In a study that included more than 71,000 stroke patients, implementation of a quality initiative was associated with improvement in the time to treatment and a lower risk of in-hospital death and intracranial hemorrhage, and an increase in the portion of patients discharged to home.
Intravenous tissue plasminogen activator reduces long-term disability when administered early to eligible patients with acute ischemic stroke, according to background information in the study, which was published in the April 23-30 issue of the Journal of the American Medical Association, a neurology-themed edition.
These benefits, however, are highly time dependent. Because of the importance of rapid treatment, national guidelines recommend that hospitals complete the evaluation of patients with acute ischemic stroke and begin intravenous tPA therapy for eligible patients within 60 minutes of hospital arrival. However, prior studies demonstrate that less than a third of patients are treated within the recommended time frame, and this measure has improved minimally over time.
Gregg C. Fonarow, MD, of UCLA, and colleagues examined the results of a national quality improvement initiative that was launched to increase timely stroke care. This study included 71,169 patients with acute ischemic stroke treated with tPA from 1,030 participating hospitals.
The Target: Stroke initiative included 10 key strategies to achieve faster door-to-needle times for tPA administration, provided clinical decision support tools, facilitated hospital participation and encouraged sharing of best practices. The strategies included promoting prenotification of hospitals by emergency medical services personnel, activating the entire stroke team with a single call or page, rapid acquisition and interpretation of brain imaging, use of specific protocols and tools, premixing tPA for high-likelihood candidates, a stroke team-based approach, and rapid feedback to the stroke team on performance, the authors wrote.
The researchers found that measures of door-to-needle time for tPA administration improved significantly during the postintervention period compared with the preintervention period, as did clinical outcomes. The median door-to-needle time for tPA administration for the preintervention period was 77 minutes, which decreased to 67 minutes for the entire postintervention period. Door-to-needle times for tPA administration of 60 minutes or less increased from 26.5% to 41.3% (and from 29.6% to 53.3% at the end of each intervention period).
Other improvements included in-hospital deaths (9.9% to 8.3%), discharge to home (38% to 43%), independence with walking (42% to 45%) and symptomatic intracranial hemorrhage within 36 hours (5.7% to 4.7%).
The researchers also found more than a four-fold increase in the yearly rate of improvement in the proportion of patients with door-to-needle times of 60 minutes or less after initiation of the intervention.
These findings further reinforce the importance and clinical benefits of more rapid administration of intravenous tPA, the authors wrote.
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