Abstract TP307: Promising Practices to Improve the Quality of Pre-Hospital Stroke Care Transitions

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Stephanie M Teixeira-Poit ◽  
Jacqueline Amoozegar ◽  
Joanna Elmi ◽  
Megan Chambard ◽  
Kyle Emery ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Care Transitions ◽  
Hospital Setting ◽  
Signs And Symptoms ◽  
Stroke Care ◽  
Hospital Staff ◽  
Promising Practices ◽  
Stroke Patients ◽  
Suspected Stroke

Introduction: Between 2012-2015 the Centers for Disease Control and Prevention’s (CDC) Paul Coverdell National Acute Stroke Program (PCNASP) funded 11 state health departments to improve the quality of stroke care across the continuum, beginning with the initial signs and symptoms of stroke through the transition from hospital to post-hospital setting. Hypothesis: We assessed the hypothesis that PCNASP quality improvement activities enhanced the quality of pre-hospital stroke care transitions. Methods: We conducted 72 semi-structured telephone interviews with stakeholders of the 11 PCNASP grantees, including program administrators, epidemiologists, quality improvement consultants, partners, emergency medical services (EMS) and hospital staff. Using grounded theory (Glaser and Strauss), we developed and applied a coding scheme to the interview transcripts to identify emerging themes related to pre-hospital quality improvement activities. Results: Many PCNASP grantees provided training and support for EMS and hospital staff that improved calling of a stroke code team and recognition of stroke, improved EMS pre-notifications about suspected stroke patients, advanced hospital holding of CT scanners in anticipation of suspected stroke patients, and reduced door-to-CT and door-to-needle time. PCNASP grantees had different approaches to balancing timeliness and quality of care. Some grantees developed statewide destination protocols that required EMS to bypass proximate hospitals for certified stroke care hospitals. Other grantees had challenges implementing statewide destination protocols because EMS agencies were decentralized with local authority to determine where to transport patients. In other cases, grantees promoted a “drip and ship” model where EMS transported patients to proximate hospitals for IV-tPA and then to a primary stroke center and focused on increasing the reach of stroke telemedicine. Conclusion: PCNASP grantees developed promising practices to improve the quality of pre-hospital stroke care transitions that accounted for their unique state context. These approaches may become the basis for best practices for improving pre-hospital transitions of stroke care across the nation.

scholarly journals Introduction of Criterion-Based Audit of Postpartum Hemorrhage in a University Hospital in Eastern Ethiopia: Implementation and Considerations

2020 ◽  
Vol 17 (24) ◽  
pp. 9281
Author(s):  
Abera Kenay Tura ◽  
Yasmin Aboul-Ela ◽  
Sagni Girma Fage ◽  
Semir Sultan Ahmed ◽  
Sicco Scherjon ◽  
...  
Keyword(s):  
Postpartum Hemorrhage ◽  
Hospital Setting ◽  
Hospital Staff ◽  
University Hospital ◽  
Local Hospital ◽  
Eastern Ethiopia ◽  
Self Reflection ◽  
Intervention Plan ◽  
Cross Matching

With postpartum hemorrhage (PPH) continuing to be the leading cause of maternal mortality in most low-resource settings, an audit of the quality of care in health facilities is essential. The purpose of this study was to identify areas of substandard care and establish recommendations for the management of PPH in Hiwot Fana Specialized University Hospital, eastern Ethiopia. Using standard criteria (n = 8) adapted to the local hospital setting, we audited 45 women with PPH admitted from August 2018 to March 2019. Four criteria were agreed as being low: IV line-setup (32 women, 71.1%), accurate postpartum vital sign monitoring (23 women, 51.1%), performing typing and cross-matching (22 women, 48.9%), and fluid intake/output chart maintenance (6 women, 13.3%). In only 3 out of 45 women (6.7%), all eight standard criteria were met. Deficiencies in the case of note documentation and clinical monitoring, non-availability of medical resources and blood for transfusion, as well as delays in clinical management were identified. The audit created awareness, resulting in self-reflection of current practice and promoted a sense of responsibility to improve care among hospital staff. Locally appropriate recommendations and an intervention plan based on available resources were formulated.

