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Mehta T, Cleland B, Madhavan S. Barriers to Enrollment in a Post-Stroke Neuromodulation and Walking Study: Implications for Recruiting Women. Neurorehabil Neural Repair 2024; 38:207-213. [PMID: 38314561 PMCID: PMC10939762 DOI: 10.1177/15459683241230028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
BACKGROUND Women have a higher risk of stroke and related disability than men but are underrepresented in stroke clinical trials. Identifying modifiable recruitment and enrollment barriers for women can improve study generalizability, statistical power, and resource utilization. OBJECTIVE In a post-stroke neuromodulation study, we determined the impact of sex on the occurrence of exclusion criteria and compared the sex distribution of screened and enrolled individuals with a broader stroke-affected population. METHODS A total of 335 individuals with chronic stroke were screened for a study examining how neuromodulation and high-intensity treadmill training affect walking speed and corticomotor excitability. Demographics and exclusions were retrospectively gathered as a secondary dataset. Exclusion criteria consisted of 6 categories (not target population, unable to do treadmill protocol, unable to do non-invasive brain stimulation, insufficient ankle motion and disinterest, and cognitive impairment). Incidence of each exclusion criterion was compared between women and men. The sex distribution was compared to a dataset from Chicago primary stroke centers. RESULTS A total of 81 individuals were enrolled and 254 were not. The percentage of women excluded was significantly greater than that of men (P = .04). No individual exclusion criterion or categories excluded women more frequently than men. Screened and enrolled individuals had a lower proportion of women and younger age than a representative stroke population (P < .001). CONCLUSIONS We identified exclusion criteria (ie, headaches, cognitive scores, and age) that are modifiable barriers to enrollment of women in this post-stroke neuromodulation study. Addressing underrepresentation of women in stroke research is pivotal for enhancing generalizability, achieving statistical power, and optimizing resources.
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Affiliation(s)
- Twinkle Mehta
- Chicago Medical School, Rosalind Franklin University
| | - Brice Cleland
- Brain Plasticity Lab, Department of Physical Therapy, College of Applied Health Sciences University of Illinois Chicago, Chicago, IL, USA
| | - Sangeetha Madhavan
- Brain Plasticity Lab, Department of Physical Therapy, College of Applied Health Sciences University of Illinois Chicago, Chicago, IL, USA
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Shah A, Diwan A. Stumbling Blocks to Stroke Thrombolysis: An Indian Perspective. Indian J Crit Care Med 2023; 27:616-619. [PMID: 37719355 PMCID: PMC10504641 DOI: 10.5005/jp-journals-10071-24517] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/26/2023] [Indexed: 09/19/2023] Open
Abstract
Background and purpose Stroke is a leading cause of morbidity and mortality worldwide. Developing countries, however, still lag behind in providing timely thrombolytic therapy (TLT) to many eligible patients owing to various reasons. This study aims to identify such factors. Materials and methods This was a descriptive observational study undertaken over a period of 18 months at a tertiary care teaching hospital and included 252 acute ischemic stroke patients of which 200 were not thrombolyzed. The reasons for nonthrombolysis were recorded and analyzed. Results The study included 252 acute ischemic stroke patients of which only 20% were thrombolyzed. Of the 200 nonthrombolyzed patients, 55% arrived out of the window period while patient-related factors were the second biggest factor preventing thrombolysis. Hospital factors at 14% and financial constraints at 4.5% contributed significantly. Delayed consent emerged as an important factor making 6% of the delays. Conclusion Stroke thrombolysis still faces various pre- and intrahospital barriers in India. There is an urgent need to improve infrastructure and organizational streamlining to enable eligible patients to receive prompt treatment. How to cite this article Shah A, Diwan A. Stumbling Blocks to Stroke Thrombolysis: An Indian Perspective. Indian J Crit Care Med 2023;27(9):616-619.
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Affiliation(s)
- Aviral Shah
- Department of Medicine, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Arundhati Diwan
- Department of Medicine, Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
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Gottesman RF, Latour L. What's the Future of Vascular Neurology? Neurotherapeutics 2023; 20:605-612. [PMID: 37129762 PMCID: PMC10275820 DOI: 10.1007/s13311-023-01374-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2023] [Indexed: 05/03/2023] Open
Abstract
The field of vascular neurology has made tremendous advances over the last several decades, with major shifts in diagnosis, treatment, prevention, and rehabilitation of patients with stroke. Furthermore, the individuals who are providing the care represent a different cohort than those who were caring for stroke patients 30 years ago, with the increasing need for rapid decision-making for acute interventions and a larger workforce being needed to provide the many complicated aspects of care of stroke patients. Understanding the history of the field is critical before one can speculate about its future directions. In summarizing some of the past massive shifts in the past few decades, this review will discuss future opportunities and future challenges and will introduce the rest of this special issue focusing on vascular neurology in a post-thrombectomy era. Although thrombolysis and thrombectomy remain a major part of ischemic stroke management and care, in the coming years, there will likely be further modifications in how we provide the care, who provides it, how we train those individuals who provide it, where it is provided, and what data inform early management decisions.
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Affiliation(s)
- Rebecca F Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke, Intramural Research Program, National Institutes of Health, Bethesda, MD, USA.
| | - Lawrence Latour
- Stroke Branch, National Institute of Neurological Disorders and Stroke, Intramural Research Program, National Institutes of Health, Bethesda, MD, USA
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Botelho A, Rios J, Fidalgo AP, Ferreira E, Nzwalo H. Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192316357. [PMID: 36498429 PMCID: PMC9735885 DOI: 10.3390/ijerph192316357] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 06/01/2023]
Abstract
BACKGROUND After onset of acute ischemic stroke (AIS), there is a limited time window for delivering acute reperfusion therapies (ART) aiming to restore normal brain circulation. Despite its unequivocal benefits, the proportion of AIS patients receiving both types of ART, thrombolysis and thrombectomy, remains very low. The organization of a stroke care pathway is one of the main factors that determine timely access to ART. The knowledge on organizational factors influencing access to ART is sparce. Hence, we sought to systematize the existing data on the type and frequency of pre-hospital and in-hospital organizational factors that determine timely access to ART in patients with AIS. METHODOLOGY Literature review on the frequency and type of organizational factors that determine access to ART after AIS. Pubmed and Scopus databases were the primary source of data. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale. RESULTS A total of 128 studies were included. The main pre-hospital factors associated with delay or access to ART were medical emergency activation practices, pre-notification routines, ambulance use and existence of local/regional-specific strategies to mitigate the impact of geographic distance between patient locations and Stroke Unit (SU). The most common intra-hospital factors studied were specific location of SU and brain imaging room within the hospital, and the existence and promotion of specific stroke treatment protocols. Most frequent factors associated with increased access ART were periodic public education, promotion of hospital pre-notification and specific pre- and intra-hospital stroke pathways. In specific urban areas, mobile stroke units were found to be valid options to increase timely access to ART. CONCLUSIONS Implementation of different organizational factors and strategies can reduce time delays and increase the number of AIS patients receiving ART, with most of them being replicable in any context, and some in only very specific contexts.
