【作者】 陈昊；

【导师】 李书章；

【作者基本信息】 第三军医大学 ， 社会医学与卫生事业管理学， 2012， 博士

【摘要】 我国心血管病发病的危险因素持续增长，心血管病发病率和死亡率居高不下，疾病负担日益加重，已成为重要公共卫生问题，加强心血管病防治刻不容缓。心血管病的急救模式在发达国家已经比较成熟，但在我国仍处于探索阶段。本研究从信息技术、管理科学与医学的学科交叉领域入手，探索依据心血管病相关专业指南，利用现代网络信息技术，构建以人为中心，高效，易推广的心血管病急救模式。在理论研究方面，通过对心血管病相关专业指南及防治现状、区域医疗协同、信息技术和管理理论的综合分析、提炼创新，提出了心血管病“时空救治”概念，并明确了其基本概念和特点，即基于现代网络信息技术和心血管病相关专业指南，通过区域医疗协同，为心血管病病人提供适时、适地、无边界的连续性医疗服务，使心血管病急救在时间和空间上达到高度统一，最终获得最好的救治效果，促进心血管病病人健康的恢复。积极探索以时空救治理论为中心的心血管病急救模式。以区域医疗协同为基本途径，通过物联网、云计算、远程医疗、移动医疗信息技术与心血管病急救流程管理的综合集成运用，实现对象的感知、急救流程的标准化处置和全过程标准化管理，将院内信息系统的集成与整合扩展到了院前，并提供远程专家会诊与诊疗指导，使院内急救向院前延伸。以远程急救与健康管理云平台为支撑，构建了“高危预警→院前急救→院内救治→重症监护”闭环管理，以及监控的数据链和标准化业务流程，形成区域性技术纽带和优势。通过中心医院-二级医院-社区医院联合，打造“移动ICU”和“远程ICU”，使其运行机制与急救机构合作机制、服务衔接机制和信息畅通机制有机结合，形成了以社区医疗服务为网底、以大型医院专科救治力量为中心的区域协同心血管病急救网络。围绕上述理论探索，进行了两个方面的实证研究：一是对8084例心血管病病人资料进行危险因素综合危险分层分析。研究发现：危险因素常规分级与综合危险分层不一致、常用正常值与个体化治疗目标的不一致、不同指南建议的治疗目标不一致，显示在临床实践中多指南综合分析、指南的个体化执行的重要性，这对于心血管病急救预警机制的建立具有重要参考价值。二是以某军区总医院胸痛中心和基于移动物联网的军地区域协同胸痛急救网建设运营为研究对象，将实施“新模式”后收治的609例胸痛病人作为研究组，实施“新模式”前收治的528例胸痛病人作为对照组，进行效果评价分析，结果显示：①缩短了救治时间：研究组82.5%病人D2B时间低于90min、最短时间24min，中位D2B时间仅为69min；对照组26.0%病人D2B时间低于90min、最短时间72min，中位D2B时间为121min，结果显示“新模式”的实施显著缩短了D2B时间（P<0.001），优于国际标准（中位D2B时间90min，D2B时间低于90min的不少于75%）。而在欧美等发达国家，中位D2B时间为55min~147min，D2B达到指南目标值的4.2%~80%，国内最近研究报道中位D2B时间为92min~135min，D2B达到指南目标值90min的仅有18.1%~58.4%。同时发现，“新模式”实施后绕行急诊科直接进心内科导管室和院前实时传输ECG是D2B时间＜90min的独立预测因素（OR1.973，95%CI：1.040~3.788，P=0.028和OR1.876，95%CI：1.030~3.465，P=0.021）。②提高了救治成功率：PCI、主动脉夹层和其他急诊手术院内死亡率研究组和对照组无明显差异（2.6%vs.2.4%,11.1%vs.22.7%,0vs.2.3%，P>0.05）；急性ST段抬高型心肌梗死PCI成功率97.4%（150/154），主动脉夹层手术成功率88.9%（24/27），而国内平均水平分别为90%和10%。③缩短了平均住院日，降低了住院费用：研究组中引起胸痛的三大重症（ST抬高型心肌梗死、非ST段抬高型心肌梗死、主动脉夹层）的平均住院费用和平均住院日均显著低于对照组（P<0.001），其中平均住院日缩短了30.3%~42.3%，人均住院费用下降了8.0%~14.5%，而国内心血管病出院人次数年平均增长速度8.28%，急性心肌梗死人均住院费用增长速度为9.68%。实证研究中通过在急救第一时间采集病人生命体征数据、生化检测指标等关键诊疗信息，并准确有效的传递，与专家远程指导的实时同步，为快速诊断、危险分层和不同救治策略的实施赢得最佳时间提供了技术保障。打造了高效的专业化急救团队，建立了快速急救反应机制和绕行急诊的绿色通道，提高了急救医疗服务传递系统中合作和沟通的效率。建立多机构、跨学科、多部门的分级救治机制、协同救治机制和科研合作机制，并在区域内形成网络化布局，中心医院参与基层医院急救，实现了信息共享、服务协同和管理协同，在不改变现有医疗资源格局前提下，充分利用大医院的资源优势带动基层医院全面发展和技术提升，创新了大医院与基层医院的帮带模式。实证启示：在我国胸痛中心建设中一是要提高对胸痛中心建设重要性的认识；二是要规范我国胸痛中心建设的基本方向；三是本研究所采用的最新信息技术和管理方法，可为胸痛中心建设提供借鉴和支撑。心血管病急救模式建设需要审慎、有计划的组织，探索定性和定量的评定和分析方法。需要详细和充分地确定医疗系统各种真正的医疗需要，探讨针对现有的医疗急救体系的优化改进方案，逐步建立起心血管病急救医疗服务及其相应的标准，对急救机构、急救专业技术人员，以及对急救医疗服务产生影响的各类社会组织和个人进行规范和培训。更多还原

