Comparison of performance achievement award recognition with primary stroke center certification for acute ischemic stroke care.

BackgroundHospital certification and recognition programs represent 2 independent but commonly used systems to distinguish hospitals, yet they have not been directly compared. This study assessed acute ischemic stroke quality of care measure conformity by hospitals receiving Primary Stroke Center (PSC) certification and those receiving the American Heart Association's Get With The Guidelines-Stroke (GWTG-Stroke) Performance Achievement Award (PAA) recognition.Methods and resultsThe patient and hospital characteristics as well as performance/quality measures for acute ischemic stroke from 1356 hospitals participating in the GWTG-Stroke Program 2010-2012 were compared. Hospitals were classified as PAA+/PSC+ (hospitals n = 410, patients n = 169,302), PAA+/PSC- (n = 415, n = 129,454), PAA-/PSC+ (n = 88, n = 26,386), and PAA-/PSC- (n = 443, n = 75,565). A comprehensive set of stroke measures were compared with adjustment for patient and hospital characteristics. Patient characteristics were similar by PAA and PSC status but PAA-/PSC- hospitals were more likely to be smaller and nonteaching. Measure conformity was highest for PAA+/PSC+ and PAA+/PSC- hospitals, intermediate for PAA-/PSC+ hospitals, and lowest for PAA-/PSC- hospitals (all-or-none care measure 91.2%, 91.2%, 84.3%, and 76.9%, respectively). After adjustment for patient and hospital characteristics, PAA+/PSC+, PAA+/PSC-, and PAA-/PSC+ hospitals had 3.15 (95% CIs 2.86 to 3.47); 3.23 (2.93 to 3.56) and 1.72 (1.47 to 2.00), higher odds for providing all indicated stroke performance measures to patients compared with PAA-/PSC- hospitals.ConclusionsWhile both PSC certification and GWTG-Stroke PAA recognition identified hospitals providing higher conformity with care measures for patients hospitalized with acute ischemic stroke, PAA recognition was a more robust identifier of hospitals with better performance

Patterns, predictors, variations, and temporal trends in emergency medical service hospital prenotification for acute ischemic stroke.

BACKGROUND#ENTITYSTARTX02014;: Emergency medical services (EMS) hospital prenotification of an incoming stroke patient is guideline recommended as a means of increasing the timeliness with which stroke patients are evaluated and treated. Still, data are limited with regard to national use of, variations in, and temporal trends in EMS prenotification and associated predictors of its use. METHODS AND RESULTS#ENTITYSTARTX02014;: We examined 371 988 patients with acute ischemic stroke who were transported by EMS and enrolled in 1585 hospitals participating in Get With The Guidelines-Stroke from April 1, 2003, through March 31, 2011. Prenotification occurred in 249 197 EMS-transported patients (67.0%) and varied widely by hospital (range, 0% to 100%). Substantial variations by geographic regions and by state, ranging from 19.7% in Washington, DC, to 93.4% in Montana, also were noted. Patient factors associated with lower use of prenotification included older age, diabetes mellitus, and peripheral vascular disease. Prenotification was less likely for black patients than for white patients (adjusted odds ratio 0.94, 95% confidence interval 0.92-0.97, P<0.0001). Hospital factors associated with greater EMS prenotification use were absence of academic affiliation, higher annual volume of tissue plasminogen activator administration, and geographic location outside the Northeast. Temporal improvements in prenotification rates showed a modest general increase, from 58.0% in 2003 to 67.3% in 2011 (P temporal trend <0.0001). CONCLUSIONS#ENTITYSTARTX02014;: EMS hospital prenotification is guideline recommended, yet among patients transported to Get With The Guidelines-Stroke hospitals it is not provided for 1 in 3 EMS-arriving patients with acute ischemic stroke and varies substantially by hospital, state, and region. These results support the need for enhanced implementation of stroke systems of care. (J Am Heart Assoc. 2012;1:e002345 doi: 10.1161/JAHA.112.002345.)

Trombolisis en la enfermedad cerebrovascular

Ischemic stroke is the leading cause of disability and the third death in modern society. The end result after a stroke depends on the speed and quality of treatment, starting at implementing strategies to reduce the delay, both extra- and intra-hospital, in health care. Assistance includes patient stabilization, with special attention to the maintenance of the airway, and the management of blood pressure and heart rate. The initial assessment should be quick and be focused on the differential diagnosis, the estimating of the size and location of the infarction, as well as consideration of therapies. Among them, the only currently approved is thrombolysis with intravenous recombinant tissue plasminogen activator or blood in selected patients with a clinical course of less than three hours.El ictus isquémico es la primera causa de invalidez y la tercera de muerte en la sociedad moderna. El resultado final tras un ictus depende de la celeridad y la calidad del tratamiento, que se inicia al aplicar las estrategias para reducir la demora, tanto extra como intrahospitalaria, en la asistencia médica. La asistencia incluye la estabilización del paciente, con especial atención al mantenimiento de la vía aérea, y el manejo de la presión arterial y del ritmo cardíaco. La evaluación inicial debe ser rápida y estar enfocada al diagnóstico diferencial, la estimación del volumen y la localización del infarto, así como a la consideración de terapias. Entre ellas, la única aprobada hasta el momento, es la trombolisis con plasminógeno tisular recombinante intravenoso o arterial en pacientes seleccionados y con un curso clínico de menos de tres horas de duración