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Affiliation(s)
- Ana Botelho
- Faculty of Economy, University of Algarve, 8005-139 Faro, Portugal
- Department of Physical Medicine and Rehabilitation, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
- Stroke Unit, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
| | - Jonathan Rios
- Department of Physical Medicine and Rehabilitation, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
| | - Ana Paula Fidalgo
- Stroke Unit, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
| | - Eugénia Ferreira
- Faculty of Economy, University of Algarve, 8005-139 Faro, Portugal
| | - Hipólito Nzwalo
- Stroke Unit, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
- Faculty of Medicine and Biomedical Sciences, University of Algarve, 8005-139 Faro, Portugal
- Algarve Biomedical Research Institute, 8005-139 Faro, Portugal
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Rodos A, Aaronson E, Rothenberg C, Goyal P, Sharma D, Slesinger T, Schuur J, Venkatesh A. Improving Sepsis Management Through the Emergency Quality Network Sepsis Initiative. Jt Comm J Qual Patient Saf 2022; 48:572-580. [PMID: 36137885 DOI: 10.1016/j.jcjq.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Public reporting of the Centers for Medicare & Medicaid (CMS) SEP-1 sepsis quality measure is often too late and without the data granularity to inform real-time quality improvement (QI). In response, the American College of Emergency Physicians (ACEP) Emergency Quality Network (E-QUAL) Sepsis Initiative sought to support QI efforts through benchmarking of preliminary draft SEP-1 scores for emergency department (ED) patients. This study sought to determine the anticipatory value of these preliminary SEP-1 benchmarking scores and publicly reported performance. METHODS Cross-sectional analysis was performed on QI data collected from hospital-based ED sites participating in the E-QUAL Sepsis Collaborative in 2017 and 2018. Participating EDs submitted SEP-1 benchmarking scores semiannually, which were compared to publicly reported CMS SEP-1 data. EDs also reported implementation data on a variety of sepsis-related QI activities for comparison based on SEP-1 performance. RESULTS Among 220 EDs participating in E-QUAL, SEP-1 benchmarking scores showed weak but statistically significant correlation with CMS SEP-1 scores (r = 0.189, p = 0.01). Mean E-QUAL SEP-1 benchmarking scores were higher than mean CMS SEP-1 scores (74.1% vs. 57.2%), with 83.2% of sites reporting a benchmarking score higher than the CMS SEP-1 score. EDs with SEP-1 scores in the bottom 20% reported completion of more sepsis-related QI activities than EDs with average or top 20% SEP-1 scores. CONCLUSION Preliminary benchmarking results demonstrate a weak, statistically significant correlation with subsequent publicly reported CMS SEP-1 scores and suggest that ED performance in sepsis care may exceed overall hospital performance inclusive of all inpatients. Sepsis quality measurement and sepsis QI efforts may be best guided by separating ED sepsis cases from in-hospital sepsis cases as is done for other acute time-sensitive conditions.
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Chen Y, Gong X, Zhong W, Wang J, Yang Z, Yan S, Geng F, Zhou Y, Zhang X, Chen Z, Hu H, Tong L, Chen H, Ke S, He Y, Wang Y, Zhang X, Wang Z, Chen Z, Zhao H, Yuan C, Lou M. Evaluation of a Multilevel Program to Improve Clinician Adherence to Management Guidelines for Acute Ischemic Stroke. JAMA Netw Open 2022; 5:e2210596. [PMID: 35522283 PMCID: PMC9077486 DOI: 10.1001/jamanetworkopen.2022.10596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Promotion of clinician adherence to stroke guidelines can improve stroke outcomes. OBJECTIVE To investigate the outcomes of a multilevel system program on clinician adherence to guidelines for treatment of patients with acute ischemic stroke (AIS). DESIGN, SETTING, AND PARTICIPANTS This quality improvement study used a prospective interrupted time series (ITS) and difference-in-difference (DID) design, from August 1, 2018, to January 31, 2020, divided into preprogram term and short and long postprogram terms; each term had 6 months. Data were collected during hospitalization and at discharge with an automated medical record data capture system in 58 public hospitals in Zhejiang province, China. Data were analyzed from August 2018 to January 2020. EXPOSURES The multilevel system program included a modularized standard template for medical records, centrally supported continuing education, continuous monitoring and feedback, and collaborative workshops. MAIN OUTCOMES AND MEASURES The primary outcome was adherence to 12 key performance indicators (KPIs), expressed as (1) percentage of patient-applicable KPIs achieved in each participant and (2) percentage of participants among whom all applicable KPIs were achieved (dichotomous all-or-none measure). The secondary outcome was severe disability or death (modified Rankin Scale 5-6) at discharge. RESULTS Among 45 091 patients (mean [SD] age, 69 [12] years; 18 347 female [40.7%]), 28 721 from 30 hospitals received the program and 16 370 from 28 hospitals continued routine care. In adjusted DID analysis, the program was associated with an increase in the absolute percentage of KPIs achieved per patient (6.46%; 95% CI, 5.49% to 7.43%), absolute rate of all-or-none success (8.29%; 95% CI, 6.99% to 9.60%), and decreased rate of severe disability or death at discharge (-1.68%; 95% CI, -2.99% to -0.38%). The ITS result showed the program was associated with an increase in KPIs achieved per patient per week (slope change in short-term period, 0.36%; 95% CI, 0.20% to 0.52%; level change in long-term period, (9.64%; 95% CI, 4.58% to 14.69%) and in all-or-none success (slope change in short-term period 0.34%; 95% CI, 0.23% to 0.46%; level change in long-term period 5.89%; 95% CI, 0.19% to 11.59%). CONCLUSIONS AND RELEVANCE The centrally supported program was associated with increases in clinician adherence to guidelines and reduced the proportion of severely disabled or deceased patients with AIS at discharge, providing support for its wider implementation.
