心房颤动ABC综合管理路径影响老年房颤缺血性卒中结局的病例对照研究

目的 研究在老年非瓣膜性心房颤动(房颤)病人中实施房颤综合管理(ABC路径)对缺血性卒中结局的影响。方法 采用病例对照研究,选取129例新发缺血性卒中老年非瓣膜性房颤病人为病例组,匹配同期未发生缺血性卒中的非瓣膜性房颤病人258例为对照组。按照性别一致、年龄±2岁进行1∶2的频数匹配。比较2组病人房颤的管理情况、基础情况、临床指标、共病及药物使用情况。采用多因素条件Logistic回归分析ABC路径对房颤病人缺血性卒中结局的影响。结果 2组房颤管理方式,β受体阻滞剂、他汀药物、非维生素K拮抗剂使用率,血压、LDL-C水平,冠心病及既往卒中占比差异均有统计学意义(P<0.05)。条件Logistic回归分析显示,校正了冠心病、既往卒中/短暂性脑缺血发作、LDL-C后,与未抗凝管理的病人相比,抗凝管理的病人缺血性卒中发生风险降低63%(OR=0.37,95%CI:0.17～0.82),而ABC路径病人的缺血性卒中发生风险降低81%(OR=0.19,95%CI:0.08～0.47)。结论 相比抗凝管理,ABC路径有进一步减少老年非瓣膜性房颤病人缺血性卒中风险的趋势。     

北京地区医院急性脑卒中治疗与预防现况调查

目的调查北京地区医院使用尿激酶(UK)和(或)重组组织型纤溶酶原激活物(rt-PA)静脉溶栓治疗的实施情况,为改进缺血性脑卒中的治疗提供依据。方法本调查为横断面调查研究,采用问卷形式调查北京地区医院脑卒中治疗相关的医疗资源方面的情况。结果北京地区被调查医院的总体结果:98.1%的医院有急诊室,92.6%的医院有24 h头颅CT,50%的医院有UK和(或)rt-PA静脉溶栓规程,7.4%的医院有卒中单元。有UK和(或)rt-PA静脉溶栓规程的医院与无此溶栓规程的医院比较差异有显著性意义的方面为:头颅CT、磁共振成像、磁共振血管造影、磁共振弥散加权成像、磁共振灌注加权成像、数字减影血管造影、神经科医生、神经外科医生、神经介入放射医生、动脉溶栓、颈动脉支架、颅内血管成形术、重症监护病房、神经重症监护病房、卒中单元、卒中治疗程序图或临床路径。结论北京地区医院应对其拥有的卒中相关医疗资源进行组织化,提高医院静脉溶栓能力,推广卒中小组、卒中单元、卒中治疗程序图或临床路径等治疗模式,以改进卒中治疗和改善卒中预后。     

营养管理是卒中急性期医疗的重要基础

近年来，我国对卒中的临床诊治工作，从观念到方法正在逐步走向国际标准化。但是，长期以来以药物治疗为主体、患者被动接受治疗的临床卒中医疗模式和观念，仍然影响着我国临床医师的医疗行为。同时在卒中治疗的整个过程中，往往注重大脑的局部问题，而忽略患者的全身状态，对卒中后患者需要施行营养管理也缺乏足够的认识，更无对卒中营养管理临床实施的具体方法。然而，卒中的发生和转归均受多因素的影响，药物治疗只是其中的一个环节。     

护理管理中临床护理路径的应用效果研究

目的探讨护理管理中临床护理路径的应用效果。方法选取2012年6月—2013年6月我院6个科室收治的患者300例,均应用临床护理路径进行护理管理,评估临床护理路径实施前后患者的满意度、医疗纠纷事件发生情况、患者住院时间及医疗费用。结果临床护理路径实施后患者满意率为96.0%(288/300),高于临床护理路径实施前的86.3%(259/300)(P0.05);临床护理路径实施后医疗纠纷事件发生率和医疗费用均低于临床护理路径实施前,住院时间短于临床护理路径实施前(P0.05)。结论护理管理中临床护理路径的应用提高了护理质量和护理满意度,减少了医疗纠纷事件的发生,保证了患者的生命健康。     

大肠息肉临床路径的实施效果及改进

目的评价大肠息肉临床路径实施效果,探索其改进方法.方法对吉林大学第一医院胃肠内科收治的大肠息肉患者临床资料进行回顾性分析,将实施大肠息肉临床路径患者作为临床路径组,另一组为对照组,对2组患者总住院费、药费、住院日、患者满意度等评价指标进行比较.将PDCA循环理论应用于大肠息肉临床路径管理,观察临床路径后各评价指标的逐年变化趋势.结果大肠息肉临床路径组患者总住院费、药费、住院日等均较对照组下降(P0.01),患者满意度增加(P0.01).实施大肠息肉临床路径后总住院日、术前住院日、总住院费、床位费及特护费、药费呈逐渐下降趋势(P0.01).结论临床路径可有效控制住院费,缩短住院天数,增加患者满意度.将PDCA循环理论应用于临床路径可对其进行持续质量改进.     

