An audit of clinical nurse practitioner led thrombolysis to improve the treatment of acute myocardial infarction

BACKGROUND: The aim of the study was to audit the impact of cardiac nurse practitioner led thrombolysis as a method of reducing call to needle times for acute myocardial infarction (AMI) in a single district hospital. METHODS: This was a prospectively planned, observational study, comparing time delay between arrival at hospital and the administration of thrombolysis ('door to needle' time) in patients presenting with AMI in a district general hospital serving a population of 270000. The 6 months before and 6 months after initiation of the scheme were compared. RESULTS: There were 151 consecutive patients (undergoing 163 thrombolysis episodes). The median door to needle time fell from 60 min (range 42-110 min) to 30 min (range 20-61 min) (p<0.01). In those patients eligible for immediate thrombolysis the number of cases treated within 30 min of arrival rose from 10/58 (17 per cent) to 48/64 (75 per cent) (p<0.01). The proportion of cases where there was an initial delay as a result of non-diagnostic ECG or possible contra-indication to therapy remained constant, 20/78 (25 per cent) cases before and 21/85 (25 per cent) cases after initiation of the scheme. The number of cases of inappropriate thrombolysis fell from 73 per cent to 30 per cent. CONCLUSION: The provision of i.v. thrombolysis by cardiac nurse practitioners is safe and should be considered as a method for achieving acceptable door to needle times in the management of acute myocardial infarction.     

并联无缝链接救护模式在急性缺血性卒中的应用

目的 探讨"并联无缝链接"救护模式在优化急性缺血性卒中患者静脉溶栓流程中的应用效果.方法 回顾性连续纳入2012年5月至2013年9月符合本研究纳入排除标准的急性缺血性卒中患者91例为对照组接受串联救护模式,实验组回顾性连续纳入2014年2月至2016年7月经"并联无缝链接"救护模式收治的符合纳入排除标准的急性缺血性卒中患者274例.两组均于发病4.5小时就诊且接受rt-PA(重组组织型纤溶酶原激活剂)静脉溶栓治疗,比较两组患者从发病到静脉溶栓用药院内救治流程各环节所耗时间的变化.结果 就诊至影像学检查时间、影像学检查到静脉溶栓时间、就诊至静脉溶栓时间,实验组较对照组明显缩短[(19.8±11)min比(60±18.6)min、(24.3±10.3)min比(68.0±28.5)min、(44.3±15.6)min比(114±26.5)min],组间差异均具有统计学意义(P<0.05).结论 "并联无缝链接"救护模式能够有效缩短DNT(door-to-needle),提高急性缺血性卒中患者rt-PA使用率.急性缺血性卒中院内静脉溶栓流程与国外先进模式相比,仍有较大改进空间;可借鉴德国柏林卒中救治成熟经验发展卒中移动单元,缩短DNT,提高静脉溶栓治疗效率.     

基于信息管理系统的急性心梗医疗质量改进分析

目的开发JCI-CCPC团队照护与患者信息管理系统,探讨导入CCPC-AMI前后STEMI医疗质量的改进效果。方法运用回顾性对比分析法,选择导入后2017年1月-6月77例患者和导入前2015年1月-6月51例患者为实验组和对照组。以患者到达急诊科至首次心电图接诊时间、到达急诊科至确诊STEMI时间、到达急诊科至采血时间、门球时间、住院天数、均次费用、是否院内AMI复发、是否院内再次PCI和转归等为评价指标。结果与对照组比较,实验组在患者到达急诊科至首次心电图接诊时间、至采血时间、门球时间、住院天数、门球时间90分钟达标率、院内AMI复发率、院内再次PCI率和患者转归等方面均有统计学差异,均次费用、至确诊急性心肌梗死时间无统计学差异。结论基于信息管理系统的CCPC-AMI可显著缩短STEMI门球时间,住院时间、院内AMI复发率、院内再次PCI率和患者病死率均显著下降,但均次费用改善效果不显著。     