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Affiliation(s)
- Yi Chen
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xiaoxian Gong
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Wansi Zhong
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Jianbing Wang
- Department of Epidemiology and Biostatistics at School of Public Health and National Clinical Research Center for Child Health of the Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zongming Yang
- Department of Epidemiology and Biostatistics at School of Public Health and National Clinical Research Center for Child Health of the Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shenqiang Yan
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Fangli Geng
- Health Policy program, Harvard University Graduate School of Arts and Sciences, Cambridge, Massachusetts
| | - Ying Zhou
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xuting Zhang
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Zhicai Chen
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Haitao Hu
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Lusha Tong
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Hongfang Chen
- Department of Neurology, Jinhua Hospital of Zhejiang University, Jinhua Municipal Central Hospital, Jinhua, China
| | - Shaofa Ke
- Department of Neurology, Taizhou Hospital, Wenzhou Medical University, Taizhou, China
| | - Yuping He
- Department of Neurology, Zhuji People's Hospital of Zhejiang Province, Shaoxing, China
| | - Yaxian Wang
- Department of Neurology, Huzhou Central Hospital, Huzhou, China
| | - Xiaoling Zhang
- Department of Neurology, Jiaxing Second Hospital, Jiaxing, China
| | - Zhimin Wang
- Department of Neurology, Taizhou First People's Hospital, Huangyan Hospital of Wenzhou Medical University, Taizhou, China
| | - Zhihui Chen
- Department of Neurology, Lanxi People's Hospital, Jinhua, China
| | - Heng Zhao
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Changzheng Yuan
- School of Public Health, Zhejiang University School of Medicine, Hangzhou, China
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Min Lou
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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Lowther HJ, Harrison J, Hill JE, Gaskins NJ, Lazo KC, Clegg AJ, Connell LA, Garrett H, Gibson JME, Lightbody CE, Watkins CL. The effectiveness of quality improvement collaboratives in improving stroke care and the facilitators and barriers to their implementation: a systematic review. Implement Sci 2021; 16:95. [PMID: 34732211 PMCID: PMC8564999 DOI: 10.1186/s13012-021-01162-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 10/05/2021] [Indexed: 11/29/2022] Open
Abstract
Background To successfully reduce the negative impacts of stroke, high-quality health and care practices are needed across the entire stroke care pathway. These practices are not always shared across organisations. Quality improvement collaboratives (QICs) offer a unique opportunity for key stakeholders from different organisations to share, learn and ‘take home’ best practice examples, to support local improvement efforts. This systematic review assessed the effectiveness of QICs in improving stroke care and explored the facilitators and barriers to implementing this approach. Methods Five electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO, and Cochrane Library) were searched up to June 2020, and reference lists of included studies and relevant reviews were screened. Studies conducted in an adult stroke care setting, which involved multi-professional stroke teams participating in a QIC, were included. Data was extracted by one reviewer and checked by a second. For overall effectiveness, a vote-counting method was used. Data regarding facilitators and barriers was extracted and mapped to the Consolidated Framework for Implementation Research (CFIR). Results Twenty papers describing twelve QICs used in stroke care were included. QICs varied in their setting, part of the stroke care pathway, and their improvement focus. QIC participation was associated with improvements in clinical processes, but improvements in patient and other outcomes were limited. Key facilitators were inter- and intra-organisational networking, feedback mechanisms, leadership engagement, and access to best practice examples. Key barriers were structural changes during the QIC’s active period, lack of organisational support or prioritisation of QIC activities, and insufficient time and resources to participate in QIC activities. Patient and carer involvement, and health inequalities, were rarely considered. Conclusions QICs are associated with improving clinical processes in stroke care; however, their short-term nature means uncertainty remains as to whether they benefit patient outcomes. Evidence around using a QIC to achieve system-level change in stroke is equivocal. QIC implementation can be influenced by individual and organisational level factors, and future efforts to improve stroke care using a QIC should be informed by the facilitators and barriers identified. Future research is needed to explore the sustainability of improvements when QIC support is withdrawn. Trial registration Protocol registered on PROSPERO (CRD42020193966). Supplementary Information The online version contains supplementary material available at 10.1186/s13012-021-01162-8.
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Affiliation(s)
- Hayley J Lowther
- Applied Health Research hub (AHRh), University of Central Lancashire (UCLan), Preston, UK. .,National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC), Liverpool, UK.
| | - Joanna Harrison
- Applied Health Research hub (AHRh), University of Central Lancashire (UCLan), Preston, UK.,National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC), Liverpool, UK
| | - James E Hill
- Applied Health Research hub (AHRh), University of Central Lancashire (UCLan), Preston, UK.,National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC), Liverpool, UK
| | - Nicola J Gaskins
- Applied Health Research hub (AHRh), University of Central Lancashire (UCLan), Preston, UK.,National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC), Liverpool, UK
| | - Kimberly C Lazo
- Applied Health Research hub (AHRh), University of Central Lancashire (UCLan), Preston, UK.,National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC), Liverpool, UK
| | - Andrew J Clegg
- Applied Health Research hub (AHRh), University of Central Lancashire (UCLan), Preston, UK.,National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC), Liverpool, UK
| | - Louise A Connell
- Faculty of Allied Health and Wellbeing, University of Central Lancashire (UCLan), Preston, UK
| | - Hilary Garrett
- National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC), Liverpool, UK
| | - Josephine M E Gibson
- Faculty of Health and Care, University of Central Lancashire (UCLan), Preston, UK
| | | | - Caroline L Watkins
- Applied Health Research hub (AHRh), University of Central Lancashire (UCLan), Preston, UK.,National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC), Liverpool, UK.,Faculty of Health and Care, University of Central Lancashire (UCLan), Preston, UK
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Prabhakaran S, Khorzad R, Parnianpour Z, Romo E, Richards CT, Meurer WJ, Lee J, Mendelson SJ, Holl JL. Door-In-Door-Out Process Times at Primary Stroke Centers in Chicago. Ann Emerg Med 2021; 78:674-681. [PMID: 34598828 DOI: 10.1016/j.annemergmed.2021.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/07/2021] [Accepted: 06/17/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE Acute stroke patients often require interfacility transfer from primary stroke centers to comprehensive stroke centers. Given the time-sensitive benefits of endovascular reperfusion, reducing door-in-door-out time at the primary stroke center is a target for quality improvement. We sought to identify modifiable predictors of door-in-door-out times at 3 Chicago-region primary stroke centers. METHODS We performed a retrospective analysis of consecutive patients with acute stroke from February 1, 2018 to January 31, 2020 who required transfer from 1 of 3 primary stroke centers to 1 of 3 affiliated comprehensive stroke centers in the Chicago region. Stroke coordinators at each primary stroke center abstracted data on type of transport, medical interventions and treatments prior to transfer, and relevant time intervals from patient arrival to departure. We evaluated predictors of door-in-door-out time using median regression models. RESULTS Of 191 total patients, 67.9% arrived by emergency medical services and 57.4% during off-hours. Telestroke was performed in 84.2%, 30.5% received alteplase, and 48.4% underwent a computed tomography (CT) angiography at the primary stroke center. The median door-in-door-out time was 148.5 (interquartile range 106 to 207.8) minutes. The largest contributors to door-in-door-out time, in minutes, were CT to CT angiography time (22 [7 to 73.5]), transfer center contact to ambulance request time (20 [8 to 53.3]), ambulance request to arrival time (20.5 [14 to 36]), and transfer ambulance time at primary stroke center (26 [21 to 35]). Factors associated with door-in-door-out time were (adjusted median differences, in minutes [95% confidence intervals]): CT angiography performed at primary stroke center (+39 [12.3 to 65.7]), walk-in arrival mode (+53 [4.1 to 101.9]), administration of intravenous alteplase (-29 [-31.3 to -26.7]), intubation at primary stroke center (+23 [7.3 to 38.7]), and ambulance request by primary stroke center (-20 [-34.3 to -5.7]). CONCLUSION Door-in-door-out times at Chicago-area primary stroke centers average nearly 150 minutes. Reducing time to CT angiography, receipt of alteplase, and ambulance request are likely important modifiable targets for interventions to decrease door-in-door-out times at primary stroke centers.