社区获得性肺炎临床路径实施效果的评价与分析

目的 了解社区获得性肺炎临床路径的实施情况,分析我院临床路径实施的效果.方法 回顾性分析我院2011年11月～2012年8月收治的253例成人社区获得性肺炎患者的临床资料,了解入径率、路径组与非路径组平均住院日、路径组抗生素使用、CURB-65评分对临床路径的价值以及未进入临床路径的原因.结果 入径率为81.0％;路径组平均住院日为（10.46±4.36）天,非路径组平均住院日为（22.31±12.53）天;路径组抗生素使用基本符合指南要求;CURB-65评分越低,越有可能进入临床路径;未能进入临床路径的原因有病情加重转入ICU,合并肺癌、肾功能衰竭、泌尿系感染、脑血管病等基础疾病、住院时间过长、使用了指南之外的抗生素、因经费问题要求出院等.结论 实施社区获得性肺炎临床路径能缩短平均住院日,促进抗生素使用规范,减少平均住院费用,有利于促进医院整体医疗安全、质量、效率及费用控制等综合管理水平的提高.     

基层医院卒中单元医疗模式的临床研究

目的观察在基层医院开展卒中单元医疗模式的临床效果。方法对90例病人实施自行设计的卒中单元医疗模式(观察组),并与0例传统治疗(对照组)进行对比分析。结果观察组总显效率为70.0%、总有效率为92.2%,高于对照组的7.5%、78.8%(P<0.01或P<0.05),常见4种并发症发生率显著低于对照组P<0.01)。结论脑卒中急性期实施卒中单元医疗模式效果优于传统治疗。     

慢性稳定型心绞痛中西医结合临床路径实施效果评价

目的评估慢性稳定型心绞痛中西医结合临床路径实施效果。方法采用非同期历史对照研究实施临床路径规范化管理后,评估其对患者安全性、住院费用、住院天数及临床疗效的影响。结果与传统组比较,路径组患者住院费用及住院天数均有明显下降(P0.05),心绞痛疗效、心电图疗效、中医证候疗效明显提高(P0.05)。结论对于慢性稳定型心绞痛患者实施中西医结合临床路径,可在保证临床疗效的同时降低住院费用及住院天数。     

急性冠脉综合征临床路径实施疗效分析

目的通过实施急性冠脉综合征(ACS)临床路径(CPACS-3)管理,持续改进诊疗质量,合理利用有限的医疗资源,使病人最大获益。方法收集我院2009年9月—2011年9月ACS病人86例作为执行路径前病例;执行路径干预后连续收集2011年10月—2014年9月ACS病例267例,根据卫生部急性冠脉综合征临床路径研究(CPACS-3),将临床路径表单附在病历中,对关键诊治环节进行干预,比较实施路径前后诊治疗效。结果实施路径后入院心电图检查时间较实施前明显缩短,实施路径后入院后溶栓时间较实施前明显提前,实施路径后介入比例较入院前明显提高,实施路径后补救PCI例数较入院前明显提高,实施路径后不良事件发生率明显降低。结论通过临床路径干预争取ACS病人接受心电图检查及溶栓的最佳时机,减少ACS病人的住院天数,提高ACS病人接受PCI的比例,降低ACS病人不良事件发生,改善预后。     

中医延续护理对缺血性卒中后睡眠障碍患者睡眠质量及生活质量的改善作用分析

目的:对中医延续护理实施后,缺血性卒中后睡眠障碍患者疾病恢复的临床效果进行评估、分析.方法:2020年4月至2021年5月期间,将我院接收的缺血性卒中后睡眠障碍80例进行分析,均按照住院号对患者实施奇偶分组,组别设置:研究组、对照组,每组患者各40例,前者对患者实施中医延续护理,后者给予常规护理.分析两组各指标变化情况...     