院前急救联合绿色通道在急性缺血性脑卒中的应用效果

目的探讨院前急救与急诊绿色通道对急性缺血性脑卒中(AIS)患者临床救治的应用效果。 方法对南京鼓楼医院急诊科2015年10月至2018年2月实施卒中院前急救、绿色通道制度化前后确诊为AIS的583例患者进行回顾性研究,其中男性319例,女性264例;年龄28～92岁,平均年龄(69.40±13.35)岁。分为制度实施前的对照组(n＝246)和制度实施后的联合治疗组(n＝337)。记录患者诊治过程时间点,比较两组静脉溶栓、血管内介入治疗或桥接治疗例数、急诊就诊到溶栓的时间(DNT)、出/入院美国国立卫生研究院卒中量表(national institute of health stroke scale,NIHSS )评分、住院天数和预后,对治疗效果进行评估。 结果实施卒中院前急救、绿色通道后,静脉溶栓例数、DTN<60 min达标率增加,差异有统计学意义(P<0.05)。较之对照组,联合治疗组患者从急诊入院到溶栓的各个时间段耗时减少,无显著后遗症患者例数增多,且差异有统计学意义(P<0.05)。但在血管介入或桥接治疗例数、死亡患者例数和住院天数方面,两组间比较无统计学意义(P>0.05)。 结论卒中院前急救、绿色通道的应用,有助于优化AIS诊疗流程,缩短DNT,有利于改善患者预后。     

心内科抗凝老年患者静脉留置针穿刺部位及留置长度探讨

目的探讨心内科抗凝老年患者静脉留置针不同穿刺部位及留置长度的临床效果。方法 196例心内科抗凝老年患者分为对照组(A1组、 A2组)和观察组(B1组、 B2组),选择不同穿刺部位及留置长度进行静脉留置针穿刺,观察各组的留置时间、不良事件发生情况。结果 B2组的留置针平均留置时间显著长于A2组,不良事件发生率显著低于A2组(P <0.05)。结论对于心内科抗凝老年患者,前臂中1/3段穿刺并保留导管2 mm在体外,能延长留置时间,降低不良事件发生率。     

医疗团队资源管理模式在急性缺血性脑卒中急救中的应用效果

目的 探讨医疗团队资源管理模式在急性缺血性脑卒中急救绿色通道中的应用效果。方法 选取2018年1月—2019年1月80例急性缺血性脑卒中患者,按随机数字表法分为观察组和对照组,各40例。对照组患者采用传统救护模式,观察组患者采用医疗团队资源管理模式进行救治,比较两组患者从进入医院到静脉溶栓开始给药时间(DNT)及健康调查简表(SF-36)评分。结果 救护后,观察组患者就诊-CT检查时间、CT检查-用药时间及DNT时间分别为(17.98±3.26)min、(69.29±4.37)min及(92.98±9.16)min,低于对照组的(24.43±5.62)min、(80.36±6.45)min及(111.25±10.55)min,(P值均<0.01);救护后,观察组患者SF-36内各维度评分均高于对照组(P值均<0.01)。结论 在急救绿色通道中采用医疗团队资源管理模式对急性缺血性脑卒中患者进行救护,可有效缩短患者DNT时间,改善患者生活质量。     

Presentation, delay, and contraindication to thrombolytic treatment in females and males with myocardial infarction