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Affiliation(s)
| | - Rebeca Khorzad
- Patient Throughput, Northwestern Medicine, Lake Forest, IL
| | - Zahra Parnianpour
- Department of Neurology, Biological Sciences Division, The University of Chicago, Chicago, IL
| | - Elida Romo
- Department of Neurology, Biological Sciences Division, The University of Chicago, Chicago, IL
| | - Christopher T Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Jungwha Lee
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Jane L Holl
- Department of Neurology, The University of Chicago, Chicago, IL
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9
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Baskar PS, Chowdhury SZ, Bhaskar SMM. In-hospital systems interventions in acute stroke reperfusion therapy: a meta-analysis. Acta Neurol Scand 2021; 144:418-432. [PMID: 34101170 DOI: 10.1111/ane.13476] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/07/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The value of in-hospital systems-based interventions in streamlining treatment delays associated with reperfusion therapy delivery in acute ischaemic stroke (AIS), in the emergency department (ED), is poorly understood. This systematic review and meta-analysis aimed to assess and quantify the value of in-hospital systems-based interventions in streamlining reperfusion therapy delivery following AIS. MATERIAL & METHODS Articles from the following databases were retrieved: Medline, Embase and Cochrane Central Register of Controlled Trials. The primary endpoint was in-hospital time metrics between the intervention and control group. The secondary endpoint included the rate of good functional outcome at 90 days. RESULTS 393 Systems intervention studies published after 2015 were screened, and 231 full articles were then read. In total, 35 studies with 35,815 patients were included in the final systematic review and 26 studies with 7,089 patients were used in the meta-analysis. The greatest time reductions from in-hospital system interventions were achieved in door-to-needle (DTN) time (SMD: -2.696, 95% CI: -2.976, -2.416, z = 3.03, p = 0.002). Systems interventions were also associated with a statistically significant improvement in mortality (RR: 0.25, 95% CI: 0.18, 0.38), rate of symptomatic intracerebral haemorrhage (RR: 0.07, 95% CI: 0.04, 0.1) and ≤60-minute reperfusion rates (RR: 0.63, 95% CI: 0.51, 0.79). CONCLUSIONS The use of in-hospital workflow optimization is imperative to expedite reperfusion therapy delivery and improving patient outcomes. To reduce the morbidity and mortality of stroke globally, in-hospital workflow guidelines should be adhered to and incorporated including the optimal elements identified in this study.
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Affiliation(s)
- Prithvi Santana Baskar
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research Clinical Sciences Stream Sydney NSW Australia
- South Western Sydney Clinical School UNSW Medicine University of New South Wales (UNSW Sydney NSW Australia
| | - Seemub Zaman Chowdhury
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research Clinical Sciences Stream Sydney NSW Australia
- South Western Sydney Clinical School UNSW Medicine University of New South Wales (UNSW Sydney NSW Australia
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research Clinical Sciences Stream Sydney NSW Australia
- Liverpool Hospital & South West Sydney Local Health District (SWSLHD) Department of Neurology & Neurophysiology Sydney NSW Australia
- Ingham Institute for Applied Medical Research Stroke & Neurology Research Group Sydney NSW Australia
- NSW Brain Clot Bank NSW Health Statewide Biobank and NSW Health Pathology Sydney NSW Australia
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10
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Holodinsky JK, Onaemo VN, Whelan R, Hunter G, Graham BR, Hamilton J, Schwartz L, Latta L, Peeling L, Kelly ME. Implementation of a provincial acute stroke pathway and its impact on access to advanced stroke care in Saskatchewan. BMJ Open Qual 2021; 10:bmjoq-2020-001214. [PMID: 34385186 PMCID: PMC8362703 DOI: 10.1136/bmjoq-2020-001214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 07/27/2021] [Indexed: 11/04/2022] Open
Abstract
Background For ischaemic stroke, outcome severity is heavily time dependent. Systems of care need to be in place to ensure that patients with stroke are treated quickly and appropriately across entire health regions. Prior to this study, the province of Saskatchewan, Canada did not have a provincial stroke strategy in place. Methods A quality improvement project was undertaken to create and evaluate a provincial stroke strategy. The Saskatchewan Acute Stroke Pathway was created using a multidisciplinary team of experts, piloted at five stroke centres and then implemented provincially. The number of stroke alerts, door-to-imaging, door-to-needle, door-to-groin puncture times and treatment rates were collected at all centres. Improvements over time were analysed using run charts and individuals control charts. Results The number of stroke alerts province-wide trended upwards in the last 6 months of the study. There were no clear trends or shifts in the proportion of stroke alerts treated with alteplase or endovascular therapy. Across the province, the weighted mean door-to-imaging time decreased from 21 to 15 min, the weighted mean door-to-needle time decreased from 62 to 47 min and the mean door-to-groin puncture time decreased from 83 to 70 min. There was high variability in the degree of improvement from centre to centre. Conclusions The implementation of a province wide acute stroke pathway has led to improvement in stroke care on a provincial basis. Further work addressing intercentre variability is ongoing.
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Affiliation(s)
- Jessalyn K Holodinsky
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Vivian N Onaemo
- Ministry of Health, Government of Saskatchewan, Regina, Saskatchewan, Canada
| | - Ruth Whelan
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gary Hunter
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Brett R Graham
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jessica Hamilton
- Saskatchewan Health Quality Council, Saskatoon, Saskatchewan, Canada
| | - Laura Schwartz
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Lori Latta
- Ministry of Health, Government of Saskatchewan, Regina, Saskatchewan, Canada
| | - Lissa Peeling
- Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Michael E Kelly
- Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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11
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Kass-Hout T, Lee J, Tataris K, Richards CT, Markul E, Weber J, Mendelson S, O'Neill K, Sednew RM, Prabhakaran S. Prehospital Comprehensive Stroke Center vs Primary Stroke Center Triage in Patients With Suspected Large Vessel Occlusion Stroke. JAMA Neurol 2021; 78:1220-1227. [PMID: 34369969 DOI: 10.1001/jamaneurol.2021.2485] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Endovascular therapy (EVT) improves functional outcomes in acute ischemic stroke (AIS) with large vessel occlusion (LVO). Whether implementation of a regional prehospital transport policy for comprehensive stroke center triage increases use of EVT is uncertain. Objective To evaluate the association of a regional prehospital transport policy that directly triages patients with suspected LVO stroke to the nearest comprehensive stroke center with rates of EVT. Design, Setting, and Participants This retrospective, multicenter preimplementation-postimplementation study used an interrupted time series analysis to compare treatment rates before and after implementation in patients with AIS arriving at 15 primary stroke centers and 8 comprehensive stroke centers in Chicago, Illinois, via emergency medical services (EMS) transport from December 1, 2017, to May 31, 2019 (9 months before and after implementation in September 2018). Data were analyzed from December 1, 2017, to May 31, 2019. Interventions Prehospital EMS transport policy to triage patients with suspected LVO stroke, using a 3-item stroke scale, to comprehensive stroke centers. Main Outcomes and Measures Rates of EVT before and after implementation among EMS-transported patients within 6 hours of AIS onset. Results Among 7709 patients with stroke, 663 (mean [SD] age, 68.5 [14.9] years; 342 women [51.6%] and 321 men [48.4%]; and 348 Black individuals [52.5%]) with AIS arrived within 6 hours of stroke onset by EMS transport: 310 of 2603 (11.9%) in the preimplementation period and 353 of 2637 (13.4%) in the postimplementation period. The EVT rate increased overall among all patients with AIS (preimplementation, 4.9% [95% CI, 4.1%-5.8%]; postimplementation, 7.4% [95% CI, 7.5%-8.5%]; P < .001) and among EMS-transported patients with AIS within 6 hours of onset (preimplementation, 4.8% [95% CI, 3.0%-7.8%]; postimplementation, 13.6% [95% CI, 10.4%-17.6%]; P < .001). On interrupted time series analysis among EMS-transported patients, the level change within 1 month of implementation was 7.15% (P = .04) with no slope change before (0.16%; P = .71) or after (0.08%; P = .89), which indicates a step rather than gradual change. No change in time to thrombolysis or rate of thrombolysis was observed (step change, 1.42%; P = .82). There were no differences in EVT rates in patients not arriving by EMS in the 6- to 24-hour window or by interhospital transfer or walk-in, irrespective of time window. Conclusions and Relevance Implementation of a prehospital transport policy for comprehensive stroke center triage in Chicago was associated with a significant, rapid, and sustained increase in EVT rate for patients with AIS without deleterious associations with thrombolysis rates or times.
