| Objective:Based on the analysis of the current status of in-hospital treatment for stroke,stroke emergency specialized nurse-led in-hospital treatment mode for stroke is constructed,and its practical effect is evaluated.In addition,our research will provide a new perspective to improve the in-hospital treatment efficiency for stroke,and establish a basis to enhance the connotation of stroke emergency care and to broaden the career development of stroke emergency nurse.Methods:1?By literature research,the current situation of in-hospital treatment mode for stroke and the research progress of stroke nurses' practice were reviewed.2?The AIS in-hospital treatment process record had been developed by the research group at the early stage.In the present work,we revised the record,and then conducted an on-site observation with the record.Combined with case review,the operation efficiency of the process was explored.Through the methods of single factor analysis and stepwise multiple Logistic regression analysis,we screened the link factors of in-hospital delay,and according to the on-site observation records,we made a summary of the delay factors in each link.3?Semi-structured interviews were conducted to explore the in-hospital stroke team members' views and suggestions on the current status of in-hospital treatment and the practice of stroke emergency nurse.4?Based on the findings of literature research,survey and qualitative interviews,the framework of stroke emergency specialized nurse-led in-hospital treatment mode for stroke was constructed by referring to the Adaptive Leadership Framework and Business Process Management theory.And then,the framework was perfected at the expert meeting.5?A quasi-experimental study was conducted to evaluate the treatment mode in terms of treatment efficiency,patient outcomes,satisfaction of stroke team members and nursing profession identification.Results:1?Literature review showed that specialized nurses could effectively shorten the inhospital treatment time of stroke,but there was no post for stroke emergency nurses in mainland China yet,and nurses' functions of professional evaluation,quality management,whole-course coordination and professional decision-making had not been highlighted in the chain of stroke care.2?In the process status survey phase,a total of 202 cases of AIS patients who visited the hospital from August 2016 to June 2017 were included through case review,and 382 cases of suspected stroke patients who visited the hospital from July to September 2017 were followed up on the spot.The results showed that the median of DNT in 142 patients who received intravenous thrombolysis was 27.85 min,and DPT in 166 patients who received endovascular therapy was 89.0min,both of which were still far from the world-class level.Stepwise multivariate Logistic regression analysis showed that the link from doctor in the consulting room was called to the doctor was present in the emergency preexamination triage(OR=21.17,95%CI:3.90~115.00),the link from the doctor was present in the emergency preexamination triage to physical examination was completed(OR=18.61,95%CI:4.04 ~ 85.78),the link from patient arrived at the CT room to CT plain scan began(OR=5.66,95%CI:1.17~27.52),the link from CT plain scan was completed to the signing of the informed consent for thrombolysis(OR= 87.79,95%CI:13.39~575.81),and the link from signing of the informed consent for thrombolysis to the implementation of intravenous thrombolysis(OR=24.60,95%CI:4.37 ~ 138.43)were the key links in the process of intravenous thrombolysis.In addition,The key links of endovascular therapy included the link from physical examination was completed to patient arrived at the CT room(OR=14.63,95%CI:3.84~55.76),the link from CT plain scan began to CT plain scan was completed(OR=7.25,95%CI:1.74~30.28),the link from completion of CTA+CTP to signing informed consent for endovascular therapy(OR=32.87,95%CI:7.47~144.63),the link from signing informed consent for endovascular therapy to arriving at catheterization room(OR=28.97,95%CI:6.35~132.11),and the link from completion of patient placement to femoral artery puncture(OR=7.58,95%CI:1.96~29.27).The analysis of link delays showed that factors including stroke team members' not in position in time,poor connection bewteen emergency department and catheterization room and delays in patient decision,had extended the time of key links.The above findings suggested stroke emergency nurses need to pay attention to the key links and take some measures,such as guiding the team members in position in time to eliminate multiple-links' startup delay,strengthening the communication and collaboration among multidisciplinary team to promote more seamless link,providing predictive health propaganda and education to shorten the decision delays,so as to reduce the possibility of in-hospital delay.3?6 topics were extracted from the semi-structured interviews:(1)the current situation of in-hospital treatment for stroke is basically recognized;(2)multiple-links delays existed