BACKGROUND: This study seeks to explore gender-relevant factors of medical history, sociodemographics, symptom presentation, and delay on thrombolysis administration (or recorded contraindication) in a sample of men and women with confirmed myocardial infarction (MI). METHODS: Cross-sectional examination of self and nurse-report data collected in the coronary care unit (CCU) from 12 hospitals across south-central Ontario, Canada. A total of 482 MI patients (347 males, 135 females; 63% response rate) were recruited. MAIN FINDINGS: There was no gender difference in the report of chest pain (chi(2)(1) = 3.78, p =.052), or in prehospital delay time (median = 96.5 minutes). Thrombolysis was administered in 158 males (68.4%) and 50 females (50.0%) without reported contraindication. Females (median = 27 minutes) had a significantly longer interval between diagnostic electrocardiogram (ECG) and administration of a thrombolytic than males (median = 22, U = 3,056). No contraindication was indicated for not administering a thrombolytic (i.e., too late, risk of bleed) in approximately 40% of females. In accordance with clinical practice guidelines, thrombolysis was more often administered in participants with a shorter time interval between symptom onset and hospital arrival. For females, thrombolysis was more often administered in younger participants (Kruskal Wallis = 5.88). CONCLUSIONS: Reducing gender, age, and socioeconomic disparities in access to thrombolysis treatment is imperative. Hospital delays with female cardiac patients may be precluding thrombolysis administration.     

LE SULFATE DE MAGNESIUM : MOLECULE ADJUVANTE DANS LA PREMIERE HEURE DE PRISE EN CHARGE DE LA FIBRILLATION ATRIALE RAPIDE AUX URGENCES.

Introduction:

Rapid Atrial fibrillation (AF) is a common arrhythmia in emergency department (ED) that requires an urgent control of ventricular rate.

Aim:

To evaluate the safety and efficiency of magnesium sulfate as an adjunctive therapy in addition to usual care for rapid AF in emergency department.   

Methods:

This was a prospective, randomized, double-blind study. We included patients who presented to ED with rapid AF >110 batt/min. Group A received 3g of magnesium in 100mL of glucose solution and group B received 100 ml of glucose solution. Primary endpoint was slowing the ventricular rates to less than 110 beats/ min in the first 12 hours of management.   

Results:

One hundred and three patients were included. Fifty-three patients in group A with a mean heart rate of 146 ± 18 beats / min and fifty patients in group B with a mean heart rate of 143 ± 17 beats / min. A significantly greater number of patients slowed down their ventricular rate in group A during the first hour of management (p = 0.02). After 12 hours, mean heart rate was significantly lower in group A (p = 0.04).

Conclusion:

The use of 3 g of magnesium sulfate slowed down the ventricular rate of a larger number of patients with rapid AF in the first hour of management. Only minor adverse effects were registered.     

Coronary thrombolysis: still too little too late?

We reviewed the case records of 109 consecutive patients with a definite diagnosis of myocardial infarction, admitted through the accident and emergency department of an inner-city general hospital to identify delays in referral to hospital, admission to the coronary care unit, and start of thrombolysis. Of the 109 patients, only 28 (26%) received streptokinase (the only thrombolytic drug used at this hospital), and at least 47 (58%) of the remaining 81 who should have benefited from it did not. However, the proportion of patients given streptokinase improved significantly after publication of the Second International Study of Infarct Survival (ISIS 2) study results. The average delay from onset of symptoms to presentation at the accident department was over 3 hours, with a further 1 hour in-hospital delay before administration of streptokinase. This study revealed considerable underuse of thrombolytic therapy in cases where treatment was clearly indicated, but this picture improved substantially during the period of audit.     

急诊创新绿色通道对急性缺血性脑卒中静脉溶栓治疗患者的抢救效果分析

目的 旨在探讨急性缺血性脑卒中静脉溶栓治疗中的急诊创新绿色通道对患者抢救效果的影响。方法 选取了2020年1月—2021年12月,本院收治的100例急性缺血性脑卒中静脉溶栓治疗患者作为研究对象。按照随机数字表法,随机将患者分为对照组(n=50)和观察组(n=50),观察组进行急诊创新绿色通道干预,对照组进行常规急诊通道干预,对比2组抢救效果、不同诊疗时间指标、2组神经损伤严重程度等。结果 观察组抢救室平均停留时间、完善CT时间、到达科室时间和急诊绿色通道救治时间比对照组短(2组差值分别为18.76±0.87、2.92±0.63、3.82±0.15、23.00±1.42),差异有统计学意义(t=8.941,2.665,4.248,8.545,P<0.001,=0.009,<0.001,<0.001);干预后2组中枢神经损伤严重程度评分观察组低于对照组(2组差值分别为6 h时为2.49±0.08、1 d时为3.22±0.35、1周时为2.36±0.04),差异有统计学意义(F_组间=6.132,F_时间=4.983,F_交互...     