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Affiliation(s)
- Tareq Kass-Hout
- Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Jungwha Lee
- Department of Preventive Medicine (Biostatistics), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Katie Tataris
- Section of Emergency Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois.,Chicago EMS System, Chicago, Illinois
| | - Christopher T Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Eddie Markul
- Chicago EMS System, Chicago, Illinois.,Department of Emergency Medicine, University of lllinois College of Medicine, Advocate Illinois Masonic Hospital, Chicago, Illinois
| | - Joseph Weber
- Chicago EMS System, Chicago, Illinois.,Department of Emergency Medicine, Cook County Health, Chicago, Illinois
| | - Scott Mendelson
- Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | | | - Renee M Sednew
- American Heart Association, Midwest Region, Chicago, Illinois
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
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12
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Sarakbi D, Mensah-Abrampah N, Kleine-Bingham M, Syed SB. Aiming for quality: a global compass for national learning systems. Health Res Policy Syst 2021; 19:102. [PMID: 34281534 PMCID: PMC8287697 DOI: 10.1186/s12961-021-00746-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 06/23/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Transforming a health system into a learning one is increasingly recognized as necessary to support the implementation of a national strategic direction on quality with a focus on frontline experience. The approach to a learning system that bridges the gap between practice and policy requires active exploration. METHODS This scoping review adapted the methodological framework for scoping studies from Arksey and O'Malley. The central research question focused on common themes for learning to improve the quality of health services at all levels of the national health system, from government policy to point-of-care delivery. RESULTS A total of 3507 records were screened, resulting in 101 articles on strategic learning across the health system: health professional level (19%), health organizational level (15%), subnational/national level (26%), multiple levels (35%), and global level (6%). Thirty-five of these articles focused on learning systems at multiple levels of the health system. A national learning system requires attention at the organizational, subnational, and national levels guided by the needs of patients, families, and the community. The compass of the national learning system is centred on four cross-cutting themes across the health system: alignment of priorities, systemwide collaboration, transparency and accountability, and knowledge sharing of real-world evidence generated at the point of care. CONCLUSION This paper proposes an approach for building a national learning system to improve the quality of health services. Future research is needed to validate the application of these guiding principles and make improvements based on the findings.
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Affiliation(s)
- Diana Sarakbi
- Health Quality Programs, Queen's University, Kingston, Canada.
- Health Quality Programs, Queen's University, Cataraqui Building, 92 Barrie Street, Kingston, ON, K7L 3N6, Canada.
| | | | | | - Shams B Syed
- Integrated Health Services, World Health Organization, Geneva, Switzerland
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13
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Eder PA, Laux G, Rashid A, Kniess T, Haeusler KG, Shammas L, Griewing B, Hofmann S, Stangl S, Wiedmann S, Rücker V, Heuschmann PU, Soda H. Stroke Angel: Effect of Telemedical Prenotification on In-Hospital Delays and Systemic Thrombolysis in Acute Stroke Patients. Cerebrovasc Dis 2021; 50:420-428. [PMID: 33774614 DOI: 10.1159/000514563] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/02/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Door-to-CT scan time (DCT) and door-to-needle time (DNT) are important process measures in acute ischemic stroke (AIS) patients undergoing intravenous thrombolysis (IVT). We examined the impact of a telemedical prenotification by emergency medical service (EMS) (called the "Stroke Angel" program) on DCT and DNT and IVT rate compared to standard of care. PATIENTS AND METHODS Two prospective observational studies including AIS patients admitted via EMS from 2011 to 2013 (cohort I; n = 496) and from January 1, 2015 to May 31, 2018 (cohort II; n = 349) were conducted. After cohort I, the 4-Item Stroke Scale and a digital thrombolysis protocol were added. Multivariable logistic and linear regression analysis was performed. RESULTS In cohort I, DCT was lower in the intervention group (13 vs. 26 min using standard of care; p < 0.001), but no significant difference in median DNT (35 vs. 39 min; p = 0.24) was observed. In cohort II, a reduction of DCT (8 vs. 15 min; p < 0.001) and DNT (25 vs. 29 min p = 0.003) was observed in the intervention group. Compared to standard of care, the likelihood of DCT ≤10 min or DNT ≤20 min in the intervention group was 2.7 (adjusted odds ratio [aOR] 2.7; 95% CI: 2.1-3.5) and 1.8 (aOR 1.8; 95% CI: 1.1-2.9), respectively. In cohort II, IVT rate was higher (aOR 1.4; 95% CI: 1.1-1.9) in the intervention group. CONCLUSION Although the positive effects of Stroke Angel in AIS provided a rationale for implementation in routine care, larger studies of practice implementation will be needed. Using Stroke Angel in the prehospital management of AIS impacts on important process measures of IVT delivery.
