.   Individual hospital systems as well as nationwide programs focused on reducing door-to-balloon times are showing great promise.   At Saint Marys Hospital, a Mayo Clinic hospital in Rochester, Minn., door-to-balloon times have decreased from 90 minutes to 66 minutes in the past 3 years.   “Eighty percent of our patients have a door-to-balloon of 90 minutes or less,” said Henry H. Ting, MD, an associate professor of medicine at the Mayo Clinic. He and his colleagues evaluated door-to-balloon times for 402 patients between May 2004 and June 2007 (Figure 1). <A href="http://www.ccheart.com.cn/supersite/batch.download.php?aid=158" target=_blank><IMG src="http://www.ccheart.com.cn/supersite/attachments/2007/10/5_200710261001021.jpg" border=0></A>   The door-to-balloon time at Saint Marys Hospital for regular hours is now a median of 64 minutes, and for off-hours, 74 minutes, Ting said. He found that the extra time during offhours occurs mostly between catheterization lab activation and catheterization lab arrival: a median of 14 minutes during regular hours vs. a median of 24 minutes during off-hours.   The Mayo Clinic has also implemented a “100-day” project to expand the new processes to the five other Mayo hospitals and has already seen dramatic decreases, Ting said. Doorto-ECG times have decreased from a median 14 minutes to 4 minutes.   This was accomplished by changing the door-to-balloon process so that when patients arrive at the hospital with chest pain, they undergo an ECG and an evaluation by the emergency department staff followed by catheterization lab activation and by final treatment. Saint Marys removed the two previous steps of evaluation by a cardiac-care unit (CCU) fellow and debrief to the CCU department,which had happened before cath lab activation under the old plan.   D2B Alliance and“Mission: Lifeline”   Harlan Krumholz, MD, professor of internal medicine and epidemiology at Yale University in New Haven, Conn., said that other hospitals also have reported successful door-to-balloon reduction times under the D2B Alliance, launched by the American College of Cardiology. MUSC Medical University of South Carolina is one such example (Figure 2). <A href="http://www.ccheart.com.cn/supersite/batch.download.php?aid=178" target=_blank></A> <SPAN lang=EN-US style="FONT-SIZE: 10.5pt; FONT-FAMILY: ’Times New Roman’; mso-bidi-font-size: 12.0pt; mso-font-kerning: 1.0pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-CN; mso-bidi-language: AR-SA; mso-fareast-font-family: 宋体"><?xml:namespace prefix = v /><v:shapetype id=_x0000_t75 coordsize="21600,21600" o:spt="75" o:preferrelative="t" path="m@4@5l@4@11@9@11@9@5xe" filled="f" stroked="f"><A href="http://www.ccheart.com.cn/supersite/batch.download.php?aid=200" target=_blank><IMG src="http://www.ccheart.com.cn/supersite/attachments/2007/11/18884_200711011628561.jpg" border=0></A></v:shapetype> Krumholz is a member of the D2B Alliance’s evidence-based review subgroup. He reported that more than 900 hospitals now have joined the D2B Alliance; the Alliance has 38 strategic partners, including the American Heart Association.   The AHA launched its own nationwide initiative called “Mission: Lifeline” earlier this year. Alice Jacobs, MD, professor of medicine at Boston University Medical Center and past president of the AHA, presented information regarding the implementation and initial success of “Mission: Lifeline” on Sunday at TCT 2007.   Jacobs cited data from a study examining door-to-balloon time between 1994 and 2004. During this period, the number of nontransfer patients for whom door-to-balloon treatment time was 90 minutes or less increased from 33.1% to 41%. The number of transfer patients for whom door-to-balloon treatment time was 90 minutes or less increased from 3.9% to 5.4%.   Jacobs acknowledged that several limitations exist that may inhibit optimal door-to-balloon time for some patients. “More than 50% of patients do not use EMS,” she said. “Furthermore, the majority of EMS systems do not do 12-lead ECG. Other limitations include the geographic distribution of hospitals, the typically prolonged transfer in rural settings, financial disincentives for patient transfer, and the current common slow transfer times.”   The AHA is now evaluating existing models for STEMI treatment.   Reduce cath lab delays   Reducing cath lab-to-balloon times can improve performance and patient outcomes, according to Jeptha P. Curtis, MD. Potential improvement strategies to reduce delays require setting high expectations, engaging personnel, fostering innovation, and providing feedback.   Curtis, instructor of medicine, section of cardiovascular medicine, Yale University, presented data from a Web-based survey of 365 hospitals using 28 candidate strategies, several of which involved in-lab processes. Another strategy to reduce delays is cath lab preparation, which includes a sterile table ready for off-hours, and a cross-trained ED and CCU, according to Curtis.   In the Web survey, 88% of responders said the lab was generally prepared in off-hours (door-to-balloon time, 105 min), 7% said it was not (door-toballoon, 103 min), and 5% said there is no policy in place (door-to-balloon, 109 min; P = .49 for all).   Most responders (95%) said their staff is not cross-trained. Door-toballoon times were lower among responders with a cross-trained staff (98 min vs. 105 min; P = .22).   Another improvement strategy involves a cath lab staff that arrives within 30 minutes of being paged – 20 minutes if possible, Curtis recommended. In the survey, 56% of responders said their staff generally responds within 21 to 30 minutes (door-to-balloon, 102 min). Thirteen percent reported a staff that responds in under 20 minutes of the page, and this group had the lowest door-to-balloon time of 97 minutes (P < .05 for all). Delays can also be ameliorated by clearing the lab when a patient with acute MI arrives, Curtis said. Nearly all responders (96%) routinely prioritize patients in this situation, and door-to- balloon times were lowest among these responders (104 min) but not different than responders who do not bump patients (107 min). [ 本帖最后由 doctor2 于 2008-3-14 10:05 编辑 ]

2007-10-26 12:36:02 by: marry88611