急诊科心肌梗塞临床救治分析

目的:观察分析急诊科心肌梗塞的临床救治方法及救治效果,总结其临床意义。方法:选取某医院72例心肌梗塞患者,遵照患者和(或)家属意见,分为静脉溶栓组与未溶栓组,各36例,静脉溶栓组采取急诊科静脉溶栓治疗,未溶栓组未给予静脉溶栓治疗,观察比较两组效果,进行统计学分析。结果:两组患者治疗后的血管再通率、心功能改善率及病死率比较存在明显差异(P<0.05),具有统计学意义。静脉溶栓组死亡原因为心室颤动1例,心源性休克1例;未溶栓组死亡原因为心室颤动4例,心源性休克2例,心脏破裂1例。结论:急诊科对心肌梗塞患者收治后应及早诊断,并尽快采取急诊溶栓治疗,减少并发症发生,改善心功能,以争取时间抢救患者生命,对全面提高治愈率,减少病死率具有重要的临床意义。     

CT灌注成像快速评估脑组织缺血半暗带指导拓宽脑卒中治疗时间窗的可行性研究

目的:探讨CT灌注成像(CTPI)快速评估脑组织缺血半暗带指导拓宽脑卒中治疗时间窗的有效性。方法:选取医院收治的30例经CTPI检查提示存在缺血半暗带的脑卒中患者,将其纳入观察组,选取同期常规时间指导下进行溶栓的50例脑卒中患者纳入对照组,所有患者均经CT、CT冠状动脉血管造影(CTCA)联合CT灌注扫描(CTP)检查确诊,行静脉溶栓治疗。对比两组发病至溶栓时间、治疗前后的灌注参数、神经功能缺损评分(NIHSS)及改良Rankin(mRS)评分变化,以及预后良好率和出血转化率等。结果:两组患者发病至溶栓时间比较,差异有统计学意义(χ²=8.287,P<0.05);观察组发病至溶栓时间6~9 h者占比达13.33%,显著高于对照组,差异有统计学意义(χ²=7.018,P<0.05)。两组溶栓后24 h、1周、2周及4周与溶栓前相比,NIHSS评分均呈下降趋势,且观察组溶栓后24 h、1周、2周及4周的NIHSS评分均显著低于对照组,差异有统计学意义(t=5.856,t=8.741,t=9.314,t=13.004;P<0.05);观察组溶栓后1个月、3个月的预后良好率均显著高于对照组,溶栓后24 h的颅内出血转化率显著低于对照组,差异有统计学意义(χ²=5.635,χ²=7.373,χ²=4.392;P<0.05)。结论:通过CTPI检查可快速评估脑卒中患者脑组织是否存在缺血半暗带,发病时间>6 h并存在缺血半暗带的患者通过静脉溶栓治疗仍可获益,CTPI可有效拓宽静脉溶栓治疗的时间窗,提高溶栓治疗效果。     

尿激酶溶栓治疗ST段抬高型心肌梗死的时间窗与疗效的相关性研究

目的：研究尿激酶溶栓治疗ST段抬高型心肌梗死的时间窗与疗效的相关性。方法：将医院急诊收治的60例ST段抬高心肌梗死患者根据接受溶栓治疗的时间分为观察组（3 h内接受溶栓）和对照组（3-6 h接受溶栓）,检测心肌细胞坏死指标及心室舒缩功能指标,并分析与溶栓时间的相关性。结果：观察组患者的cTnT、LDH及CK-MB水平均低于对照组,与溶栓时间呈正相关,E峰、E/A值、LVEF及LVEDD均高于对照组,且与溶栓时间呈负相关。结论：心肌梗死发生后溶栓治疗时间越短,治疗后心肌细胞坏死越少、心室功能恢复越好,临床价值也越明显。     

Delay in presentation after myocardial infarction.