The implementation of intravenous tissue plasminogen activator in acute ischaemic stroke – a scientific position statement from the National Stroke Foundation and the Stroke Society of Australasia

Intravenous tissue plasminogen activator (tPA) has been licensed in Australia for thrombolysis in selected patients with acute ischaemic stroke since 2003. The use of tPA is low but is increasing across Australia and national audits indicate efficacy and safety outcomes equivalent to international benchmarks. Implementing tPA therapy in clinical practice is, however, challenging and requires a coordinated multidisciplinary approach to acute stroke care across prehospital, emergency department and inpatient care sectors. Stroke care units are an essential ingredient underpinning safe implementation of stroke thrombolysis. Support systems such as care pathways, therapy delivery protocols, and thrombolysis-experienced multidisciplinary care teams are also important enablers. Where delivery of stroke thrombolysis is being planned, health systems need to be re-configured to provide these important elements. This consensus statement provides a review of the evidence for, and implementation of, tPA in acute ischaemic stroke with specific reference to the Australian health-care system.     

Effects of care pathways on stroke care practices at regional hospitals

Background: Our previous work identified deficiencies in stroke care practices at regional hospitals in comparison to standards suggested by published stroke care guidelines. These deficiencies might be improved by the implementation of clinical pathways. The aim of this study was to assess changes in acute stroke care practices following the implementation of stroke care pathways at four regional Queensland hospitals. Methods: The medical records of two cohorts of 120 patients with a discharge diagnosis of stroke or transient ischaemic attack were retrospectively audited before and after implementation of stroke care pathways to identify differences in the use of acute interventions, investigations and secondary prevention strategies. Results: Following pathway implementation there were clinically important, but not statistically significant, increases in the rates of swallow assessment, allied health assessment (significant for occupational therapy, P = 0.04) and use of deep vein thrombosis prevention strategies (also significant, P = 0.006). Fewer patients were discharged on no anti‐thrombotic therapy (statistically significant in the subgroup of patients with atrial fibrillation, P = 0.02). Only 37% of the patients audited were actually enrolled on the pathway. Among this subgroup there were significant increases in the rates of swallow assessment (first 24 h, P = 0.01; any time during admission, P = 0.0001), allied health assessments (all P < 0.05), estimation of blood glucose level (P = 0.0015) and the use of deep vein thrombosis prevention strategies (P = 0.0003). Conclusion: Stroke care pathways appear to improve the process of care. Whether this influences outcomes such as mortality, functional and neurological recovery, the incidence of complications, length of stay or the cost of care was beyond the scope of this study and will require further examination.     

Development of clinical pathways for stroke management: an example from Saint Luke's Hospital, Kansas City.

Clinical pathways for stroke are important tools for improved case management and outcome assessment. The clinical path created at St. Luke's Hospital in Kansas City is described here. It evolved through the collaboration of a multidisciplinary team of clinical experts and is still evolving. Ideally, a clinical path should be used as a guide rather than a standard of care, which is to be individualized for each patient. This article describes the methods for writing the pathways and how they are used for documentation. It also summarizes how the pathway data support stroke outcome assessment.     

Integrated care pathways in stroke management

BACKGROUND: an organized, goal-defined and time-specified plan of management as envisaged by the integrated care pathway approach can achieve quality outcomes at lower cost. Integrated care pathways may have applications to stroke management because diagnosis is well defined, complex interdisciplinary inputs are required and there is good evidence on best practice. METHOD: we reviewed medical, nursing, rehabilitation and health services databases to identify studies on integrated care pathways in stroke management. Criteria for inclusion were: use of a care pathway or similar methods in acute or rehabilitation settings, randomized studies or non-randomized comparisons with concurrent or historical controls and some form of outcome assessment. RESULTS: we identified six non-randomized studies of acute stroke. One used concurrent controls; the rest used historical controls. Only one study investigated stroke rehabilitation and this used a quasi-randomized controlled design. Five studies in the acute setting demonstrated reduced hospital stay. A reduction in costs of care was reported in all five studies that examined costs. Two studies reported improved uptake of medical interventions. No difference in length of hospital stay, costs or functional status was seen in the rehabilitation study. CONCLUSIONS: integrated care pathway methodology may facilitate quality and cost improvements in stroke care, but evidence is weak and uncertainty exists. Further evidence is needed before implementation in practice.     