Abstract WP237: Improved Thrombolysis Rates and Quality of Care for Stroke Patients Through a Provincial Emergency Department Quality Improvement Initiative

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Devin R Harris ◽  
Robert Stenstrom ◽  
Eric Grafstein ◽  
Mark Collison ◽  
Grant Innes ◽  
...  
Keyword(s):  
Emergency Department ◽  
Quality Improvement ◽  
Quality Of Care ◽  
Performance Measures ◽  
Large Scale ◽  
Primary Outcome ◽  
Baseline Data ◽  
Quality Improvement Initiative ◽  
Stroke Patients

Background: The care of stroke patients in the emergency department (ED) is time sensitive and complex. We sought to improve quality of care for stroke patients in British Columbia (B.C.), Canada, emergency departments. Objectives: To measure the outcomes of a large-scale quality improvement initiative on thrombolysis rates and other ED performance measures. Methods: This was an evaluation of a large-scale stroke quality improvement initiative, within ED’s in B.C., Canada, in a before-after design. Baseline data was derived from a medical records review study performed between December 1, 2005 to January 31, 2007. Adherence to best practice was determined by measuring selected performance indicators. The quality improvement initiative was a collaboration between multidisciplinary clinical leaders within ED’s throughout B.C. in 2007, with a focus on implementing clinical practice guidelines and pre-printed order sets. The post data was derived through an identical methodology as baseline, from March to December 2008. The primary outcome was the thrombolysis rate; secondary outcomes consisted of other ED stroke performance measures. Results: 48 / 81 (59%) eligible hospitals in B.C. were selected for audit in the baseline data; 1258 TIA and stroke charts were audited. For the post data, 46 / 81 (57%) acute care hospitals were selected: 1199 charts were audited. The primary outcome of the thrombolysis rate was 3.9% (23 / 564) before and 9.3% (63 / 676) after, an absolute difference of 5.4% (95% CI: 2.3% - 7.6%; p=0.0005). Other measures showed changes: administration of aspirin to stroke patients in the ED improved from 23.7% (127 / 535) to 77.1% (553 / 717), difference = 53.4% (95% CI: 48.3% - 58.1%; p=0.0005); and, door to imaging time improved from 2.25 hours (IQR = 3.81 hours) to 1.57 hours (IQR 3.0), difference = 0.68 hours (p=0.03). Differences were found in improvements between large and small institutions, and between health regions. Conclusions: Implementation of a provincial emergency department quality improvement initiative showed significant improvement in thrombolysis rates and adherence to other best practices for stroke patients. The specific factors that influenced improvement need to be further explored.

Abstract 20: Acute Stroke Care and Thrombolysis at Critical Access Hospitals in Illinois

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Shyam Prabhakaran ◽  
Robin Hamann ◽  
Kathleen O’Neill ◽  
Michelle Gardner ◽  
Peggy Jones
Keyword(s):  
Quality Improvement ◽  
Acute Stroke ◽  
Stroke Care ◽  
The United States ◽  
Critical Access Hospitals ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Improvement Program ◽  
Discharge Disposition ◽  
Intravenous Tissue Plasminogen Activator