Thrombolytic therapy reduces mortality in acute myocardial infarction (AMI), giving maximal benefit with early treatment. In the UK delayed presentation after AMI may reduce the advantages of thrombolysis. To assess this, 103 patients presenting with AMI to two London Hospitals were interviewed to determine the length and cause of delay from onset of chest pain to arrival at hospital. Forty-nine per cent of patients took longer than 2 h to arrive at hospital, and 21% took longer than 4 h. Patients who contacted their general practitioner (GP) had a significantly prolonged time delay (160 mins; 65-730: median; range) compared to those who went directly to hospital by ambulance (82 mins; 15-395; P < 0.0005), or on their own (90 min; 15-855; P < 0.005). Patients calling their GP took a similar duration to decide to seek help [decision time (30 min versus 25 mins) P = NS], but significantly longer to reach hospital once the decision was made (110 min versus 56 min; P < 0.0001), than those proceeding directly to hospital. Believing the pain was cardiac in origin significantly shortened decision time (15 min versus 45 min; P < 0.05), as did knowledge of the existence of thrombolysis (15 min versus 50 min; P < 0.05) and lack of prior cardiac symptoms (18 min versus 42 min; P < 0.05). Only 14% were aware of thrombolysis. Rank correlation confirmed that decision and total delay time were age independent. Delays of this magnitude may compromise the efficiency of thrombolysis.(ABSTRACT TRUNCATED AT 250 WORDS)     

主动脉内球囊反搏对冠心病患者手术治疗效果的影响

目的:分析主动脉内球囊反搏(IABP)对冠状动脉粥样硬化性心脏病(简称,冠心病)患者手术治疗效果的影响。方法:回顾性分析于2016年4月~2020年4月在本院接受介入治疗的60例冠心病患者的临床资料,根据患者的IABP置入时机分别归纳为术前预防组(30例)、术中术后紧急置入组(30例),对比分析两组患者的IABP置入时间、机械通气时间、住CCU时间、住院费用、住院病死率。结果:术前预防组患者的IABP置入时间、机械通气时间、住CCU时间均短于术中术后紧急置入组,且住院费用与住院病死率均低于对照组,组间差异统计学意义成立(P<0.05)。结论:冠心病患者接受介入治疗前预防置入IABP,可提高治疗安全性,减少患者的住CCU时间以及治疗费用。     

Coronary care follow-up study: acute care required immediately following thrombolytic therapy.

We carried out a prospective survey of the outcome of patients with 'suspected myocardial infarction', in order to determine where they should be nursed. The delay between onset, admission, transfer to the CCU, the sequelae and side-effects of thrombolytic therapy were noted and were documented prospectively. Of 217 admissions to CCU with a history of chest pain and suspected acute myocardial infarction during a four-month period (mean age was 62.8 years range 31 to 86 years) 202 fulfilled the criteria for suspected myocardial infarction. Streptokinase was given in 129 and alteplase in one patient. The delay between onset of pain and admission was < 4 h in 73, 4 to 12 h in 30 and > 12 h in 23. Elderly patients were just as likely as younger ones to receive thrombolytic therapy (Chi 2 = 3.6; P = 0.6). An eventual diagnosis of acute myocardial infarction was made in 133 of whom 100 received streptokinase. Dysrhythmia or shock was encountered in one-third of those given streptokinase and a quarter of the remainder. Reactions to streptokinase were recorded in 32 mainly hypotension or bradycardia alone or in combination. Forty-five per cent experienced either cardiac complications or drug reactions or both. During one month there were 57 admissions, 50 of whom arrived by ambulance. The mean delay between call out and arrival in the A&E department was 55 min. We concluded patients who are given thrombolytic therapy need close supervision and they should be nursed in a CCU or its equivalent.     

