□ 王仙伟 WANG Xian-wei 王敏霞 WANG Min-xia 李萍 LI Ping 杨海 YANG Hai 陈姬雅 CHEN Ji-ya

Objective To introduce value Stream method into the flow management of intravenous thrombolysis and endovascular treatment for analysis and optimization of current process, so as to improve key medical service flow. Methods The flow before and after intravenous thrombolysis and endovascular treatment for acute ischemic stroke was optimized and the clinical effect was evaluated. Results From April to September 2020,a total of 127 cases of intravenous thrombolysis and 69 cases of endovascular treatment were completed in the hospital. After the optimization,Door-to-needle time (DNT) was shortened from 62.7±34.5min to 36.9±20.7min, onset-to-puncture time (OTP) was shortened from 336.2±74.8min to 261.4±67.5min, and the rate of intravenous thrombolysis and endovascular treatment for AIS within 6 hours of arrival was improved from 53.67% (7.52%) to 91.83% (26.65%). Conclusion The application of value stream obviously shortens DNT and OTP, improves the rate of intravenous thrombolysis and endovascular treatment of AIS in the hospital, improves the treatment capacity for ischemic stroke patients, and reduces the disability rate of patients and social burden.

脑卒中是神经内科常见的急重疾病之一，具有高发病率、高致残率、高死亡率、高复发率和高经济负担等特点[1]。早期静脉溶栓(intravenous thrombolysis，IVT)及血管内治疗(endovascular treatment，EVT)是急性脑梗死最有效的治疗措施，越早治疗，患者梗死血管的再通率越高，神经功能恢复也越好[2-4]，因此，规范与优化静脉溶栓及血管内治疗流程对提高急救效率和质量有着重要意义。本研究将价值流方法引入急诊静脉溶栓及血管内治疗流程管理，对相关流程进行分析及优化，改进关键医疗服务过程，以进一步提升医院急性缺血性脑卒中(acute ischemic stroke，AIS)静脉溶栓及血管内治疗能力。

研究内容与方法

1.研究对象及纳入标准。选取医院2019年10月-2020年9月就诊的急性缺血性脑卒中需要静脉溶栓及血管内治疗的患者。(1)发病6小时内如符合IVT适应症、排除禁忌症的缺血性卒中患者需进行标准静脉溶栓治疗(发病4.5小时内rt-PA 0.9mg/Kg、发病4.5-6小时内尿激酶100万-150万IU静脉注射)，临床症状改善不明显(NIHSS评分下降＜4分)或进行性加重患者经家属同意可桥接EVT治疗。(2)发病6-12小时的缺血性脑卒中属于《急性大血管闭塞性缺血性卒中血管内治疗中国专家共识2017》[4]的患者行EVT治疗。(3)发病12-24小时的后循环卒中患者经RAPID软件评VCBF＜30%＜50ml内患者经家属同意行EVT治疗。

2.方法。在院领导牵头领导下，成立IVT及EVT院内流程现状研究小组，成员包括神经内科、急诊内科、检验科、放射科、麻醉科等各骨干成员，明确各科室成员分工及责任，研究小组成员倾听一线声……