Abstract 3896: Positive Deviance of Acute Ischemic Stroke Care: Time Truly is Brain at Best Practice Hospitals

Abstract

Objectives As of July 31, 2011, only 133 national stroke centers have been recognized on the AHA Target: Stroke Honor Roll. At these hospitals, at least 50% of treated ischemic stroke patients receive IV thrombolysis within an hour of arrival. Utilizing positive deviance methodology, successful strategies and institutional culture were identified among a selection of these hospitals. Methods Structured phone interviews were conducted with Stroke Program Coordinators of 12 Honor Roll centers. Detailed descriptions of evaluation and treatment process and methodology were elicited. Emphasis was placed on changes instituted, barriers, and delays. Each hospital was asked which elements were critical to their success. Common themes were identified. Utilization of the 10 AHA Target: Stroke best practice strategies was assessed. Findings Seven of ten AHA best practice strategies were employed by 100% of the interviewed hospitals: “Advance Hospital Notification by EMS”, “Rapid Triage Protocol and Stroke Team Notification”, “Rapid Acquisition and Interpretation of Brain Imaging”, “Rapid Laboratory Testing (Including point of Care Testing if indicated)”, “Rapid Access to Intravenous rt-PA, Team-Based Approach”, and “Prompt Data Feedback”. 58% of the hospitals utilized “Single Call Activation System”. “Stroke Tools” and “Mix rt-PA Medication Ahead of Time” were implemented by 50% of the hospitals. Additional strategies identified included: active time monitoring, allowing t-PA ordering with lab results pending, utilization of non-Neurologist staff as lead in stroke alerts, required NIHSS training for all ED staff, and visual feedback of performance to staff. Common themes of institutional culture included strong stroke champions in multiple departments, empowering staff to find department-specific solutions to solve the common challenge, and setting progressively more ambitious targets. A unifying theme throughout all hospitals was an extreme sense of urgency and utmost priority on time to stroke treatment. Conclusion Positive deviance methodology examines a common challenge and identifies successful outliers. Although the majority of the AHA strategies were supported by the interviewed hospitals, many centers modified methods to achieve the goal of Target: Stroke. For rapid treatment of ischemic stroke the positive deviance lies in institutional culture of urgency and continuous improvement. Best practice hospitals create a healthy competition amongst staff, solidify interdepartmental partnerships, instill an equal sense of accountability, open communication, and an atmosphere of teamwork. A great deal of variation was discovered in roles and processes employed by the hospitals, though all identified the essential goal of fostering a culture of motivation and urgency.