Background: Critical access hospitals (CAH) are the first point of stroke care in many rural regions of the United States (US). The Illinois Critical Access Hospital Network (ICAHN), a network of 51 CAH in Illinois, began a quality improvement program to address acute stroke care in 2009. We evaluated the performance on several metrics in acute stroke care at CAH between 2009 and 2011. Methods: Currently, 28 of 51 CAHs in Illinois currently participate in the American Heart Association’s Get With The Guidelines - Stroke (GWTG-S) registry for quality improvement. The GWTG-S registry captured elements including demographics, diagnosis, times of arrival, imaging completion, and intravenous tissue plasminogen activator (IV tPA) administration, and final discharge disposition. We analyzed the change in percent of stroke patients receiving tPA, door-to-needle (DTN) time, and proportion of total stroke patients admitted versus transferred to another facility over the 3 years. Fisher’s exact and Mann-Whitney tests were used as appropriate. Results: In the baseline assessment (2009), there were 111 strokes from 8 sites which grew to 12 sites and 305 strokes in year 1 (2010) and 14 sites and 328 strokes in year 3 (2011). The rate of tPA use for ischemic stroke was 2.2% in 2009, 4.0% in 2010, and 6.2% in 2011 (P=0.20). EMS arrival (41.1%), EMS pre-notification (82.6%), door-to-CT times (median 35 minutes; 34.6% < 25 minutes), and DTN times (average 93 minutes; 13.3% DTN time < 60 minutes) were not different over time. The rate of transfer from CAH to another hospital (51.3%) was constant. Every patient that received tPA except 1 (96.9%) was transferred (drip-ship) for post-tPA care. Conclusions: Improving acute stroke care at CAHs is feasible and represents a significant opportunity to increase tPA utilization in rural areas. As stroke systems develop, it is vital that CAHs be included in quality improvement efforts. The ICAHN stroke collaborative provided the opportunity to coordinate resources, share best practices, participate in targeted educational programming, and utilize data for performance improvement through the funded GWTG-S registry.

Abstract 122: Quality of Care for Patients With Acute Ischemic Stroke as a Function of Hospital Intravenous Thrombolysis With Recombinant Tissue Plasminogen Activator Capability: Insights From China National Stroke Registry II

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Zhenzhen Rao ◽  
Zixiao Li ◽  
Hongqiu Gu ◽  
Yilong Wang ◽  
Yongjun Wang
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Stroke Care ◽  
Care Quality ◽  
Composite Score ◽  
Stroke Patients ◽  
Stroke Registry

Background: Intravenous Thrombolysis with Recombinant Tissue Plasminogen Activator (rt-PA) availability at Chinese hospitals varies and may affect care quality for acute ischemic stroke patients. Limited research has shown whether there were differences in quality of care at China National Stroke Registry (CNSR II) hospitals based on rt-PA capability. Methods: For acute ischemic stroke patients admitted to CNSR II hospitals between 2012 and 2013, care quality at hospitals with or without Intravenous rt-PA capability was examined by evaluating conformity with performance and quality measures. The primary outcome was guideline-concordant care, defined as compliance with 10 predefined individual guideline-recommended performance metrics and composite score. A composite score was defined as the total number of interventions actually performed among eligible patients divided by the total number of recommended interventions among eligible patients. Propensity score matching was used to balance the baseline characteristics. We used cox model with shared frailty model and logistic regression with generalized estimating equation to compare the relationship between hospitals with rt-PA capability and hospitals without rt-PA on quality measures. Results: This study included 19604 acute ischemic stroke patients admitted to 219 CNSR II hospitals. Before matching, there were 7928 patients admitted to 86 (40.4%) hospitals with rt-PA capability and 11676 patients admitted to 133 (59.6%) hospitals without rt-PA capability. After matching, 7606 pairs of patients in rt-PA-capable hospitals and rt-PA-incapable hospitals were analyzed. Before matching, the composite score of guideline-concordant process of care was higher at hospitals with rt-PA capability than hospitals without rt-PA capability (74% versus 73%, P=0.0126). Hospitals with rt-PA capability were more likely to perform deep vein thrombosis prophylaxis within 48 hours of admission, dysphagia screening, assessment or receiving of rehabilitation, discharge antithrombotic, anticoagulation for atrial fibrillation and medications for lowering low-density lipoprotein (LDL) ≥100mg/dL. But hospitals with rt-PA capability were less likely to perform antithrombotic medication within 48 hours of admission and hypoglycemic therapy at discharge for patients with diabetes. After matching, differences of stroke care quality between hospitals with rt-PA capability and without rt-PA capability still exist after adjusting covariates. Conclusions: The CNSR II hospitals were associated with better performance in some of the hospitals but not all of them. The difference in conformity between rt-PA-capable hospitals and rt-PA-incapable hospitals was modest for performance measures of stroke care. However, more room for improvement still exists in key quality performance measures and further studies should be explored.

Abstract WP340: Is There a Ceiling Effect For EMS Stroke Diagnostic Accuracy?