Geographic and Sociodemographic Disparities in Drive Times to Joint Commission–Certified Primary Stroke Centers in North Carolina, South Carolina, and Georgia

Introduction: Timely access to facilities that provide acute stroke care is necessary to reduce disabilities and death from stroke. We examined geographic and sociodemographic disparities in drive times to Joint Commission–certified primary stroke centers (JCPSCs) and other hospitals with stroke care quality improvement initiatives in North Carolina, South Carolina, and Georgia. Methods: We defined boundaries for 30- and 60-minute drive-time areas to JCPSCs and other hospitals by using geographic information systems (GIS) mapping technology and calculated the proportions of the population living in these drive-time areas by sociodemographic characteristics. Age-adjusted county-level stroke death rates were overlaid onto the drive-time areas. Results: Approximately 55% of the population lived within a 30-minute drive time to a JCPSC; 77% lived within a 60-minute drive time. Disparities in percentage of the population within 30-minute drive times were found by race/ethnicity, education, income, and urban/rural status; the disparity was largest between urban areas (70% lived within 30-minute drive time) and rural areas (26%). The rural coastal plains had the largest concentration of counties with high stroke death rates and the fewest JCPSCs. Conclusion: Many areas in this tri-state region lack timely access to JCPSCs. Alternative strategies are needed to expand provision of quality acute stroke care in this region. GIS modeling is valuable for examining and strategically planning the distribution of hospitals providing acute stroke care

Time Trends in Survival Following First Hemorrhagic or Ischemic Stroke Between 1991 and 2015 in the Rotterdam Study

Background and Purpose- The introduction of stroke units and the implementation of evidence-based interventions have been a breakthrough in the management

Substantial Progress Yet Significant Opportunity for Improvement in Stroke Care in China

BACKGROUND AND PURPOSE: Stroke is a leading cause of death in China. Yet the adherence to guideline-recommended ischemic stroke performance metrics in the past decade has been previously shown to be suboptimal. Since then, several nationwide stroke quality management initiatives have been conducted in China. We sought to determine whether adherence had improved since then. METHODS: Data were obtained from the 2 phases of China National Stroke Registries, which included 131 hospitals (12 173 patients with acute ischemic stroke) in China National Stroke Registries phase 1 from 2007 to 2008 versus 219 hospitals (19 604 patients) in China National Stroke Registries phase 2 from 2012 to 2013. Multiple regression models were developed to evaluate the difference in adherence to performance measure between the 2 study periods. RESULTS: The overall quality of care has improved over time, as reflected by the higher composite score of 0.76 in 2012 to 2013 versus 0.63 in 2007 to 2008. Nine of 13 individual performance metrics improved. However, there were no significant improvements in the rates of intravenous thrombolytic therapy and anticoagulation for atrial fibrillation. After multivariate analysis, there remained a significant 1.17-fold (95% confidence interval, 1.14-1.21) increase in the odds of delivering evidence-based performance metrics in the more recent time periods versus older data. The performance metrics with the most significantly increased odds included stroke education, dysphagia screening, smoking cessation, and antithrombotics at discharge. CONCLUSIONS: Adherence to stroke performance metrics has increased over time, but significant opportunities remain for further improvement. Continuous stroke quality improvement program should be developed as a national priority in China

Risks and Benefits Associated With Prestroke Antiplatelet Therapy Among Patients With Acute Ischemic Stroke Treated With Intravenous Tissue Plasminogen Activator