The Use of Qualitative Methods in Developing Implementation Strategies in Prevention Research for Stroke Survivors in Nigeria

Implementing complex clinical interventions is a key challenge in many global regions. Local communities play a necessary role in enhancing feasibility and strengthening adaptive issues in the design and implementation of stroke interventions in developing countries. Drawing on the knowledge of physicians, patients, and caregivers, the authors employed qualitative methods as a phase 1 strategy to explore the challenges of stroke management and improve the adaptability and efficient delivery of a multimodal preventive intervention for secondary stroke disease in Nigeria. A total of 22 individual interviews were conducted with healthcare professionals, as well as 12 focus groups with patients and caregivers. Findings revealed four operational domains to improve strategies for phase 2 implementation and intervention: (1) barriers influencing optimal adherence in stroke survivors, (2) patient health beliefs and perceptions of patient health beliefs by others, (3) adoption of the “patient report card,” and (4) “medical action plan” and family management strategies.     

Evidenzbasierte Leitlinien und Behandlungspfade

Even methodological sound guidelines will only achieve their goals when the recommendations are transferred into practice. Guideline introduction and dissemination must therefore be accompanied by active implementation measures. For inpatient care clinical pathways can serve as tools, especially taking advantage of their sequential character. Complementary evidence based guidelines can serve as an optimal source of systematically appraised evidence in developing clinical pathways. Considering them is of major help to assure that the content of clinical pathways is in accordance with evidence. The article highlights methodological requirements in guideline and pathway development and gives prospects on how both tools can be used together.     

Evidence based guidelines and clinical pathways: complementation or contradiction?

Even methodological sound guidelines will only achieve their goals when the recommendations are transferred into practice. Guideline introduction and dissemination must therefore be accompanied by active implementation measures. For inpatient care clinical pathways can serve as tools, especially taking advantage of their sequential character. Complementary evidence based guidelines can serve as an optimal source of systematically appraised evidence in developing clinical pathways. Considering them is of major help to assure that the content of clinical pathways is in accordance with evidence. The article highlights methodological requirements in guideline and pathway development and gives prospects on how both tools can be used together.     

Stroke Prevention in Nonvalvular Atrial Fibrillation: A Stakeholder Perspective

Ischemic stroke in patients with atrial fibrillation is associated with substantial morbidity and mortality. The growing epidemic of atrial fibrillation worldwide has raised concerns about the dire need for effective stroke prevention systems in these patients. Fortunately, the last decade has witnessed a plethora of data on novel stroke prevention methods in patients with nonvalvular atrial fibrillation. However, optimal selection and effective implementation of these preventative strategies require an integrative approach that takes into account not only the available clinical data but also the perspective of each of the stakeholders involved (patient, physician, and society). The goal of this review was to discuss the contemporary issues surrounding stroke prevention in atrial fibrillation from the perspective of these 3 major stakeholders.     

Does an integrated care pathway improve processes of care in stroke rehabilitation? A randomized controlled trial

OBJECTIVE: to evaluate whether integrated care pathways improve the processes of care in stroke rehabilitation. DESIGN: comparison of processes of care data collected in a randomized controlled trial. PARTICIPANTS: acute stroke patients undergoing rehabilitation randomized to receive integrated care pathways management (n=76) or conventional multidisciplinary care (n=76). MEASUREMENTS: proportion of patients meeting recommended standards for processes of care using a validated stroke audit tool. RESULTS: integrated care pathways methodology was associated with higher frequency of stroke specific assessments, notably testing for inattention (84% versus 60%; P=0.015) and nutritional assessment (74% versus 22%, P<0.001). Documentation of provision of certain information to patients/carers (89% versus 70%; P=0.024) and early discharge notification to general practitioners (80% versus 45%; P<0.001) were also more common in this group. There were no significant differences in the processes of interdisciplinary co-ordination and patient management between the integrated care pathways group and the control group. CONCLUSION: integrated care pathways may improve assessment and communication, even in specialist stroke settings.     

Thrombolysis for acute stroke in the United Kingdom

The publication of the National Institute of Neurological Disorders and Stroke trial of thrombolysis has not led to the widespread implementation of alteplase for acute ischaemic stroke in the United Kingdom. However, the Cochrane systematic review of thrombolysis for acute ischaemic stroke suggests that alteplase is the most promising treatment for acute ischaemic stroke. Successful implementation of thrombolysis in the United Kingdom will depend on continued investment in acute stroke services, attention to the known barriers to treatment, further data from randomized controlled trials and the licensing of alteplase for this indication.