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Diane Handler ◽  
Catherine Kane ◽  
Michelle Wehr ◽  
Anne W Alexandrov
Keyword(s):  
Diagnostic Accuracy ◽  
Formal Education ◽  
Hospital Setting ◽  
Report Card ◽  
Ceiling Effect ◽  
Stroke Patients ◽  
Chi Square ◽  
Continuous Feedback ◽  
Suspected Stroke ◽  
Stroke Mimic

Background: The accuracy of paramedic diagnosis of stroke is essential to the American Heart Association’s Stroke Chain of Survival. The highest rate of stroke diagnostic accuracy reported in the literature is 79% (Wojner-Alexandrov et al, 2005) and resulted from continuous feedback education. We aimed to see whether an EMS Report Card intervention could achieve similar results in a rural community hospital setting. Methods: Consecutive EMS-diagnosed stroke patients were evaluated by the Stroke Team. An EMS Report Card was developed to provide feedback on all suspected stroke patients and formal education was provided based on trends in EMS reports to support improved diagnostic accuracy. Results: A total of 198 EMS diagnosed Stroke Alerts were analyzed; 41 were admitted in 2009, 83 in 2010, 74 in 2011. The rate of stroke mimic transports for EMS was 29% in 2009 (sensitivity=71%), and improved to 26% in 2010 (sensitivity=73%), and improved to 23% by 2011 (sensitivity=77%). Specificity was not calculated. Table 1 shows the frequency of stroke mimic diagnoses for this 3 year period. The number of EMS admissions treated with intravenous tPA was 8 for 2009 (door to bolus time 55.6 minutes + 21.7, median 60.5 minutes, range 25-84 minutes), 22 for 2010 (door to bolus time 52.1 minutes + 14.5, median 50.5 minutes, range 20-90 minutes), and 17 for 2011 (door to bolus time 50.8 minutes + 18.3, median 51 minutes, range 28-68 minutes). The number of intravenous tPA treatments, and door to bolus time were not significantly different over the 3 year period. There was a trend towards increased tPA treated patients by EMS squad (Chi Square=23.3; p=0.078). Conclusion: Accuracy of stroke paramedic diagnosis is important. While our intervention did not demonstrate further improvement, this may indicate a ceiling effect for paramedic stroke diagnostic accuracy above 77-79% that should be considered acceptable.

Ambulance service call handler and clinician identification of stroke in North East Ambulance Service

2021 ◽  
Vol 6 (2) ◽  
pp. 59-65
Author(s):  
Graham McClelland ◽  
Emma Burrow
Keyword(s):  
Acute Stroke ◽  
Early Recognition ◽  
Stroke Care ◽  
Service Evaluation ◽  
Ambulance Service ◽  
Stroke Patients ◽  
Face To Face ◽  
North East ◽  
Audit Data ◽  
Suspected Stroke

Introduction: Emergency medical services (EMS) are the first point of contact for most acute stroke patients. The EMS response is triggered by ambulance call handlers who triage calls and then an appropriate response is allocated. Early recognition of stroke is vital to minimise the call to hospital time as the availability and effectiveness of reperfusion therapies are time dependent. Minimising the pre-hospital phase by accurate call handler stroke identification, short EMS on-scene times and rapid access to specialist stroke care is vital. The aims of this study were to evaluate stroke identification by call handlers and clinicians in North East Ambulance Service (NEAS) and report on-scene times for suspected stroke patients.Methods: A retrospective service evaluation was conducted linking routinely collected data between 1 and 30 November 2019 from three sources: NEAS Emergency Operations Centre; NEAS clinicians; and hospital stroke diagnoses.Results: The datasets were linked resulting in 2214 individual cases. Call handler identification of acute stroke was 51.5% (95% CI 45.3‐57.8) sensitive with a positive predictive value (PPV) of 12.8% (95% CI 11.4‐14.4). Face-to-face clinician identification of stroke was 76.1% (95% CI 70.4‐81.1) sensitive with a PPV of 27.4% (95% CI 25.3‐29.7). The median on-scene time was 33 (IQR 25‐43) minutes, with call handler and clinician identification of stroke resulting in shorter times.Conclusion: This service evaluation using ambulance data linked with national audit data showed that the sensitivity of NEAS call handler and clinician identification of stroke are similar to figures published on other systems but the PPV of call handler and clinician identification stroke could be improved. However, sensitivity is paramount while timely identification of suspected stroke patients and rapid transport to definitive care are the primary functions of EMS. Call handler identification of stroke appears to affect the time that clinicians spend at scene with suspected stroke patients.

scholarly journals Trajectories of Stroke Care in Ontario: Which Path to Best Care?

