如何建立高质量的卒中中心培训课件.ppt

1、The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。组织化管理卒中患者的医疗模式组织化管理卒中患者的医疗模式把传统治疗脑卒中的各种独立方法，如药物治

2、疗、肢体康复、语言训练、把传统治疗脑卒中的各种独立方法，如药物治疗、肢体康复、语言训练、心理康复、健康教育等组合成一种综合的治疗系统心理康复、健康教育等组合成一种综合的治疗系统目的是提供给目的是提供给卒中患者卒中患者最佳医疗服务最佳医疗服务，包括高质量、标准化、有效的和花包括高质量、标准化、有效的和花费效果合适的措施费效果合适的措施缩短入院到影像检查和治疗的时间缩短入院到影像检查和治疗的时间快速神经科评价快速神经科评价更多的病人收入急性卒中单元更多的病人收入急性卒中单元减少死亡率和致残率减少死亡率和致残率减少医疗成本减少医疗成本什么是卒中中心？建立卒中中心有什么好处？The Needs of

3、The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。 综合卒中中心 卒中中心 未获得资质的医疗机构病人病人病人病人病人病人卒中中心网络病人就诊及转运示意图卒中中心网络病人就诊及转运示意图The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，

4、请联系改正。六个方面急诊室、实验室/CT(24/7)、卒中单元卒中小组(24/7)、神经科医生、放射科医生、检验科医生、护理师、康复师CT/实验室检查/心电图(24/7)、心超、颈动脉超声急性期rt-PA溶栓、血管内治疗、二级预防、康复治疗24小时生命体征、神经功能评分、随访计划医学继续教育、医疗服务质量数据库登记The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。绩效绩效编号编号绩效项目绩效项目

5、缺血性卒中缺血性卒中TIA出血性卒中出血性卒中 1rt-PA治疗248小时内抗栓治疗3吞咽困难筛查4深静脉血栓预防5康复评价6出院时抗栓治疗7合并心房颤动抗凝8出院时降胆固醇治疗8a出院时他汀治疗9戒烟建议10卒中教育The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。不同学科独立作战不同学科独立作战多学科并肩作战多学科并肩作战卒中中心建设将打破原有分科治疗的壁垒，整合神经内外科、急救室、影像、介

6、入科的力量，实现多学科协作的无缝对接，真正体现以患者为中心的服务理念。过去诊疗模式卒中中心诊疗模式The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。 卒中小组评估60分钟内静脉溶栓 血管内治疗 手术干预 抗栓 血压、血糖、血脂管理 制定目标 运动治疗 语言训练 制定计划 定期随访The Needs of The Patients and The Customers Come FirstThe N

7、eeds of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。院内多学科联合服务-团队建设超声 发病 神内急诊多模式影像 静脉溶栓 血管造影机械取栓症状恢复康复治疗 溶栓小组评估影像神外康复神内病房神内急诊院前影像检验The Needs of The Patients and

8、 The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。DWIPWIMRA多模式影像学指导下超时间窗静脉溶栓者的3月预后不劣于时间窗内溶栓治疗组（45.8% vs 53.3%,p=0.297）；两组的症状性出血发生率无显著性差异（6.8% vs 3.1%,p=0.250），提示多模式影像指导下的超时间窗溶栓治疗是有效的。多模式MRI指导超时间窗溶栓治疗The Needs of The Patients and The Customers Come First

9、The Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。11核心区体积 = 11.7 mL ，半暗区组织 = 127.9 mL多模式CT 指导溶栓和墨尔本大学合作The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。 3h内获益最大2011年The Needs of The Patients and The Cu

10、stomers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。 定义定义: : Door-to-Needle Time (DNT) 指急性脑梗指急性脑梗死患者从到达医院至开始静脉使用死患者从到达医院至开始静脉使用rt-PA的的时间间隔时间间隔 将将DNT时间分为两部分：时间分为两部分： 到达医院到达医院-出发影像检查出发影像检查 出发影像检查出发影像检查-开始用药开始用药 组成质量改进小组组成质量改进小组The Needs of The Patients and The Cus

11、tomers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。时间追踪模式 时间追踪表（左图）时间追踪表（左图） 每环节时间定位到分每环节时间定位到分 责任到人责任到人 双人核对填写，登记二次复核双人核对填写，登记二次复核 每周讨论、追责、改进每周讨论、追责、改进The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料

12、仅供参考,不当之处，请联系改正。2014年8-12月达到目标值，并低于指南要求的60分钟第三期第三期PDCAPDCA溶栓流程的持续质量改进The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。改进措施举例问题问题改进措施改进措施具体实施具体实施急诊溶栓患者急诊溶栓患者绿色通道绿色通道执行执行不到位不到位溶栓患者急诊优先处置溶栓患者急诊优先处置溶栓病人可以溶栓病人可以先检查再付费先检查再付费溶栓小组成

13、员职责不明溶栓小组成员职责不明 人员定岗，明确职责人员定岗，明确职责1.1.成立专门的成立专门的溶栓小组溶栓小组，安排值班，确保，安排值班，确保溶栓小组在溶栓小组在医院待命医院待命2.2.溶栓小组每周开会对上一周的溶栓病例溶栓小组每周开会对上一周的溶栓病例进行汇总回顾，进行汇总回顾，发现问题和总结经验发现问题和总结经验急诊溶栓流程培训不足急诊溶栓流程培训不足 对急诊室护士进行培训对急诊室护士进行培训由溶栓小组医生及急诊溶栓护理负责人定由溶栓小组医生及急诊溶栓护理负责人定期对期对急诊护士急诊护士进行溶栓病人评估及溶栓流进行溶栓病人评估及溶栓流程的程的培训培训没有预留溶栓床位没有预留溶栓床位预留溶

