院前流程优化对缺血性脑卒中患者干预效果的Meta分析

doi:10.3761/j.issn.2096-7446.2023.07.016

摘要/Abstract

摘要： 目的了解院前流程优化对缺血性脑卒中患者干预效果的影响。方法计算机检索PubMed、Embase、Cochrane Library、Web of Science、中国生物医学文献数据库、万方数据知识服务平台、中国知网、维普数据库关于院前流程优化相关的干预性研究或队列研究,检索时限为建库至2022年11月。由2名接受过循证培训的研究者根据纳入排除标准独立筛选文献、提取资料、质量评价后使用RevMan 5.3软件进行Meta分析。结果最终纳入24篇文献,共197 154例患者。结果显示,院前流程优化可提升缺血性脑卒中患者的再灌注治疗率[OR=1.98,95%CI（1.57,2.49）,Z=5.75,P<0.001],缩短症状出现到溶栓治疗时间[WMD=-21.64,95%CI（-33.32,-9.97）,Z=3.63,P<0.001]、呼叫救护车到溶栓治疗时间[WMD=-30.29,95%CI（-44.14,-16.45）,Z=4.29,P<0.001]以及院内溶栓时间或血管内治疗时间,改善患者临床结局[OR=1.99,95%CI（1.29,3.05）,Z=3.12,P=0.002],但对症状出现到急诊室入门时间改善无显著影响[WMD=-6.88,95%CI（-16.62,2.86）,Z=1.38,P=0.17]。结论院前流程优化能够有效提升缺血性脑卒中患者的再灌注治疗率和预后,但对院前时间延迟的改善较小,提示院前阶段流程还需进一步优化。

关键词: 缺血性脑卒中, 流程优化, 急救医疗服务, 院前延迟, 专题Meta分析

Abstract: Objective To investigate the effect of prehospital procedure optimization on treatment delay and clinical outcome of ischemic stroke. Methods We searched PubMed,Embase,Cochrane Library,Web of Science,China Biomedical Literature Database,Wanfang data knowledge service platform,China National Knowledge Infrastructure,VIP database to collect intervention studies or cohort studies related to pre-hospital workflow optimization. The search period was from the database establishment to November 2022. Two evidence-based trained researchers independently screened literature,extracted data,and evaluated quality according to inclusion and exclusion criteria. Meta-analysis was performed using RevMan 5.3 software. Results Twenty-four literatures with a total of 197 154 patients were included. The results showed that prehospital procedure optimization could improve the rate of reperfusion therapy in patients with ischemic stroke[OR=1.98,95%CI（1.57,2.49）,Z=5.75,P<0.001] and shorten the time from symptom onset to thrombolytic therapy[WMD=-21.64,95%CI（-33.32,-9.97）,Z=3.63,P<0.001],the time from ambulance call to thrombolytic therapy[WMD=-30.29,95%CI（-44.14,-16.45）,Z=4.29,P<0.001] and the time of intra-hospital thrombolytic therapy or intravascular therapy to improve the clinical outcome of patients[OR=1.99,95%CI（1.29,3.05）,Z=3.12,P=0.002],but had no significant effect on the improvement of entry time from symptom onset to emergency room[WMD=-6.88,95%CI（-16.62,2.86）,Z=1.38,P=0.17]. Conclusion Prehospital procedure optimization can effectively improve the reperfusion treatment rate and prognosis of patients with ischemic stroke,but the improvement of prehospital time is small,suggesting that the prehospital process needs to be further optimized.

Key words: Ischemic Stroke, Procedure Optimization, Emergency Medical Services, Prehospital Delay, Meta-Analysis as Topic

郭芝廷, 金静芬, 刘苑菲, 傅雨佳, 王旭阳, 郭二菱, 张玉萍. 院前流程优化对缺血性脑卒中患者干预效果的Meta分析[J]. 中华急危重症护理杂志, 2023, 4(7): 644-653.

GUO Zhiting, JIN Jingfen, LIU Yuanfei, FU Yujia, WANG Xuyang, GUO Erling, ZHANG Yuping. The effect of prehospital process optimization on treatment delay in patients with ischemic stroke：a Meta-analysis[J]. Chinese Journal of Emergency and Critical Care Nursing, 2023, 4(7): 644-653.