2017 ◽  
Vol 44 (3) ◽  
pp. 261-266 ◽  
Author(s):  
Ruth E. Hall ◽  
Diana Sondergaard ◽  
Walter P. Wodchis ◽  
Jiming Fang ◽  
Prosanta Mondal ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Best Practices ◽  
Hospital Admissions ◽  
Inpatient Rehabilitation ◽  
Stroke Care ◽  
Administrative Databases ◽  
Prevention Measures ◽  
Stroke Patients ◽  
Health Card

AbstractBackground:Few studies have tracked stroke survivors through transitions across the health system and identified the most common trajectories and quality of care received. The objectives of our study were to examine the trajectories that incident stroke patients experience and to quantify the extent to which their care adhered to the best practices for stroke care.Methods:A population-based cohort of first-ever stroke/transient ischemic attack (TIA) patients from the 2012/13 Ontario Stroke Audit was linked to administrative databases using an encrypted health card number to identify dominant trajectories (N=12,362). All trajectories began in the emergency department (ED) and were defined by the transitions that followed immediately after the ED. Quality indicators were calculated to quantify best practice adherence within trajectories.Results:Six trajectories of stroke care were identified with significant variability in patient characteristics and quality of care received. Almost two-thirds (64.5%) required hospital admission. Trajectories that only involved the ED had the lowest rates of brain and carotid artery imaging (91.5 and 44.2%, respectively). Less than 20% of patients in trajectories involving hospital admissions received care on a stroke unit. The trajectory involving inpatient rehabilitation received suboptimal secondary prevention measures.Conclusions:There are six main trajectories stroke patients follow, and adherence to best practices varies by trajectory. Trajectories resulting in patients being transitioned to home care following ED management only are least likely and those including inpatient rehabilitation are most likely to receive stroke best practices. Increased time in facility-based care results in greater access to best practices. Stroke patients receiving only ED care require closer follow-up by stroke specialists.

scholarly journals Measuring Quality of Life in Stroke Survivors

2020 ◽  
Vol 25 (3) ◽  
pp. 11-16
Author(s):  
M. Tsalta-Mladenov ◽  
D. Georgieva ◽  
S. Andonova
Keyword(s):  
Quality Of Life ◽  
Treatment Options ◽  
Stroke Care ◽  
Stroke Survivors ◽  
Stroke Patients ◽  
Post Stroke ◽  
High Dependency ◽  
Evaluation Time ◽  
Number Of Patients

Introduction: The number of patients living with the consequences of stroke is increasing worldwide due to the improving stroke care and the modern differentiated treatment options for ischemic stroke – thrombolysis and thrombectomy. Hence, a significant interest has arisen in quality of life (QOL) measurement in post-stroke patients. Objectives. Measuring QOL in stroke survivors can be achieved by using various generic and stroke specific questionnaires. All tools should assess different domains of health such as physical acting, communication, daily activities and others. This article describes the most commonly used scales for measuring post-stroke QOL. Methods. We searched the PubMed electronic databases with the keywords — Quality of life, Stroke, Measuring for the period from January 2000 to May 2020. Results. Various generic and specific scales for quality of life measuring are available. The advantages of the specific scales include high accuracy and detailed information for the assessed domains. The limitations are due to numerous items, long evaluation time and high dependency on patient’s compliance. The generic scales give the ability to compare the QOL in patients with different diseases. The disadvantage is lack of detailed information for the health status in certain disease or condition. Conclusion. Measuring the different aspects of QOL in post-stroke patients is powerful tool in order to focus the further efforts to the most affected domains. A combination between generic and stroke-specific measure might be considered in order to overcome the limitations. The choice of measuring scales must be balanced in the terms of lengthy and repetitive surveys.