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Affiliation(s)
- Patrick Andreas Eder
- Innovation management, Zentrum für Telemedizin Bad Kissingen, Bad Kissingen, Germany.,Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Gunter Laux
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Asarnusch Rashid
- Innovation management, Zentrum für Telemedizin Bad Kissingen, Bad Kissingen, Germany
| | - Tobias Kniess
- Department of Neurological Rehabilitation, Campus Rhön Klinikum AG, Bad Neustadt/Saale, Germany
| | | | - Layal Shammas
- Innovation management, Zentrum für Telemedizin Bad Kissingen, Bad Kissingen, Germany
| | - Bernd Griewing
- Medical Board Division, Campus Rhön Klinikum AG, Bad Neustadt/Saale, Germany
| | - Susanne Hofmann
- Department of Neurology, Campus Rhön Klinikum AG, Bad Neustadt/Saale, Germany
| | - Stephanie Stangl
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Silke Wiedmann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Viktoria Rücker
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany.,Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Hassan Soda
- Department of Neurology, Campus Rhön Klinikum AG, Bad Neustadt/Saale, Germany
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14
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Hasnain MG, Attia JR, Akter S, Rahman T, Hall A, Hubbard IJ, Levi CR, Paul CL. Effectiveness of interventions to improve rates of intravenous thrombolysis using behaviour change wheel functions: a systematic review and meta-analysis. Implement Sci 2020; 15:98. [PMID: 33148294 PMCID: PMC7641813 DOI: 10.1186/s13012-020-01054-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 10/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite being one of the few evidence-based treatments for acute ischemic stroke, intravenous thrombolysis has low implementation rates-mainly due to a narrow therapeutic window and the health system changes required to deliver it within the recommended time. This systematic review and meta-analyses explores the differential effectiveness of intervention strategies aimed at improving the rates of intravenous thrombolysis based on the number and type of behaviour change wheel functions employed. METHOD The following databases were searched: MEDLINE, EMBASE, PsycINFO, CINAHL and SCOPUS. Multiple authors independently completed study selection and extraction of data. The review included studies that investigated the effects of intervention strategies aimed at improving the rates of intravenous thrombolysis and/or onset-to-needle, onset-to-door and door-to-needle time for thrombolysis in patients with acute ischemic stroke. Interventions were coded according to the behaviour change wheel nomenclature. Study quality was assessed using the QualSyst scoring system for quantitative research methodologies. Random effects meta-analyses were used to examine effectiveness of interventions based on the behaviour change wheel model in improving rates of thrombolysis, while meta-regression was used to examine the association between the number of behaviour change wheel intervention strategies and intervention effectiveness. RESULTS Results from 77 studies were included. Five behaviour change wheel interventions, 'Education', 'Persuasion', 'Training', 'Environmental restructuring' and 'Enablement', were found to be employed among the included studies. Effects were similar across all intervention approaches regardless of type or number of behaviour change wheel-based strategies employed. High heterogeneity (I2 > 75%) was observed for all the pooled analyses. Publication bias was also identified. CONCLUSION There was no evidence for preferring one type of behaviour change intervention strategy, nor for including multiple strategies in improving thrombolysis rates. However, the study results should be interpreted with caution, as they display high heterogeneity and publication bias.
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Affiliation(s)
- Md Golam Hasnain
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
| | - John R. Attia
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
- John Hunter Hospital, New Lambton Heights, New South Wales Australia
| | - Shahinoor Akter
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Department of Anthropology, Jagannath University, Dhaka, Bangladesh
| | - Tabassum Rahman
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Centre for Development, Economics and Sustainability, Monash University, Melbourne, Victoria Australia
| | - Alix Hall
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
| | - Isobel J. Hubbard
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
| | - Christopher R. Levi
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, New South Wales Australia
| | - Christine L. Paul
- School of Medicine and Public Health (SMPH), University of Newcastle (UoN), Callaghan, New South Wales Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, New South Wales Australia
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15
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Hategeka C, Ruton H, Karamouzian M, Lynd LD, Law MR. Use of interrupted time series methods in the evaluation of health system quality improvement interventions: a methodological systematic review. BMJ Glob Health 2020; 5:e003567. [PMID: 33055094 PMCID: PMC7559052 DOI: 10.1136/bmjgh-2020-003567] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/07/2020] [Accepted: 09/10/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND When randomisation is not possible, interrupted time series (ITS) design has increasingly been advocated as a more robust design to evaluating health system quality improvement (QI) interventions given its ability to control for common biases in healthcare QI. However, there is a potential risk of producing misleading results when this rather robust design is not used appropriately. We performed a methodological systematic review of the literature to investigate the extent to which the use of ITS has followed best practice standards and recommendations in the evaluation of QI interventions. METHODS We searched multiple databases from inception to June 2018 to identify QI intervention studies that were evaluated using ITS. There was no restriction on date, language and participants. Data were synthesised narratively using appropriate descriptive statistics. The risk of bias for ITS studies was assessed using the Cochrane Effective Practice and Organisation of Care standard criteria. The systematic review protocol was registered in PROSPERO (registration number: CRD42018094427). RESULTS Of 4061 potential studies and 2028 unique records screened for inclusion, 120 eligible studies assessed eight QI strategies and were from 25 countries. Most studies were published since 2010 (86.7%), reported data using monthly interval (71.4%), used ITS without a control (81%) and modelled data using segmented regression (62.5%). Autocorrelation was considered in 55% of studies, seasonality in 20.8% and non-stationarity in 8.3%. Only 49.2% of studies specified the ITS impact model. The risk of bias was high or very high in 72.5% of included studies and did not change significantly over time. CONCLUSIONS The use of ITS in the evaluation of health system QI interventions has increased considerably over the past decade. However, variations in methodological considerations and reporting of ITS in QI remain a concern, warranting a need to develop and reinforce formal reporting guidelines to improve its application in the evaluation of health system QI interventions.
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Affiliation(s)
- Celestin Hategeka
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Hinda Ruton
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
- School of Public Health, University of Rwanda, Kigali, Rwanda
| | - Mohammad Karamouzian
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
- HIV/STI Surveillance Research Centre, and WHO Collaborating Centre for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Larry D Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Center for Health Evaluation and Outcome Sciences, Providence Health Research Institute, Vancouver, British Columbia, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
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16
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Kamal N, Jeerakathil T, Stang J, Liu M, Rogers E, Smith EE, Demchuk AM, Siddiqui M, Mann B, Bestard J, Lang E, Shand E, Benard M, Collins L, Martin K, Hartley C, Reiber M, Valaire S, Mrklas KJ, Hill MD, Allen D, Anderson B, Angelstand J, Anokye E, Antymniuk C, Arsenault N, Ashman B, Baker K, Bakker J, Balenga D, Berg M, Berry LA, Betzner M, Black L, Blain D, Boutilier T, Brady J, Lynn Brewster S, Brown P, Buchynski K, Bugbee E, Bullard M, Burke D, Burnett C, Butcher K, Cackett P, Canham H, Chiovetti A, Chivers L, Cobb C, Cote M, Coutts S, Currie D, Eric Daniels J, Desouza N, Diebert M, Dixon T, Dotchin J, Duckett S, Dustow V, Dwyer R, Dymond M, Edmond C, Eesa M, Elias N, Elliott T, Empson S, Falls L, Forder M, Foreman R, Forsythe D, Fortier T, Fowler L, Franklin S, Garland J, Garon C, Gerl D, Ghauri I, Gough S, Mark KG, Mary-Lou Halabi G, Halldorson S, Harsch J, Hatcher C, Hebner K, Hemsley R, Holloway D, Holman D, Holsworth S, Holton S, Hull G, Hyciek B, Ibach R, Imoukhuede O, Jeal B, Jill D, Johnson M, Jones O, Kabaroff A, Kalashyan H, Kay F, Kaytor P, Keppy T, King P, Kiszszak S, Klick R, Koshurba E, Kruhlak R, Lacasse J, Lane M, Laughs T, Laut-Barss L, Lavalee P, Leclair T, Linden P, Linderman T, Livingstone J, Lodder M, Lundgard K, Lyle E, Mackenzie K, Malarczuk A, Malfair D, Malone J, Manosalva Alzate H, McCann K, McCarthy S, McKenzie M, McRobert L, Meroniuk D, Millar R, Miller R, Mir B, Montpetit J, Morissette J, Morrison L, Murray-Galbraith F, Mydeen F, Namagiri L, Neidig N, Neil G, Newcommon N, Newell C, Nichol C, Norris C, Norton D, Noseworthy S, O’Hara L, O’Neail S, Orr W, Panes E, Panes T, Paradis J, Parry T, Peacock D, Peebles T, Petersen S, Phelps I, Pooley R, Potvin N, Pryor R, Ramsahoye M, Rashead M, Reedyk K, Reynolds D, Rideout S, Rimmer K, Salih E, San Agustin P, Sandbeck D, Sattar S, Sauter N, Schmidt K, Seib E, Selzler J, Sevcik B, Sharman D, Shuaib A, Smith D, Snider B, Snider J, Stander J, Stephenson C, Stewart C, Stoyberg C, Suranyi Y, Tablin M, Taralson C, Throndson J, Traverse K, van der Nest D, Van Mulligan T, Van Vuuren C, Vanderlinde E, Vilneff R, Volk G, Wall K, Wang DJ(T, Warharft D, Watson J, Weir L, Weiss D, Welch D, Winder T, Winsor W, Woudstra D, Youn D, Young L, Zerna C. Provincial Door-to-Needle Improvement Initiative Results in Improved Patient Outcomes Across an Entire Population. Stroke 2020; 51:2339-2346. [DOI: 10.1161/strokeaha.120.029734] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Improving door-to-needle times (DNTs) for thrombolysis of acute ischemic stroke patients improves outcomes, but participation in DNT improvement initiatives has been mostly limited to larger, academic medical centers with an existing interest in stroke quality improvement. It is not known whether quality improvement initiatives can improve DNT at a population level, including smaller community hospitals. This study aims to determine the effect of a provincial improvement collaborative intervention on improvement of DNT and patient outcomes.