in endovascular therapy process;(3)the demand for extending the stroke emergency nursing force to endovascular therapy;(4)The functions of stroke emergency nurse could be further expanded;(5)the demand for training stroke emergency specialized nurse to lead the inhospital treatment of stroke by playing the roles and functions of liaison,educator,quality controller and decision maker;(6)the demand for improving the related factors to guarantee stroke emergency nurses' leading role.4?The stroke emergency specialized nurse-led in-hospital treatment mode consisted of six core elements,including the principles of mode construction,organization framework,process,personnel security,technology and hardware support,system guarantee.In this mode,stroke emergency specialized nurse played a leading role through providing wholeprocess direct nursing,coordinating a multidisciplinary team,supervising the team members' in-position efficiency and providing dynamic feedback on the process operation quality with the help of information technology,conducting multiple-link and predictive health education,taking part in the decision-making.5?In the quasi-experimental study phase,the control group included 338 patients with stroke who visited the hospital from August 2016 to December 2017,and the observation group included 257 patients with stroke who visited the hospital from February 2018 to October 2018.Compared with the control group,the median of DNT and DPT in the observation group was shortened from 28.20 min to 20.90 min and 90.10 min to 70.00 min respectively,and the proportion of DNT?30min and DPT?90min increased from 54.44% to 79.05% and 49.77% to 80.87% respectively,with statistically significant differences(P < 0.0001).Median arrival time of doctors in the consulting room,thrombolytic doctors and interventional doctors was shortened from 2.50 min to 1.90 min,4.80 min to 4.00 min and 6.50 min to 4.50 min respectively,with statistically significant differences(P < 0.0001).The median time from CT scanning to femoral artery puncture,from signing the informed consent for endovascular therapy to reaching the angiography suite,and from patient placement to femoral artery puncture was shortened from 71.70 min to 56.62 min,12.10 min to 5.20 min,and 15.20 min to 11.50 min respectively,with statistically significant differences(P < 0.0001).The median time from the completion of CT to the signing of informed consent for intravenous thrombolysis was shortened from 9.00 min to 3.50min(P < 0.0001),and the median time from the completion of CTA+CTP to the signing of informed consent for endovascular therapy was shortened from 34.00 min to 29.50min(P > 0.05).Under the stroke emergency specialized nurse-led in-hospital treatment mode,the hospitalization time was shortened and statistically significant(P < 0.0001).There were no statistical differences in NIHSS score within 24 h and a week after treatment,the incidence of symptomatic intracranial hemorrhage,the percentage of mRS ? 2 within 90 days after treatment,hospitalization expenses between these two groups(P > 0.05).Each dimension scores of team member's satisfaction were higher than that of the period before the practice of the mode,and the differences were statistically significant(P < 0.0001).Each dimension and overall scores of the nursing profession identification scale of stroke emergency specialized nurses were higher than that of stroke emergency nurses,and the differences were statistically significant(P<0.05).Conclusion:1 ? Through literature research,inventory survey,qualitative interviews and expert meetings,the stroke emergency specialized nurse-led in-hospital treatment mode for stroke was constructed,which consisted of six elements,including principles of mode construction,organization framework,process,personnel security,technology and hardware support,system guarantee.Stroke emergency specialized nurse led to efficient operation of the inhospital treatment process for stroke through assisting professional evaluation and decisionmaking,offering multidisciplinary liaison and early warning,supervising the in position efficiency of team members,providing feedbacks on the process operation status and conducting predictive health education.2?The empirical research showed that the stroke emergency specialized nurse-led inhospital treatment mode for stroke could effectively improve the in position efficiency of stroke team members,shorten patients' decision time,promote the seamless connection of multiple links,thus the overall efficiency of in-hospital treatment of stroke was improved.In the meanwhile,patients' safety was guaranteed when the time was shortened and the utilization ratio of health resources was increased.3?The practice of stroke emergency specialized nurse had improved the satisfaction of in-hospital stroke team members on stroke emergency care.By leading the in-hospital treatment of stroke,stroke emergency specialized nurses themselves had also gained a higher professional identity. |
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