参考文献

[1] 中华医学会神经病学分会,中华医学会神经病学分会脑血管病学组. 中国急性缺血性脑卒中诊治指南2018[J]. 中华神经科杂志,2018,51(9):666-682.
Neurology Branch of Chinese Medical Association, Cerebrovas-cular Disease Group of Neurology Branch of Chinese Medical Association. Chinese guidelines for diagnosis and treatment of acute ischemic stroke 2018[J]. Chin J Neurol,2018,51(9):666-682.
[2] 《中国脑卒中防治报告》编写组. 《中国脑卒中防治报告2020》概要[J]. 中国脑血管病杂志,2022,19(2):136-144.
Writing Group of Report on Stroke Prevention and Treatment In China. Brief report on stroke prevention and treatment in China,2020[J]. Chin J Cerebrovasc Dis,2022,19(2):136-144.
[3] 刘丽萍,陈玮琪,段婉莹,等. 中国脑血管病临床管理指南(节选版):缺血性脑血管病临床管理[J]. 中国卒中杂志,2019,14(7):709-726.
Liu LP,Chen WQ,Duan WY,et al.Chinese stroke association guidelines for clinical management of cerebrovascular disorders (excerpts)—clinical management of ischemic cerebrovascular disorders[J]. Chin J Stroke,2019,14(7):709-726.
[4] 陈红芳,龚筱弦,徐冬娟,等. 治疗时间提前可改善缺血性脑卒中患者再灌注治疗的预后[J]. 浙江大学学报(医学版),2019, 48(3):247-253.
Chen HF,Gong XX,Xu DJ,et al.Advanced treatment time improves outcomes of patients with ischemic stroke undergoing reperfusion therapy[J]. J Zhejiang Univ Med Sci,2019,48(3):247-253.
[5] Jauch EC,Saver JL,Adams HP Jr,et al.Guidelines for the early management of patients with acute ischemic stroke:a guideline for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke,2013,44(3):870-947.
[6] 赵博,李思颉,吉训明. 急性缺血性卒中患者院前延迟的影响因素研究进展[J]. 中国脑血管病杂志,2015,12(1):51-55.
Zhao B,Li SJ,Ji XM.Research progress on influencing factors of pre-hospital delay in patients with acute ischemic stroke[J]. Chin J Cerebrovasc Dis,2015,12(1):51-55.
[7] 梁宏艳,李明,惠文,等. 急性缺血性卒中患者救治时间延迟的研究进展[J]. 中国脑血管病杂志,2019,16(12):662-666.
Liang HY,Li M,Hui W,et al.Research progress of delayed treatment time process for acute ischemic stroke patients[J]. Chin J Cerebrovasc Dis,2019,16(12):662-666.
[8] 杨丽,刘琴琴,赵秋利,等. 基于CiteSpace的脑卒中就医延迟可视化分析[J]. 现代预防医学,2020,47(9):1714-1720.
Yang L,Liu QQ,Zhao QL,et al.Visualization analysis of stroke medical treatment delay based on CiteSpace[J]. Mod Prev Med, 2020,47(9):1714-1720.
[9] Ruff IM,Ali SF,Goldstein JN,et al.Improving door-to-needle times:a single center validation of the target stroke hypothesis[J]. Stroke,2014,45(2):504-508.
[10] Vidale S,Arnaboldi M,Bezzi G,et al.Reducing time delays in the management of ischemic stroke patients in Northern Italy[J]. Int J Cardiol,2016,215:431-434.
[11] Yuan J,Li MH,Liu Y,et al.Analysis of time to the hospital and ambulance use following a stroke community education intervention in China[J]. JAMA Netw Open,2022,5(5):e2212674.
[12] Green S,Higgins JP.Preparing a Cochrane review[M]. Wiley-Blackwell,2008.
[13] 周英凤,顾莺,胡雁,等. JBI循证卫生保健中心关于不同类型研究的质量评价工具:干预性研究的质量评价[J]. 护士进修杂志,2018,33(2):112-113.
Zhou YF,Gu Y,Hu Y,et al.JBI evidence-based health cen-ter's quality assessment tool for different types of research:quality evaluation of intervention research[J]. J Nurses Train,2018,33(2):112-113.
[14] Stang A.Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses[J]. Eur J Epidemiol,2010,25(9):603-605.
[15] Walter S,Kostopoulos P,Haass A,et al.Diagnosis and treat-ment of patients with stroke in a mobile stroke unit versus in hospital:a randomised controlled trial[J]. Lancet Neurol,2012, 11(5):397-404.
[16] Ebinger M,Winter B,Wendt M,et al.Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke:a randomized clinical trial[J]. JAMA,2014,311(16):1622-1631.
[17] Helwig SA,Ragoschke-Schumm A,Schwindling L,et al.Preho-spital stroke management optimized by use of clinical scoring vs mobile stroke unit for triage of patients with stroke:a randomized clinical trial[J]. JAMA Neurol,2019,76(12):1484-1492.
[18] Czap AL,Singh N,Bowry R,et al.Mobile stroke unit com-puted tomography angiography substantially shortens door-to-puncture time[J]. Stroke,2020,51(5):1613-1615.
[19] Price CI,Shaw L,Islam S,et al.Effect of an enhanced pa-ramedic acute stroke treatment assessment on thrombolysis delivery during emergency stroke care:a cluster randomized clinical trial[J]. JAMA Neurol,2020,77(7):840-848.
[20] 钟楚锋,周环,萧嘉颖,等. 基于医联体卒中120网络模式的基层卒中救治体系建设[J]. 中国卫生标准管理,2021,12(6):41-45.
