Quality improvement program helps lower risk of bleeding, death following stroke

April 22, 2014

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, intracranial hemorrhage (bleeding in the brain), and an increase in the portion of patients discharged to their home, according to the study appearing in the April 23/30 issue of JAMA, a neurology theme issue.

Intravenous tissue plasminogen activator (tPA; an enzyme that helps dissolve clots) reduces long-term disability when administered early to eligible with . 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 one-third of patients are treated within the recommended time frame, and that this measure has improved minimally over time, according to background information in the article.

Gregg C. Fonarow, M.D., of the University of California, Los Angeles, and colleagues examined the results of a national quality improvement initiative (Target: Stroke), that was launched to increase timely stroke care. The initiative included 10 key strategies to achieve faster door-to-needle (DTN) times for tPA administration, provided clinical decision support tools, facilitated hospital participation, and encouraged sharing of best practices. This study included 71,169 patients with acute ischemic stroke treated with tPA from 1,030 participating hospitals.

The researchers found that measures of DTN time for tPA administration improved significantly during the postintervention period compared with the preintervention period as did clinical outcomes. The median (midpoint) 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 percent to 41.3 percent (and from 29.6 percent to 53.3 percent at the end of each intervention period). Other improvements included in-hospital deaths (9.9 percent to 8.3 percent); discharge to home (38 percent to 43 percent); independence with walking (42 percent to 45 percent); and symptomatic intracranial hemorrhage within 36 hours (5.7 percent to 4.7 percent).

There was also a more than 4-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 write.

In an accompanying editorial, James C. Grotta, M.D., of the Memorial Hermann Hospital, Clinical Innovation and Research Institute, Houston, comments on the two studies in this issue of JAMA regarding improving the time of tPA administration for stroke.

"Whatever benefits occur from interventions to achieve more rapid tPA treatment for patients with need to be balanced against the costs to establish and maintain them, both to the payers who will pay for them and the hospital and emergency medical services organizations that will implement and operate them. This issue requires carefully constructed cost-effectiveness studies carried out in the environments where the interventions will be implemented; these are likely to differ between cities in the United States and in other countries and between rural and urban areas."

"The studies by Fonarow et al and Ebinger et al in this issue of JAMA indicate exactly where and how to direct efforts in improving treatment outcomes for patients with acute ischemic —namely by reducing time from symptom onset to treatment."

Explore further: Quality program linked with faster stroke treatment and better outcomes

More information: DOI: 10.1001/jama.2014.3203
DOI: 10.1001/jama.2014.3322

Related Stories

Quality program linked with faster stroke treatment and better outcomes

February 17, 2014
A national quality improvement initiative focusing on quicker stroke treatment was associated with better stroke treatment and outcomes, according to a late-breaking science report presented at the American Stroke Association's ...

Earlier treatment following stroke linked with reduced risk of in-hospital death

June 18, 2013
In a study that included nearly 60,000 patients with acute ischemic stroke, thrombolytic treatment (to help dissolve a blood clot) that was started more rapidly after symptom onset was associated with reduced in-hospital ...

Study examines out-of hospital stroke policy at Chicago hospitals

July 1, 2013
Implementing an out-of hospital stroke policy in some Chicago hospitals was associated with significant improvements in emergency medical services use and increased intravenous tissue plasminogen activator (tPA) use at primary ...

Lean process methods expedite care in ischemic stroke

November 10, 2012
(HealthDay)—Use of lean process improvement methodology can reduce the time to stroke care without compromising patient safety, according to a study published online Nov. 8 in Stroke.

Use of tPA for ischemic stroke nearly doubled from 2003 to 2011

August 21, 2013
Use of the "clot-busting" drug tissue plasminogen activator (tPA) to treat patients with strokes caused by a blockage of blood flow nearly doubled between 2003 and 2011. In their paper receiving online release in the journal ...

Recommended for you

The neural codes for body movements

July 21, 2017
A small patch of neurons in the brain can encode the movements of many body parts, according to researchers in the laboratory of Caltech's Richard Andersen, James G. Boswell Professor of Neuroscience, Tianqiao and Chrissy ...

Faulty support cells disrupt communication in brains of people with schizophrenia

July 20, 2017
New research has identified the culprit behind the wiring problems in the brains of people with schizophrenia. When researchers transplanted human brain cells generated from individuals diagnosed with childhood-onset schizophrenia ...

Scientists discover combined sensory map for heat, humidity in fly brain

July 20, 2017
Northwestern University neuroscientists now can visualize how fruit flies sense and process humidity and temperature together through a "sensory map" within their brains, according to new research.

Scientists reveal how patterns of brain activity direct specific body movements

July 20, 2017
New research by Columbia scientists offers fresh insight into how the brain tells the body to move, from simple behaviors like walking, to trained movements that may take years to master. The discovery in mice advances knowledge ...

Team traces masculinization in mice to estrogen receptor in inhibitory neurons

July 20, 2017
Researchers at Cold Spring Harbor Laboratory (CSHL) have opened a black box in the brain whose contents explain one of the remarkable yet mysterious facts of life.

Speech language therapy delivered through the Internet leads to similar improvements as in-person treatment

July 20, 2017
Telerehabilitation helps healthcare professionals reach more patients in need, but some worry it doesn't offer the same quality of care as in-person treatment. This isn't the case, according to recent research by Baycrest.

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.