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Abstract
Background: Despite proven efficacy of intravenous tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT) in acute ischemic stroke, there has been slow administration of these therapies in the real world practice. We examined the ongoing quality improvement in acute stroke care at our comprehensive stroke center. Methods: Consecutive patients with acute ischemic stroke from 2013 to 2018 were studied. Patients were managed using Code Stroke algorithm per concurrent AHA guidelines and a simple quality improvement protocol implemented in 2015. Demographics and clinical data were collected from Get-With-The-Guideline-Stroke registry and electronic medical records. Patients were divided into 3 groups per admission and implementation date of quality improvement initiatives. Quality measures, including rates of intravenous tPA and EVT, door-to-needle (DTN) time, and door-to-puncture (DTP) time, were analyzed with general mean linear regression models and Jonckheere-Terpstra test. Results: Of the 1,369 eligible patients presenting within 24 hours of symptom onset or wakeup stroke, the rate of intravenous tPA was 20%, 30% and 22%, respectively, in 2013-2014, 2015-2016, and 2017-2018. In contrast, EVT rate was 9%, 14% and 15%, respectively. Based on Jonckheere-Terpstra test, there was significant ongoing improvement in the median DTN time (57, 45, 39 minutes; p < 0.001) and DTP time (172, 130, 114 minutes; p =0.009) during the 3 time periods, with DTN time ≤ 60 and ≤45 minutes in 80% and 63% patients, respectively, in 2017-2018. Conclusions: Getting with the guidelines and simple quality improvement initiatives are associated with satisfactory rates of acute stroke therapy and ongoing improvement in door to treatment times.
Highlights
Stroke is the 5th cause of death and a leading cause of long-term disability in the United States [1,2]
From January 1, 2013 to December 31, 2018, 1,759 patients were admitted to the medical center for acute ischemic stroke (AIS) within 24 hours of symptom onset or wakeup stroke
390 patients were excluded from the study for the following reasons (Figure 1): 1). 274 patients were transferred from outside hospitals for higher level of care, including 58 treated with intravenous tissue plasminogen activator (tPA) at outside facilities; 2). 78 patients were inpatient consultations for suspected ischemic stroke; 3). 25 patients presented with subacute infarction that was confirmed by brain imaging, 4). 12 patients were outliners for LOS (≥ 28 days) and discharge outcome due to insurance issue; and 5). 1 patient left hospital against medical advice
Summary
Stroke is the 5th cause of death and a leading cause of long-term disability in the United States [1,2]. Intravenous thrombolysis with tissue plasminogen activator (tPA) is the only proven medical therapy for acute ischemic stroke (AIS) within 4.5 hours of symptoms onset [3, 4]. Despite proven efficacy of intravenous tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT) in acute ischemic stroke, there has been slow administration of these therapies in the real world practice. Quality measures, including rates of intravenous tPA and EVT, door-to-needle (DTN) time, and door-to-puncture (DTP) time, were analyzed with general mean linear regression models and Jonckheere-Terpstra test. Conclusions: Getting with the guidelines and simple quality improvement initiatives are associated with satisfactory rates of acute stroke therapy and ongoing improvement in door to treatment times.
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