提升急性缺血性腦中風病人抵達急診120分鐘內接受動脈內機械取栓術治療達成率

Improving Door-to-Puncture Time in the Emergency Department for Patients with Acute Ischemic Stroke Undergoing Endovascular Thrombectomy

急性缺血性腦中風(Acute Ischemic Stroke)發作8小時內接受機械取栓術(Endovascular Thrombectomy, EVT)治療，可提升病人預後、降低殘疾嚴重程度，分析2018年1月1日至2019年4月30日共計55位個案，其中7位案例合併其他原因、急性疾病故排除，因此由急診檢傷至抵達血管攝影室接受穿刺止之個案數共計48名。參考文獻後，將檢傷至穿刺時間(Door-to-Puncture Time)之目標值設定為120分鐘。48名個案從入急診到接受EVT時間平均值為173分鐘，達成率僅10.4%，平均住院日為36.8天。參考國際文獻及標竿北市醫中後，發現仍有改善空間，即成立跨領域照護團隊，分析延遲原因為人員對檢查流程備物生疏、傳呼不到傳送員、資訊系統不完備、訊息傳遞異常等，團隊共同制定跨單位機械取栓護理交班單、搶救急性中風衛教單、創意研發固定帶、增設計時器及EVT Bundle包、修訂腦中風暨機械取栓標準流程及傳送員管理辦法後，接受EVT病人平均時間由173分鐘降至112.6分鐘、120分鐘內完成EVT比率由10.4%提升至68.8%。由品管圈的執行，不但優化了各單位作業流程、縮短治療時間，更提供病人即時且優質的照護。

 

Multiple studies have indicated that receiving an endovascular thrombectomy (EVT) within 8 hours from the onset of acute ischemic stroke substantially improves the patient’s prognosis and reduces the likelihood of disability. In this study, we analyzed 55 patients with acute ischemic stroke who underwent an EVT between January 1, 2018, and April 30, 2019, at Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. From these patients, 48 were included in the final analysis and 7 were excluded for other reasons, such as having concomitant acute illnesses. According to a literature review, we set our optimum door-to-puncture (D2P) time to within 120 minutes, starting from the arrival at the emergency department to the time of arterial puncture for EVT. The average D2P time for the 48 patients was 173 minutes, and only 10.4% of the patients had a D2P time that was less than 120 minutes (our target), with an average hospital stay of 36.8 days. Room for improvement remained, as indicated by comparisons with data from international studies and from other medical centers in Taipei. Therefore, we formed a multidisciplinary team and identified the causes of the delays, including staff unfamiliarity with the clinical protocol, insufficient manpower for transportation, lack of information technology support, and ineffective communication among different departments. The team then worked together and formulated a nursing staff sign-off checklist for EVT, published educational pamphlets advocating timely interventions for acute stroke for the general public, and invented a head immobilization hood for patients with stroke. A timer was also placed at the triage desk to assist with adherence to the protocol. In addition, an institutional protocol including porter management was established as part of our EVT bundle. After the implementation of such an EVT bundle strategy, 68.8% of our patients had a D2P time of less than 120 minutes (up from 10.4%) and the average D2P time decreased from 173 to 112.6 minutes. In conclusion, by establishing a quality control circle, we not only streamlined the workflow among different departments but also optimized the treatment cycle and provided our patients with the best care possible.