Methods:
A pre post cohort study was conducted over 10 years in the Canadian province of Alberta with 17 designated stroke centers. All ischemic stroke patients who received thrombolysis in the Canadian province of Alberta were included in the study. The quality improvement intervention was an improvement collaborative that involved creation of interdisciplinary teams from each stroke center, participation in 3 workshops and closing celebration, site visits, webinars, and data audit and feedback.
Results:
Two thousand four hundred eighty-eight ischemic stroke patients received thrombolysis in the pre- and postintervention periods (630 in the post period). The mean age was 71 years (SD, 14.6 years), and 46% were women. DNTs were reduced from a median of 70.0 minutes (interquartile range, 51–93) to 39.0 minutes (interquartile range, 27–58) for patients treated per guideline (
P
<0.0001). The percentage of patients discharged home from acute care increased from 45.6% to 59.5% (
P
<0.0001); the median 90-day home time increased from 43.3 days (interquartile range, 27.3–55.8) to 53.6 days (interquartile range, 36.8–64.6) (
P
=0.0015); and the in-hospital mortality decreased from 14.5% to 10.5% (
P
=0.0990).
Conclusions:
The improvement collaborative was likely the key contributing factor in reducing DNTs and improving outcomes for ischemic stroke patients across Alberta.
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Affiliation(s)
- Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Nova Scotia, Canada (N.K.)
- Department of Clinical Neurosciences (N.K., E.E.S., A.M.D., M.D.H.), University of Calgary, Alberta, Canada
| | - Thomas Jeerakathil
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (T.J., M.S.)
| | - Jillian Stang
- Data Analytics, Alberta Health Services, Canada (J.S., M.L.)
| | - Mingfu Liu
- Data Analytics, Alberta Health Services, Canada (J.S., M.L.)
| | - Edwin Rogers
- Strategic Management Branch, Government of Saskatchewan, Regina, Canada (E.R.)
| | - Eric E. Smith
- Department of Clinical Neurosciences (N.K., E.E.S., A.M.D., M.D.H.), University of Calgary, Alberta, Canada
- Department of Community Health Sciences (E.E.S., K.J.M., M.D.H.), University of Calgary, Alberta, Canada
| | - Andrew M. Demchuk
- Department of Clinical Neurosciences (N.K., E.E.S., A.M.D., M.D.H.), University of Calgary, Alberta, Canada
- Department of Radiology (A.M.D., M.D.H.), University of Calgary, Alberta, Canada
| | - Muzaffar Siddiqui
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (T.J., M.S.)
- Grey Nuns Community Hospital, Edmonton, Alberta, Canada (M.S.)
| | - Balraj Mann
- Cardiovascular Health and Stroke, Strategic Clinical Network, Alberta Health Services, Edmonton, Canada (B.M., S.V.)
| | | | - Eddy Lang
- Department of Emergency Medicine (E.L.), University of Calgary, Alberta, Canada
| | - Elaine Shand
- Red Deer Regional Hospital Centre, Alberta, Canada (J.B., E.S.)
| | | | - Lisa Collins
- North Zone, Alberta Health Services, Cold Lake, Canada (L.C.)
| | - Kevin Martin
- Chinook Regional Hospital, Lethbridge, Alberta, Canada (K.M., C.H.)
| | - Corinna Hartley
- Chinook Regional Hospital, Lethbridge, Alberta, Canada (K.M., C.H.)
| | - Marnie Reiber
- Lloydminster Hospital, Lloydminster, Alberta/Saskatchewan, Canada (M.R.)
| | - Shelley Valaire
- Cardiovascular Health and Stroke, Strategic Clinical Network, Alberta Health Services, Edmonton, Canada (B.M., S.V.)
| | - Kelly J. Mrklas
- Department of Community Health Sciences (E.E.S., K.J.M., M.D.H.), University of Calgary, Alberta, Canada
- System Innovation and Programs, Strategic Clinical Networks, Alberta Health Services, Calgary, Canada (K.J.M.)
| | - Michael D. Hill
- Department of Clinical Neurosciences (N.K., E.E.S., A.M.D., M.D.H.), University of Calgary, Alberta, Canada
- Department of Community Health Sciences (E.E.S., K.J.M., M.D.H.), University of Calgary, Alberta, Canada
- Department of Radiology (A.M.D., M.D.H.), University of Calgary, Alberta, Canada
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Knowledge, Motivation and Sustainability: Divergent Effects of a Staff Training Program on Residents and Specialists in Acute Stroke Care. J Stroke Cerebrovasc Dis 2020; 29:104694. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 12/27/2019] [Accepted: 01/25/2020] [Indexed: 11/23/2022] Open
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Temporal sustainability of guideline based door-to-needle times for intravenous thrombolysis for acute ischemic stroke. J Clin Neurosci 2020; 74:164-167. [PMID: 32094070 DOI: 10.1016/j.jocn.2020.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/08/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Door to needle (DTN) time provides valuable insight into stroke care workflow and is a performance indicator of an acute stroke unit. The aim of the current study was to ascertain whether a door to needle time of less than 60 min can be achieved for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) and maintained long term in a comprehensive stroke unit. METHODS Patients with AIS treated with IVT in the stroke unit formed the study group. Demographic and clinical characteristics including door to imaging (DTI) time, DTN time, and 3 month functional outcome were abstracted. Pairwise comparison was done of yearly median DTI and DTN times with Bonferroni correction. RESULTS Over a period of 6 years a total of 196 patients with mean age of 61.5 ± 13.1 years and median (IQR) NIHSS 11 (8-16) underwent IVT. The median DTI time and DTN time over the study period was 15 (12-21) minutes and 40 (30-50) minutes respectively. A total of 90.1%, 69.4% and 29.1% patients received IVT within 60 min, 45 min and 30 min respectively. On pairwise comparison of the median yearly DTN Year 2016 and 2017 were lower compared to most of the earlier years (p < 0.0001). Good functional outcome (mRS ≤ 2) was noted in 68.7% patients at 3 months follow-up. CONCLUSION It is possible to sustainably reduce DTN time for IVT in AIS to well below the current 60 min benchmark with hospital system training and teamwork.