Abstract TP291: Developing an Electronic Medical Record Based Data Abstraction Tool to Allow for Real Time Clinical Quality Review in Stroke Patients

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Angela Lewis ◽  
Erin Rindels ◽  
Mark Ackman ◽  
Mark Renshaw ◽  
Enrique Leira ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Data Collection ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Stroke Care ◽  
Quality Data ◽  
Data Abstraction ◽  
Stroke Patients ◽  
Time Saving ◽  
Clinical Quality

Background: University of Iowa Hospitals and Clinics (UIHC) participates in American Heart Association’s Get with the Guidelines® - Stroke (GWTG) registry to help drive quality improvement. As the only Comprehensive Stroke Center in Iowa, UIHC discharges many stroke patients and experiences exponential stroke patient growth each year. Due to ever-growing patient volumes and limited staff resources, UIHC identified a need to be able to abstract more quickly and efficiently to assess patient level clinical quality and adherence to evidence-based stroke guidelines. Purpose: UIHC engaged their Information Technology (IT) Department to assist in developing a process to expedite the process and reduce the workload associated with collecting stroke data for quality improvement, with the aim of collecting data as close as possible to the episode of care. Methods: UIHC pioneered the connection between GWTG - Stroke and Epic, their electronic medical record, via a re-abstraction tool embedded in Epic. The IT team worked closely with the stroke coordinator and quality improvement team to identify efficient workflows and time saving strategies. Gaps in discrete data collection were identified and collaboration between interdisciplinary care teams commenced to standardize processes for improved charting. Results: Historically, a self-reported average of 30 minutes was spent on each patient chart in GWTG. As of August 2019, that time declined to an average of 10 minutes per chart, representing a 66% reduction in manual labor required. Prior to project implantation, lag time from patient discharge to data abstraction averaged 4 weeks. After implementing the tool, quality data is abstracted and chart review to compare the stroke care episode against current guidelines occurs while the patient is still an inpatient. Conclusions: Investing in and fostering collaboration between IT, stroke, and quality departments at UIHC led to substantial, sustainable reduction in manual work required to collect stroke quality data. Hospitals should explore their ability to create an EMR based re-abstraction tool to not only save time but improve the quality and timeliness of data collection.

Auditing integrated stroke care to support quality improvement activities: development of a peer-to-peer audit framework

2022 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Bianca Buijck ◽  
Bert Vrijhoef ◽  
Monique Bergsma ◽  
Diederik Dippel
Keyword(s):  
Quality Improvement ◽  
Integrated Care ◽  
Care Program ◽  
Stroke Care ◽  
Peer To Peer ◽  
Multiple Stakeholders ◽  
Content Type ◽  
Care Services ◽  
Continuous Quality

PurposeTo organize stroke care, multiple stakeholders work closely together in integrated stroke care services (ISCS). However, even a well-developed integrated care program needs a continuous quality improvement (CQI) cycle. The current paper aims to describe the development of a unique peer-to-peer audit framework, the development model for integrated care (DMIC), the Dutch stroke care standard and benchmark indicators for stroke.Design/methodology/approachA group of experts was brought together in 2016 to discuss the aims and principles of a national audit framework. The steering group quality assurance (SGQA) consisted of representatives of a diversity of professions in the field of stroke care in the Netherlands, including managers, nurses, medical specialists and paramedics.FindingsAuditors, coordinators and professionals evaluated the framework, agreed on that the framework was easy to use and valued the interesting and enjoyable audits, the compliments, feedback and fruitful insights. Participants consider that a quality label may help to overcome necessity issues and have health care insurers on board. Finally, a structured improvement plan after the audit is needed.Originality/valueAn audit offers fruitful insights into the functioning of an ISCS and the collaboration therein. Best practices and points of improvement are revealed and can fuel collaboration and the development of partnerships. Innovative cure and care may lead to an increasing area of support among professionals in the ISCS and consequently lead to improved quality of delivered stroke care.

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