【Abstract】 The risk factors of cardiovascular disease (CVD) are increasing persistently in Chinawith the morbidity and mortality of CVD remaining at a high level.The aggravating burden ofCVD becomes an important issue of public health.The prevention and treatment of CVDshould be reinforced immediately.The emergency cardiovascular care model，though maturein developed countries is still at exploring stage in China. This study is to build apeople-centred emergency cardiovascular care model with high efficiency, easyreproducibility and dissemination to facilitate the implementation of multiple clinical practicguidelines based on modern network information technology，which involved the fields ofinformation technology，management science and medicine.At theoretical level, the conception of time-space emergency cardiovascular care was firstexplored through comprehensive analysis and innovation on the cardiovascular CPGs，regional cooperative healthcare，information technology and related management theory.time-space emergency cardiovascular care was defined as to provide continuous emergencycardiovascular care for anyone， anywhere and anytime through regional cooperativehealthcare，which promotes evidence-based processes and modern network informationtechnology， resulting in improved quality outcomes for cardiac patients.Time-space emergency cardiovascular care mode could be developed under the supportof regional cooperative healthcare，which integrated the latest progress of emergencycardiovascular care process management and the most advanced communication technologyand information technology such as internet of things，cloud computing，telemedicine andm-Health.Specialists in rescue center can guide the remote-site first medical aid to elevate thesuccess rate of rescue as well as to promote the professional technology of rural/communityhospitals. Based on the real-time remote transmission system of life-monitoring，we set up theintegrative system of heart attack risk assessment, early screening， pre-hospital andin-hospital care，ICU treatment. Based on the network with rural/community hospitals，we established remote ICU and mobile ICU，so that informations of patients with CVD inrural/community hospital can be transmitted to central hospital. Specialists in central hospitalcould guide of remote-site first aid treatment and transport ST-elevation myocardial infarction（STEMI） patient more rapidly and safely.On the basis of above theory explored，two empirical researches were conducted.Firstly，retrospective charts review of8084patients with CVD or risk factors wereassessed by the the implementation of multiple clinical practic guidelines for CVD. Thesurvey showed that disparities in apparent manifestation and stratified risk levels，disparitiesin standard normal value and guidelines recommended treatment target，disparities inrecommendations between guidelines，the disparities in the manifested appearances andcomprehensive assessment，demonstrated the importance of implementation of guidelines，which will play an early screening role in emergency cardiovascular care model.Secondly，we studied the1st normalized Chest Pain Center（CPC）and the regionalizedCPC networks based mobile internet of things in China which was established in GuangzhouGeneral Hospital. Patients with acute chest pain before and after new mode established wereevaluated. Median D2B time decreased from121min in the control group to69min in thestudy group (P<0.001).The percentage of D2B times<90min increased from26.0%to82.5%between the two groups（P<0.001）.After adjusting for patients and hospital characteristics，clinical pathway bypassing emergency department admission and pre-hospitalelectrocardiograph （PH-ECG） were independent predictors of D2B time within90min（OR1.973，95%CI:1.040~3.788， P=0.028and OR1.876，95%CI:1.030~3.465，P=0.021）.In-hospital mortality of percutaneous coronary intervention（PCI），aortic dissection（AD） and other operations did not differ significantly between2groups(2.6%vs.2.4%，1.1%vs.22.7%，0vs.2.3%，respectively；P>0.05). The mean hospitalization days and costs ofSTEMI，USTEMI，and AD were significantly reduced30.3%~42.3%，and8.0%~14.5%respectively in the study group (P<0.001). The study results showed that in-hospitalmortality，mean costs and days of hospitalization reduced by reducing time to diagnosis andtreatment， PH-ECG and clinical pathway bypassing emergency department admissionsignificantly reduces D2B time in STEMI patients.Finally，on the basis of the empirical study results，we conclude that new mode can helpto promote the professional skills of the physicians in rural/community hospitals in two ways： The circular training under the requirement of international certification of CPC helps toestablish the standard clinical pathways and the process of diagnosis and treatment.Theremote ICU helps to make decisions in daily practice with intensive care patients. Resourcesof general hospital were remotely used by rural/community hospital and promote the qualityrural/community hospital rescue more life. We should pay more attention to the importanceand normalized direction of CPC established in China，the most advanced IT and principles ofmanagement which used in this study may support the establishing of CPC.Emergency cardiovascular care model establishment should be organized in scrupulosityand designation，explored qualitative and quantitative methods in evaluation and analysis.Weshould definite the real demands of medical system in detail，promote optimized programstoward the existing emergency medical system，establish the standardization of emergencycardiovascular care model step by step to norm various kinds of social organization andindividual that may influence the emergency medical care.更多还原