【ISC2015】卒中患者接受的护理更加优质和及时

纳什维尔– 2月11日，美国卒中学会2015年国际卒中大会（ISC2015）上发表的一项研究表示，在接受时间依赖性抗血栓药物治疗的急性卒中患者中，每4例中就有1例能由急诊科或较小规模的社区医院迅速转诊至具有资质的卒中中心。

这项研究同一时间还将发表于美国心脏学会期刊《Stroke》上。

静脉（IV）组织纤溶酶原激活物，即tPA，是一种抗血栓药物，可恢复脑血流。如在卒中发生3小时内进行给药，tPA或可显著增加患者的康复几率。尽管这是FDA批准用于治疗急性缺血性卒中的唯一治疗方案，但该药的给药率仍较低。

“四分之一是非常高的比例了，虽然我们不知道最佳目标是什么，但这或许仍有改进的空间，”研究的主要作者、康涅狄格州纽黑文市耶鲁医学院神经重症监护及急诊神经科主任Kevin N. Sheth, M. D.表示，“我们必须了解tPA患者转院的地理及社区差异，为什么一些社区会比其他社区有更多转院患者。最终目的是让国内所有患者不论是在何处首次就诊，都能接受tPA治疗。”

为了研究卒中护理方面的这些差异性，研究者们对2003年-2010年间1440家医院中3小时内接受了tPA治疗的44 667例缺血性卒中患者（中位年龄72岁；49%为女性）数据进行了分析。

研究者们比较了到达医院后接受tPA治疗之后收治入院的患者以及到达医院后接受了tPA治疗之后转至经认证卒中中心的患者。

在转诊至经认证卒中中心的1/4患者中，

· 多数更年轻，多为男性，多为白色人种

· 转诊患者在非高峰时间（周一至周五的7 a.m. – 5 p.m.）入院的可能性更大

· 转诊医院规模较大，有更多床位，更可能是学术医疗中心，获得了指定卒中中心的认证，每年的卒中病例量均维持在较高水平

· 接受转诊卒中患者的医院更多见于美国中西部

研究者们表示，这项研究提示更多患者在转入有资质的卒中中心以前即获得了所需的关键药物，“时间就是大脑”，这意味着要抓紧一切时间将卒中患者转移至配有卒中专家、合适的诊断设备以及治疗的医疗机构。并非所有机构都具备这些条件，尤其是规模较小的社区医院。在不同的医院中，卒中患者接受tPA治疗的速度不同。由较小规模的社区医院转诊至指定卒中中心的患者范围也有很大差异。

美国每年有795 000人发生卒中，这是排名第5的死因。2003年起，美国心脏学会“遵循指南进行院内卒中治疗项目”促进了人们对最新科学治疗方案的持续遵从，其中包括tPA快速给药。转院或许有助于促进及时应用tPA并拯救患者生命，因为这意味着患者在转至卒中中心前无论是在哪里就诊均能接受tPA治疗。

Dr. Sheth表示他很意外颅内出血（颅骨内出血）在转院的卒中患者中更为常见，这一发现有待于进一步的研究。“我们并不知道这些患者最初的卒中严重程度，也不清楚为什么将一些患者转至卒中中心，而其他的不转院，可能转院的是病情较重的患者，”他说。为何一些地区的卒中转院患者比其他地区更多、转院如何帮助医院增加tPA的使用，这些问题仍需进一步研究，Sheth表示。

研究的联合作者为Eric E. Smith M.D.、Maria V. Grau-Sepulveda, M.D., M.P.H.、Dawn Kleindorfer, M.D.、Gregg C. Fonarow, M.D.和Lee H. Schwamm, M.D.。作者的利益声明见研究摘要。

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NASHVILLE, Tenn., Feb. 11, 2015 – One in four acute ischemic stroke patients treated with a time-dependent clot-busting drug were quickly transferred from an emergency department or smaller community hospital to a certified stroke center, according to research presented at the American Stroke Association’s International Stroke Conference 2015.

This study will also publish simultaneously in the American Heart Association’s journal Stroke.

Intravenous (IV) tissue-plasminogen activator, or tPA, is a clot-busting drug that restores blood flow to the brain. If administered within three hours of the start of a stroke, tPA may significantly improve a patient's chances of recovery. Even though it is the only FDA-approved treatment for acute ischemic stroke, rates of its administration are low.

“One in four is a very good number, and while we don’t know the best target, there may be room for improvement,” said Kevin N. Sheth, M.D., lead study author and Chief of Neurocritical Care and Emergency Neurology Division at Yale School of Medicine in New Haven, CT. “We have to understand geographic and community variation in usage of inter-hospital transfer of tPA patients, and why some communities may use it more than other communities. Ultimately, the goal is to have any patient that presents to their initial hospital anywhere in the country be able to receive tPA.”

To look at these variations in stroke care, researchers analyzed data on 44,667 ischemic stroke patients (median age 72; 49 percent women) who received tPA in less than three hours at 1,440 hospitals between 2003 and 2010.

Researchers compared patients who arrived at the hospital, received tPA and were later admitted there to those patients who received tPA at the arriving hospital and then were transferred to a certified stroke center.

Among the one-fourth who were transferred to certified stroke centers they found:

Most were younger, more often male, and more often white.

Transferred patients were more likely to arrive during off-hours (7 a.m.-5 p.m. Monday-Friday).

Hospitals that accepted transferred patients were bigger with more beds, were more likely to be academic medical centers, have achieved certification as a designated stroke center, and have maintained a higher volume of stroke cases per year.

Hospitals that accepted transferred stroke patients were more common in the Midwest.

Researchers said their study suggests that more patients are getting the critical medication they need before being transferred to a certified stroke center. When it comes to stroke, ‘time is brain,’ which means every hour counts in moving a stroke patient to a facility equipped with stroke experts, the proper diagnostic equipment and treatment. Not all facilities have this, particularly smaller community hospitals. Different hospitals vary on how fast stroke patients receive tPA. There’s also wide variation in the type of patients who are transferred from smaller community hospitals to designated stroke centers.

Stroke occurs in 795,000 Americans every year and is the fifth-leading cause of death. Since 2003, the American Heart Association's Get With the Guidelines in-hospital stroke treatment program has promoted consistent compliance with the latest scientific treatment protocols, including the rapid administration of tPA. Inter-hospital transfer may help boost the timely use of tPA and save lives because it means patients received tPA no matter where they went for care before being transferred to a stroke center.

Dr. Sheth said he was surprised intracranial hemorrhage (a bleeding within the skull) was higher among transferred stroke patients, a finding that warrants further study. “We don't know the initial stroke severity for these patients and it's unclear why some patients were chosen to be transferred to a stroke center and others were not, though it's possible the sicker patients were the ones who were transferred to another facility,” he said. Why some geographic regions transfer stroke patients more than others and how can this transfer approach help facilitate increased use of tPA also needs further study, Sheth said.

Co-authors are Eric E. Smith M.D., Maria V. Grau-Sepulveda, M.D., M.P.H., Dawn Kleindorfer, M.D., Gregg C. Fonarow, M.D., and Lee H. Schwamm, M.D. Author disclosures are on the abstract.

Copyright © 2015 Elsevier Inc. All rights reserved.