在肝硬化诊断中采用彩色多普勒超声的临床意义研究

目的：探讨彩色多普勒超声在肝硬化诊断中的应用价值。方法：选择2019年3月～2021年4月院内肝硬化治疗患者34例作为考察组,另选取同时间段体检健康者34例作为对比组,对于两组门静脉管径、门静脉血流速度、门静脉血流量进行测量,将考察组患者按照肝功能分级,对比不同级别肝功能患者上述指标差异性。结果：考察组患者门静脉管径、门静脉血流速度、门静脉血流量与对比组患者相比较,数据差异性有统计学意义（P<0.05）,考察组A级、B级、C级患者门静脉管径、门静脉血流速度、门静脉血流量差异较大（P<0.05）。结论：彩色多普勒超声可实现肝硬化准确诊断,临床应用价值显著。     

标准通道辅助微通道经皮肾镜取石术在肾铸型结石治疗中的效果与安全性

目的 评价标准通道辅助微通道经皮肾镜取石术治疗肾铸型结石效果和安全性.方法 78例经皮肾镜取石术患者,分为标准通道辅助微通道组(n=42)和双微通道组(n=36),对比分析两组碎石时间及结石清除率、手术时间、手术并发症.结果 患者均Ⅰ期成功建立经皮肾通道,标准通道辅助微通道组手术时间为(71.69±13.83) min,明显短于双微通道组(95.20±14.51)min;结石清除率为90.5％,高于双微通道组69.4％,差异均有统计学意义(P＜0.05);而两组术中出血量、术后住院时间比较,差异无统计学意义;标准通道辅助微通道组术后迟发持续性出血1例,术后发热4例;双微通道组术后迟发持续性出血1例,术后发热6例,患者经保守治疗后痊愈.结论 与双微通道比较,标准通道辅助微通道缩短了手术时间,提高了结石清除率,治疗肾铸型结石安全有效.     

急性心肌梗死患者溶栓治疗后心电图早期T波倒置、BNP变化对左室重构的意义

目的观察急性心肌梗死患者接受静脉溶栓治疗后心电图T波倒置、血浆中BNP的水平变化与左室重构之间的关系,探讨T波倒置、BNP对左室重构的预测价值。方法首次急性心肌梗死患者共54例,溶栓治疗后持续24h监测心电图,A组(溶栓治疗后24小时出现T波倒置,n=38)与B组(溶栓治疗后24小时T波仍直立,n=16)于治疗前及治疗后第7天,采用电化学发光法对血浆BNP水平进行检测,并随访复查急性心肌梗死后2~3天及第3个月超声心动图。结果溶栓治疗后BNP水平,A组明显小于B组;A组内治疗前后BNP比较,治疗后明显减小;B组治疗后BNP水平明显增加。A组患者溶栓治疗后2~3天及3个月时LVEDD比较,差异无显著性;B组患者溶栓治疗后3个月时LVEDD明显增大,B组左室重构发生率明显高于A组。结论急性心肌梗死患者溶栓治疗后心电图早期T波倒置和BNP水平降低对于预测左室重构有重要意义。     

900例腹部横切口皮内“抽芯”缝合术临床探讨

目的:探讨妇产科腹部横切口皮内不同缝合方法对皮肤愈合的影响。方法:用皮内"抽芯"式缝皮法对900例(研究组)腹式横切口皮肤进行缝合,均利用小型三角针和1号丝线,与普通的间断外缝合(对照组b),可吸收或华丽康内缝合(对照组a)进行比较。结果:皮内"抽芯"缝皮法在1～2min内完成,术后疼痛轻,855例未要求应用镇痛剂,占95.00%,全部甲级愈合,无皮下硬结,术后2个月、6个月随访900例,切口愈合疤痕纤细,与皮肤皱褶一致,无缝线的异物反应及排斥问题。研究组平均手术时间、皮下出血量、术后留置导尿时间明显少于对照组b,差别有统计学意义(P0.05);而术后平均住院天数比较差别无统计学意义(P0.05)。结论:皮内"抽芯"式缝皮法简单、省时,术后疼痛轻,缩短住院时间,费用低,切口愈合好,无缝线的异物反应及排斥问题。