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Improving Door-to-needle Times in the Treatment of Acute Ischemic Stroke Across a Canadian Province: Methodology. Crit Pathw Cardiol 2019; 18:51-56. [PMID: 30747766 DOI: 10.1097/hpc.0000000000000173] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Alteplase is a proven medical treatment for acute ischemic stroke; however, the effectiveness of this treatment is highly time dependent. Therefore, it is imperative that hospitals treat acute ischemic stroke patients as quickly as possible. The measure, door-to-needle time, is the time from hospital arrival to when alteplase administration begins. OBJECTIVE The goal in the Canadian province of Alberta was to reduce the door-to-needle time to a median of 30 minutes and to increase the percent of patients treated within 60 minutes to 90%. OVERVIEW OF METHODOLOGY A modified version of Institute for Healthcare Improvement Breakthrough Series Collaborative was used. All stroke centers self-enrolled into the collaborative after initial contact, and sites created interdisciplinary teams to participate in the Collaborative. Leadership and faculty were highly experienced in quality improvement and acute stroke. There were 3 daylong face-to-face learning sessions that were attended by enrolled teams, which included presentation about the evidence, site presentations to promote cross-site learning, and time to plan changes with their teams. The sites were also supported by site visits, webinars, and data feedback.
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Klingner C, Günther A, Brodoehl S, Witte OW, Klingner CM. Talk About Thrombolysis. Regular Case-Based Discussions of Stroke Thrombolysis Improve Door-to-Needle Time by 20%. J Stroke Cerebrovasc Dis 2019; 28:876-881. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/12/2018] [Accepted: 12/05/2018] [Indexed: 11/29/2022] Open
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21
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Mendelson SJ, Aggarwal NT, Richards C, O'Neill K, Holl JL, Prabhakaran S. Racial disparities in refusal of stroke thrombolysis in Chicago. Neurology 2018; 90:e359-e364. [PMID: 29298854 PMCID: PMC10681073 DOI: 10.1212/wnl.0000000000004905] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 08/24/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate race differences in tissue plasminogen activator (tPA) refusal among eligible patients with acute ischemic stroke (AIS) in Chicago. METHODS Using the Get With The Guidelines-Stroke registry data from 15 primary stroke centers between January 2013 and June 2015, we performed a retrospective analysis of patients with AIS presenting to the emergency department within 4.5 hours from symptom onset. Patient or proxy refusal was captured as a reason for nonadministration of tPA to eligible patients in the registry. We assessed whether tPA refusal differed by race using logistic regression. RESULTS Among 704 tPA-eligible patients with AIS, tPA was administered to 86.2% (black race, 82.5% vs nonblack race, 89.5%; p < 0.001). Fifty-three (7.5%) tPA refusals were documented. Refusal was more common in black vs nonblack patients (10.6% vs 4.8%; p = 0.004). In multivariable analysis, the following were associated with tPA refusal: black race (adjusted odds ratio [OR] 2.5, 95% confidence interval [CI] 1.3-4.6), self-pay status (adjusted OR 3.23, 95% CI 1.2-8.71), prior stroke (adjusted OR 2.11, 95% CI 1.14-3.90), age (adjusted OR 1.04, 95% CI 1.02-1.07), and NIH Stroke Scale score (adjusted OR 0.94, 95% CI 0.90-0.99). CONCLUSIONS Among tPA-eligible patients with AIS in Chicago, over 7% refused tPA. Refusal was more common in black patients and accounted for the apparent lower rates of tPA use in black vs nonblack patients. Further research is needed to understand barriers to consent and overcome race-ethnic disparities in tPA treatment for AIS.
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Affiliation(s)
- Scott J Mendelson
- From the Department of Neurology (S.J.M., S.P.), Department of Emergency Medicine (C.R.), and Center for Healthcare Studies (J.L.H.), Northwestern University Feinberg School of Medicine; Department of Neurologic Sciences and the Rush Alzheimer's Disease Center (N.T.A.), Rush University Medical Center; and American Heart Association (K.O.), Midwest Affiliate, Chicago, IL.
| | - Neelum T Aggarwal
- From the Department of Neurology (S.J.M., S.P.), Department of Emergency Medicine (C.R.), and Center for Healthcare Studies (J.L.H.), Northwestern University Feinberg School of Medicine; Department of Neurologic Sciences and the Rush Alzheimer's Disease Center (N.T.A.), Rush University Medical Center; and American Heart Association (K.O.), Midwest Affiliate, Chicago, IL
| | - Christopher Richards
- From the Department of Neurology (S.J.M., S.P.), Department of Emergency Medicine (C.R.), and Center for Healthcare Studies (J.L.H.), Northwestern University Feinberg School of Medicine; Department of Neurologic Sciences and the Rush Alzheimer's Disease Center (N.T.A.), Rush University Medical Center; and American Heart Association (K.O.), Midwest Affiliate, Chicago, IL
| | - Kathleen O'Neill
- From the Department of Neurology (S.J.M., S.P.), Department of Emergency Medicine (C.R.), and Center for Healthcare Studies (J.L.H.), Northwestern University Feinberg School of Medicine; Department of Neurologic Sciences and the Rush Alzheimer's Disease Center (N.T.A.), Rush University Medical Center; and American Heart Association (K.O.), Midwest Affiliate, Chicago, IL
| | - Jane L Holl
- From the Department of Neurology (S.J.M., S.P.), Department of Emergency Medicine (C.R.), and Center for Healthcare Studies (J.L.H.), Northwestern University Feinberg School of Medicine; Department of Neurologic Sciences and the Rush Alzheimer's Disease Center (N.T.A.), Rush University Medical Center; and American Heart Association (K.O.), Midwest Affiliate, Chicago, IL
| | - Shyam Prabhakaran
- From the Department of Neurology (S.J.M., S.P.), Department of Emergency Medicine (C.R.), and Center for Healthcare Studies (J.L.H.), Northwestern University Feinberg School of Medicine; Department of Neurologic Sciences and the Rush Alzheimer's Disease Center (N.T.A.), Rush University Medical Center; and American Heart Association (K.O.), Midwest Affiliate, Chicago, IL
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22
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Mendelson SJ, Prabhakaran S. Pace of Progress in Stroke Thrombolysis. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.003438. [DOI: 10.1161/circoutcomes.116.003438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Scott J. Mendelson
- From the Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Shyam Prabhakaran
- From the Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL
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