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目的了解急性心肌梗死病种质量影响因素,以规范诊疗流程,提高病种质量和管理水平。方法回顾性调查2011年急性心肌梗死患者的急诊和住院病历,按照质量标准进行统计与分析。结果 193例患者中,治愈好转患者170例,平均住院日14.5天,未实施PCI手术患者平均费用8624.18元,PCI手术患者平均费用44144.4元。在环节质量指标调查中,入院24小时内能完成心脏超声检查115例,未在标准时间内完成78例;35例实施药物溶栓的患者,药物溶栓开始时间均超过标准时间;110例实施PCI手术患者,在标准时间内完成41例,超过规定时间完成69例;实施低密度脂蛋白胆固醇评估仅28例,实施健康教育尤其是戒烟劝告与咨询仅35例。还存在病历书写不规范和用药不合理因素。结论医院应制定病种诊疗流程、进行医院培训和科室内训、设计开发单病种临床路径系统、加强病历质量监控等,持续改进急性心肌梗死病种质量。
Objective To understand the influencing factors of quality of acute myocardial infarction in order to standardize the diagnosis and treatment process and improve the quality of disease and management. Methods The emergency medical records and hospital records of patients with acute myocardial infarction in 2011 were retrospectively analyzed and statistically analyzed according to the quality standard. Results Among the 193 patients, 170 patients were cured and the mean hospital stay was 14.5 days. The average cost of patients without PCI was 8624.18 yuan and the average cost of PCI patients was 44,144.4 yuan. In the link quality index survey, 115 cases of cardiac ultrasonography were completed within 24 hours after admission, 78 cases were not completed within the standard time. Thirty-five patients undergoing drug thrombolysis started the thrombolytic therapy more than the standard time; In the PCI group, 41 cases were completed within the standard time and 69 cases were completed within the prescribed time. Only 28 cases were evaluated with LDL cholesterol, and only 35 cases with health education, especially smoking cessation advice and counseling. There are also non-standard medical records and medication unreasonable factors. Conclusion The hospital should formulate the diagnosis and treatment process of disease, conduct hospital training and internal training, design and develop the single pathological clinical path system, strengthen the medical records quality control, and continuously improve the quality of the acute myocardial infarction.