14、栓床位预留溶栓床位两张病床作为两张病床作为专用溶栓床位专用溶栓床位The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。启动时间追踪后DNT缩短显著（108.452.4min vs. 87.633.2min，P0.001），以发病1小时内就诊者缩短最为显著（132.546.0min vs. 90.321.0min，P0.001）;启动时间追踪前后，DNT与ODT从显著负相关（r=-0.169，P=0

15、.015）转化为无明显相关（r=-0.013，P=0.885）。时间追踪模式：取消主观因素的影响The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。2015年目标JAMA April 23/30, 2014TARGET:STROKE 卒中质量改善计划我们医院的数据（2012.10-2014.12）2015年目标值：年目标值：DNT60min比率大于比率大于60%指南建议：DNT60min比率大于8

16、0%The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。12015年：启动院前急救通知的溶栓流程溶栓小组接到通知记录患者信息及评估预检挂号通知急诊抢

17、救室联系影像科通知上级医生抽血送检化验内容血常规血生化凝血谱心肌酶谱 基本生命体征 心电图启动溶栓流程绿色通道准备转至影像检查溶栓知情同意谈话The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。启动院前流程后显著缩短ONT参数Non-PNPn=141PNPn=41检验值p值年龄，y69.912.366.515.42=1.4850.139女性，%48（34.0）17（41.5）2=0.7620.38

18、3TIA/卒中史，%2（4.9）28（19.9）2=5.1780.023基线NIHSS，IQR10.0(4.0-16.0)12.0(6.5-16.5)Z=-1.0610.289ONT，min219.7108.6174.5493.0t=2.4170.017ODT，min159.495.0132.188.6t=1.6380.103DNT，min56.021.541.410.8t=4.1130.001到达急诊-离开急诊，min18.211.29.25.4t=4.9230.001出发检查-开始影像，min9.55.78.94.0t=0.6600.510开始影像-完成检查，min9.85.38.32.8

19、t=1.7460.083完成检查开始用药，min16.610.315.08.0t=0.8630.389The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。 B值95%CIpPNP-57.810-94.12421.4960.002年龄-1.399-2.5660.2330.019糖尿病-30.139-67.298-7.0190.111房颤-17.357-48.984-14.2700.280TIA/卒中

20、史-52.265-93.68410.8460.014影响发病到溶栓时间（影响发病到溶栓时间（ONT）的多因素分析）的多因素分析参数OR95%CIp值基线NIHSS0.8160.765-0.8700.001年龄0.9830.955-1.0110.220PNP2.4441.050-5.6890.038预后的多因素分析预后的多因素分析The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。The Needs

21、 of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。u微信群：溶栓团队群、血管内治疗群、院前急救群u卒中急诊救治网络： 接诊无多模影像支持医院转来的溶栓患者 接诊无取栓条件医院转来的溶栓患者u双向转诊网络： 脑血管病专科门诊随诊、长期跟踪 与社区医院开展双向转诊 与地区各级医院开展远程会诊The Needs of The Patients and The Customers Come FirstThe Needs

22、of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。通过远程会诊系统对协作医院医通过远程会诊系统对协作医院医务人员进行培训，技术指导务人员进行培训，技术指导充分利用与社区的双向转诊体系，充分利用与社区的双向转诊体系，将防治工作深入到社区。将防治工作深入到社区。 浙医二院基层医疗机构浙医二院基层医疗机构 浙江省、上海、贵州省、安徽省111家协作医院16家社区服务中心大医院、大课堂、精医术、广教育 浙医二院基层医疗机构浙医二院基层医疗机构 浙江省、上海、贵州省、安徽省111家协作医院16家社区服务中心The Needs of

23、The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。举办国家级继续教育培训和学术研讨会巡讲进修医师及研究生的培养和教育开展技术推广工作远程教育积极构建协作体系浙医二院卒中中心The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。

24、卒中中心网络建设综综合卒中中心合卒中中心卒中中心卒中中心未获得资质的医疗机构病人病人病人院前120合作（急救群）院内多学科联合(溶栓/取栓.)院后 随访管理防复发高危人群医院随访危险人群社区管理远程医疗/教育双向转诊专科门诊持续质量改进持续质量改进The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。The Needs of The Patients and The Customers Come F

25、irstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。人工智能识别病历扫描件疾病相关数据的呈现扫描病历、上传病历扫描件至云平台数据自动上传至质控中心人人工工智智能能质质控控云云平平台台The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。The Needs of The Patients and The

26、 Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients a

27、nd The Customers Come First资料仅供参考,不当之处，请联系改正。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。近3年已经发表卒中相关论文50余篇 ，其中SCI论文30余篇以第一作者单位发表在 Stroke（6篇）、Neurology、JNNP、JCBF&M 、 Eur Radio、Neurobiol Dis 、 AGE 、AJNR 总影响因子超过 170 分，均为临

28、床研究科研指导并服务临床，临床启迪并促进科研科研指导并服务临床，临床启迪并促进科研基于多模式影像指导静脉溶栓和桥接取栓，研究新型影像标志、结局预测、出血预测等。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First资料仅供参考,不当之处，请联系改正。谢谢！谢谢！广济医院（现“浙医二院”）首任院长梅腾更先生与小患者互相鞠躬致敬