IMPORTANCE: Intravenous tissue plasminogen activator (tPA) is known to improve outcomes in ischemic stroke; however, many patients may have been receiving antiplatelet therapy before acute ischemic stroke and could face an increased risk for bleeding when treated with tPA. OBJECTIVE: To assess the risks and benefits associated with prestroke antiplatelet therapy among patients with ischemic stroke who receive intravenous tPA. DESIGN, SETTING, AND PARTICIPANTS: This observational study used data from the American Heart Association and American Stroke Association Get With the Guidelines-Stroke registry, which included 85 072 adult patients with ischemic stroke who received intravenous tPA in 1545 registry hospitals from January 1, 2009, through March 31, 2015. Data were analyzed during the same period. EXPOSURES: Prestroke antiplatelet therapy before tPA administration for acute ischemic stroke. MAIN OUTCOMES AND MEASURES: Symptomatic intracranial hemorrhage (sICH), in-hospital mortality, discharge ambulatory status, and modified Rankin Scale score (range, 0 [no symptoms] to 6 [death]). RESULTS: Of the 85 072 registry patients, 38 844 (45.7%) were receiving antiplatelet therapy before admission; 46 228 patients (54.3%) were not. Patients receiving antiplatelet therapy were older (median [25th-75th percentile] age, 76 [65-84] vs 68 [56-80] years) and had a higher prevalence of cardiovascular risk factors. The unadjusted rate of sICH was higher in patients receiving antiplatelet therapy (5.0% vs 3.7%). After risk adjustment, prior use of antiplatelet agents remained associated with higher odds of sICH compared with no use (adjusted odds ratio [AOR], 1.18 [95% CI, 1.10-1.28]; absolute difference, +0.68% [95% CI, 0.36%-1.01%]; number needed to harm [NNH], 147). Among patients enrolled on October 1, 2012, or later, the highest odds (95% CIs) of sICH were found in 15 116 patients receiving aspirin alone (AOR, 1.19 [1.06- 1.34]; absolute difference [95% CI], +0.68% [0.21%-1.20%]; NNH, 147) and 2397 patients receiving dual antiplatelet treatment of aspirin and clopidogrel (AOR, 1.47 [1.16-1.86]; absolute difference, +1.67% [0.58%-3.00%]; NNH, 60). The risk for in-hospital mortality was similar between those who were and were not receiving antiplatelet therapy after adjustment (8.0% vs 6.6%; AOR, 1.00 [0.94-1.06]; nonsignificant absolute difference, -0.01% [-0.37% to 0.36%]). However, patients receiving antiplatelet therapy had a greater risk-adjusted likelihood of independent ambulation (42.1% vs 46.6%; AOR, 1.13 [1.08-1.17]; absolute difference, +2.23% [1.55%-2.92%]; number needed to treat, 43) and better functional outcomes (modified Rankin Scale score, 0-1) at discharge (24.1% vs 27.8%; AOR, 1.14; 1.07-1.22; absolute difference, +1.99% [0.78%-3.22%]; number needed to treat, 50). CONCLUSIONS AND RELEVANCE: Among patients with an acute ischemic stroke treated with intravenous tPA, those receiving antiplatelet therapy before the stroke had a higher risk for sICH but better functional outcomes than those who were not receiving antiplatelet therapy

Prehospital Phase of the Stroke Chain of Survival : A Prospective Observational Study

Background-Few studies have discussed the emergency call and prehospital care as a continuous process to decrease the prehospital and in-hospital delays for acute stroke. To identify features associated with early hospital arrival ( Methods and Results-This was a 2-year prospective observational study. All stroke patients who were transported to the hospital by emergency medical services and received recanalization therapy were recruited for the study. For a sample of 308 patients, the stroke code was activated in 206 (67%) and high priority was used in 258 (84%) of the emergency calls. Emergency medical services transported 285 (93%) of the patients using the stroke code and 269 (87%) using high priority. In the univariate analysis, the most dominant predictors of early hospital arrival were transport using stroke code (P= 0.001) and high priority (P= 0.002) and onset-to-call (P 23.5 minutes) for both early and late-arriving patients. Conclusions-Fast emergency medical services activation and ambulance transport promoted early hospital arrival and treatment. Although patient-dependent delays still dominate the prehospital process, it should be ensured that the minutes on the scene are well spent.Peer reviewe

The Role of Empowerment Among a Code Stroke Team and its Effect on Stroke Outcomes

Background: Code Stroke Teams in hospitals provide emergency deployment of stroke clinical care experts for treatment of an acute stroke. Code Stroke Teams monitor their effectiveness using standards for stroke patient outcomes provided by the American Heart Association (AHA) and American Stroke Association (ASA) Stroke measures. This project was conducted in a Southern California suburban hospital where changes in leadership and high turnover rates had led to Code Stroke Team members experiencing decreased motivation, job satisfaction and low morale leading to substandard stroke patient outcomes. Aim: This quality improvement project aimed to empower staff, improve performance and stroke outcomes by giving monthly presentations of successful Code Stroke cases to the Stroke Performance Improvement Committee leaders and stroke team staff. Methods: Stroke Performance Improvement Committee leaders and stroke team staff participated monthly in an empowerment intervention through presentation of a stroke case on a “Code Stroke Spotlight” handout (Educational Empowerment Tool) over a 3 month period. Using a repeated measures, pre- post design, staff empowerment (measured by the Psychological Empowerment Instrument) and American Heart Association (AHA) Core Emergency Department Stroke Measures were collected prior to the intervention at baseline and post empowerment intervention following monthly implementation over 3 months.Results: Results showed statistically significant improvement in all items on the Psychological Empowerment (PE) Instrument using Wilcoxon signed-rank test (p<0.05) (N = 32). Door to neuro MD (neurologic expertise consult) <15 minutes showed significant improvement post intervention (z =-2.285, p = 0.023). Door to PT/INR result <45 minutes showed statistical significance (z =-2.931, p = 0.003). Door to CT film <20 minutes showed no change (z=0.000, p = 1.000). For the remaining goals there was improvement in right direction, demonstrating decreased door to activation times, though these did not reach statistical significance. Discussion: Implementation of the ‘Code Stroke Empowerment Spotlight’ intervention effectively improved staff empowerment and performance on American Heart Association (AHA) and American Stroke Association (ASA) Stroke core measures. Future studies are needed to evaluate positive reinforcement, meaningful recognition, and empowerment specific to those caring for stroke patients