Organization and Implementation of a Stroke Center in Panamá, a Model for Implementation of Stroke Centers in Low and Middle Income Countries

Perceptions of Chinese hospital leaders on joint commission international accreditation: a qualitative study

Background

Joint Commission International (JCI) accreditation plays a significant role in improving the quality of care and patient safety worldwide. Hospital leadership is critical in making international accreditation happen with successful implementation. Little is known about how Chinese hospital leaders experienced and perceived the impact of JCI accreditation. This paper is the first study to explore the perceptions of hospital leaders toward JCI accreditation in China.

Methods

Qualitative semi-structured interviews were used to explore the perceptions of the chief operating officers, the chief medical officers, and the chief quality officers in five JCI-accredited hospitals in China. Thematic analysis was used to analyze the interview transcripts and identify the main themes.

Results

Fifteen hospital leaders participated in the interviews. Three themes emerged from the analysis, namely the motivations, challenges, and benefits related to pursuing and implementing JCI accreditation. The qualitative study found that eight factors influenced hospital leadership to pursue JCI accreditation, five challenges were identified with implementing JCI standards, and eight benefits emerged from the leadership perspective.

Conclusion

Pursuing JCI accreditation is a discretionary decision by the hospital leadership. Participants were motivated by prevalent perceptions that JCI requirements would be used as a management tool to improve the quality of care and patient safety in their hospitals. These same organizational leaders identified challenges associated with implementing and sustaining JCI accreditation. The significant challenges were a clear understanding of the foreign accreditation standards, making staff actively participate in JCI processes, and changing staff behaviors accordingly. The top 5 perceived benefits to JCI accreditation from the leaders' perspective were improved leadership and hospital safety, improvements in the care processes, and the quality of care and the learning culture improved. Other perceived benefits include enhanced reputation, better cost containment, and a sense of pride in the staff in JCI-accredited hospitals.

Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care

Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.

Reducing Laboratory Turnaround Time in Patients With Acute Stroke and the Lack of Impact on Time to Reperfusion Therapy

CONTEXT.—

Timely reperfusion improves the recovery of patients with acute ischemic stroke. Laboratory results are crucial to guide treatment decisions in patients when abnormal laboratory tests are suspected.

OBJECTIVE.—

To implement a new laboratory workflow for acute stroke patients and compare laboratory turnaround time (TAT) preimplementation and postimplementation.

DESIGN.—

We conducted a retrospective pre-post intervention study of patients with suspected acute stroke during the 4-month periods before and after the implementation of a new laboratory workflow process. The improvement process included relocating the specimen registration site, laboratory notification before specimen arrival, a color-coding system on tubes, timing at all processes, and eliminating the smear review if platelets were normal. TATs of the laboratory and door-to-clinical intervention times before and after the improvement process were compared.

RESULTS.—

Postintervention, median specimen transportation time decreased from 11 (interquartile range [IQR], 8.4-16.4) to 9 minutes (IQR, 6.3-12.8), P < .001. The intralaboratory and total TATs of complete blood cell count, coagulation tests, and creatinine significantly decreased (P < .001 for all). Blood drawn-to-laboratory reported time decreased from 43 (IQR, 36.0-51.5) to 33 minutes (IQR, 29.2-35.8, P < .001). However, door-to-needle time for thrombolysis and door-to-puncture time and door-to-recanalization time for mechanical thrombectomy were not statistically different (P = .11, .69, and .50, respectively).

CONCLUSIONS.—

The new laboratory workflow significantly decreased transportation time, TAT of individual tests, and the blood drawn-to-laboratory reported time. However, the time to treatment of acute ischemic stroke patients was not different between preimplementation and postimplementation.

Delivering acute stroke care in a middle-income country. The Mexican model: "ResISSSTE Cerebro"

Introduction

Founded in 2019, the "ResISSSTE Cerebro" program is the first and only stroke network within the Mexican public health system. One advanced stroke center (ASC) and seven essential stroke centers (ESC) provide acute stroke (AS) care through a modified hub-and-spoke model. This study describes the workflow, metrics, and outcomes in AS obtained during the program's third year of operation.

Materials and methods

Participants were adult beneficiaries of the ISSSTE health system in Mexico City with acute focal neurological deficit within 24 h of symptom onset. Initial evaluation could occur at any facility, but the stroke team at the ASC took all decisions regarding treatment and transfers of patients. Registered variables included demographics, stroke risk factors, AS treatment workflow time points, and clinical outcome measures.

Results

We analyzed data from 236 patients, 104 (44.3%) men with a median age of 71 years. Sixty percent of the patients were initially evaluated at the ESC, and 122 (85.9%) were transferred to the ASC. The median transfer time was 123 min. The most common risk factor was hypertension (73.6%). Stroke subtypes were ischemic (86.0%) and hemorrhagic (14.0%). Median times for onset-to-door, door-to-imaging, door-to-needle, and door-to-groin were: 135.5, 37.0, 76.0, and 151.5 min, respectively. The rate of intravenous thrombolysis was 35%. Large vessel occlusion was present in 63 patients, from whom 44% received endovascular therapy; 71.4% achieved early clinical improvement (median NIHSS reduction of 11 points). Treatment-associated morbimortality was 3.4%.

Conclusion

With the implementation of a modified hub-and-spoke model, this study shows that delivery of AS care in low- and middle-income countries is feasible and achieves good clinical outcomes.