Zhong CF,Zhou H,Xiao JY,et al.Construction of a basic stroke treatment system based on the medical association stroke 120 network model[J]. China Health Stand Manag,2021, 12(6):41-45.
[21] Quain DA,Parsons MW,Loudfoot AR,et al.Improving access to acute stroke therapies:a controlled trial of organised pre-hospital and emergency care[J]. Med J Aust,2008,189(8):429-433.
[22] Taqui A,Cerejo R,Itrat A,et al.Reduction in time to treat-ment in prehospital telemedicine evaluation and thrombolysis[J]. Neurology,2017,88(14):1305-1312.
[23] van Schaik SM,van der Veen B,van den Berg-Vos RM,et al. Achieving a door-to-needle time of 25 minutes in throm-bolysis for acute ischemic stroke:a quality improvement pro-ject[J]. J Stroke Cerebrovasc Dis,2014,23(10):2900-2906.
[24] Sakamoto Y,Tanabe M,Masuda K,et al.Feasibility of using magnetic resonance imaging as a screening tool for acute stroke thrombolysis[J]. J Neurol Sci,2016,368:168-172.
[25] Cerejo R,John S,Buletko AB,et al.A mobile stroke treat-ment unit for field triage of patients for intraarterial revas-cularization therapy[J]. J Neuroimaging,2015,25(6):940-945.
[26] Zaidi SF,Shawver J,Espinosa Morales A,et al.Stroke care:initial data from a County-based bypass protocol for patients with acute stroke[J]. J Neurointerv Surg,2017,9(7):631-635.
[27] Kummer BR,Lerario MP,Hunter MD,et al.Geographic analy-sis of mobile stroke unit treatment in a dense urban area:the New York city METRONOME registry[J]. J Am Heart Assoc,2019,8(24):e013529.
[28] 陈奕菲,张春鹏,王慎安,等. 医联体模式下院前急救联合绿色通道在急性缺血性脑卒中救治中的应用效果[J]. 解放军预防医学杂志,2019,37(6):180-181.
Chen YF,Zhang CP,Wang SA,et al.Application effect of medical combination model of anterior first aid combined with green channel in acute ischemic stroke[J]. J Prev Med Chin PLA,2019,37(6):180-181.
[29] 郑建涛,周婵娟,许佳俊,等. 优化卒中急救流程对脑卒中治疗及预后的影响[J]. 创伤与急诊电子杂志,2022,10(2):73-79.
Zheng JT,Zhou CJ,Xu JJ,et al.Influence of optimizing emergency procedures on stroke treatment and prognosis[J]. J Trauma Emerg Electron Version,2022,10(2):73-79.
[30] Mazya MV,Berglund A,Ahmed N,et al.Implementation of a prehospital stroke triage system using symptom severity and teleconsultation in the Stockholm stroke triage study[J]. JAMA Neurol,2020,77(6):691-699.
[31] Mohamed GA,Marmarchi F,Fonkeu Y,et al.Cincinnati preho-spital stroke scale implementation of an urban county severity-based stroke triage protocol:impact and outcomes on a comprehensive stroke center[J]. J Stroke Cerebrovasc Dis,2022,31(8):106575.
[32] Nehme A,Deschaintre Y,Labrie M,et al.Cincinnati preho-spital stroke scale for EMS redirection of large vessel occlusion stroke[J]. Can J Neurol Sci,2019,46(6):684-690.
[33] Prabhakaran S,O'Neill K,Stein-Spencer L,et al. Prehospital tria-ge to primary stroke centers and rate of stroke thrombolysis[J]. JAMA Neurol,2013,70(9):1126-1132.
[34] Schott AM,Termoz A,Viprey M,et al.Short and long-term impact of four sets of actions on acute ischemic stroke management in Rhône County,a population based before-and-after prospective study[J]. BMC Health Serv Res,2021,21(1):12.
[35] Jin H,Qu Y,Guo ZN,et al.Impact of Jilin Province stroke emergency maps on acute stroke care improvement in northeast China[J]. Front Neurol,2020,11:734.
[36] Saver JL.Time is brain:quantified[J]. Stroke,2006,37(1):263-266.
[37] Wang YL,Li ZX,Zhao XQ,et al.Effect of a multifaceted qua-lity improvement intervention on hospital personnel adherence to performance measures in patients with acute ischemic stroke in China:a randomized clinical trial[J]. JAMA,2018, 320(3):245-254.
[38] Mosley I,Nicol M,Donnan G,et al.Stroke symptoms and the decision to call for an ambulance[J]. Stroke,2007,38(2):361-366.
[39] Zeng Y,He GP,Yi GH,et al.Knowledge of stroke warning signs and risk factors among patients with previous stroke or TIA in China[J]. J Clin Nurs,2012,21(19/20):2886-2895.
[40] 赵洁,常红,王佳姝,等. 社区人群对缺血性脑卒中早期症状识别及溶栓治疗决策的现状调查[J]. 中国急救复苏与灾害医学杂志,2017,12(11):1069-1072.
Zhao J,Chang H,Wang JS,et al.Investigation on the status of early symptom recognition and thrombolytic treatment deci-sion of ischemic stroke in community population[J]. China J Emerg Resusc Disaster Med,2017,12(11):1069-1072.