Abstract TP303: Institutional Stroke Quality Improvement and Impact on Vascular Neurology Fellows Practice Patterns

Background and objectives: The American Heart Association quality improvement (QI) program Target Stroke is focused on reducing door-to-needle (DTN) time for IV tissue plasminogen activator (tPA) therapy to ≤60 minutes. Multidisciplinary QI procedures similar to the Target Stroke best practices have been shown to improve DTN times at an MRI based program. Whether these strategies improve the performance of trainees is unclear. The objective of this study was to determine the impact of a multidisciplinary QI program on the practice patterns of vascular neurology (VN) fellows at an MRI based stroke program. Methods: Case logs from the NIH Stroke Program VN fellows (N=22) were reviewed from July 2008-July 2015. Data was collected for the following: total patients screened, patients triaged, stroke code proceeds, tPA treated cases, and door to needle time (DTN) for each patient treated including DTN ≤60 minutes. QI processes that included stroke team education and process changes were initiated in 2013 to improve stroke care at two hospitals where VN fellows provide clinical care. We compared VN fellow practice patterns before (2008-12) and after (2013-15) QI implementation. Results: A total of 5093 cases were reviewed for the study. From 2008-15, fellows screened a yearly average of 232 patients, triaged 54% (125) to acute imaging, and treated 7.8% (18) patients each year with IV tPA. VN fellow practice patterns after QI implementation (2013-15) improved for percent treated with IV tPA (5.8% vs. 9.9%, p<0.05), median DTN (83 vs. 71 min.; p<0.05), and percentage treated ≤60 minutes (11% vs. 40%; p<0.05). The mean number of patients screened was slightly higher before 2013 (238 vs. 225), and triage rates were similar (52.4% vs. 55%, p=0.58). Conclusion: The results of this study suggest that an institutional multidisciplinary QI stroke program can improve the practice patterns of VN fellows at an MRI based stroke program.

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Development of the Madrid Stroke Programme: Milestones and Changes in Stroke Trends and Mortality from 1997 to 2017

Neuroepidemiology ◽

10.1159/000514077 ◽

2021 ◽

pp. 1-6

Author(s):

Silvia Pastor ◽

Elena de Celis ◽

Itsaso Losantos García ◽

María Alonso de Leciñana ◽

Blanca Fuentes ◽

...

Keyword(s):

Hospital Mortality ◽

Hospital Admissions ◽

Temporal Trends ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Care Organization ◽

Stroke Units ◽

Health Region ◽

Number Of Patients ◽

The Impact

Introduction: Stroke is a serious health problem, given it is the second leading cause of death and a major cause of disability in the European Union. Our study aimed to assess the impact of stroke care organization measures (such as the development of stroke units, implementation of a regional stroke code, and treatment with intravenous thrombolysis and mechanical thrombectomy) implemented from 1997 to 2017 on hospital admissions due to stroke and mortality attributed to stroke in the Madrid health region. Methods: Epidemiological data were obtained from the National Statistics Institute public website. We collected data on the number of patients discharged with a diagnosis of stroke, in-hospital mortality due to stroke and the number of inhabitants in the Madrid health region each year. We calculated rates of discharges and mortality due to stroke and the number of inhabitants per SU bed, and we analysed temporal trends in in-hospital mortality due to stroke using the Daniels test in 2 separate time periods (before and after 2011). Figures representing annual changes in these data from 1997 to 2017 were elaborated, marking stroke care organizational measures in the year they were implemented to visualize their temporal relation with changes in stroke statistics. Results: Hospital discharges with a diagnosis of stroke have increased from 170.3/100,000 inhabitants in 1997 to 230.23/100,000 inhabitants in 2017. However, the in-hospital mortality rate due to stroke has decreased (from 33.3 to 15.2%). A statistically significant temporal trend towards a decrease in the mortality percentage and rate was found from 1997 to 2011. Conclusions: Our study illustrates how measures such as the development of stroke units, implementation of a regional stroke code and treatment with intravenous thrombolysis coincide in time with a reduction in in-hospital mortality due to stroke.

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Applying quality improvement principles to improve accident and emergency department overcrowding and flow in Rwanda: a case study

Journal of Hospital Administration ◽

10.5430/jha.v4n5p47 ◽

2015 ◽

Vol 4 (5) ◽

pp. 47 ◽

Cited By ~ 3

Author(s):

Jean Claude Byiringiro ◽

Rex Wong ◽

Caroline Davis ◽

Jeffery Williams ◽

Joseph Becker ◽

...

Keyword(s):

Emergency Department ◽

Quality Improvement ◽

Success Factors ◽

Low Cost ◽

Post Intervention ◽

Triage System ◽

Accident And Emergency ◽

Number Of Patients ◽

Accident And Emergency Department ◽

The Impact

Few case studies exist related to hospital accident and emergency department (A&E) quality improvement efforts in lowerresourced settings. We sought to report the impact of quality improvement principles applied to A&E overcrowding and flow in the largest referral and teaching hospital in Rwanda. A pre- and post-intervention study was conducted. A linked set of strategies included reallocating room space based on patient/visitor demand and flow, redirecting traffic, establishing a patient triage system and installing white boards to facilitate communication. Two months post-implementation, the average number of patients boarding in the A&E hallways significantly decreased from 28 (pre-intervention) to zero (post-intervention), p < .001. Foot traffic per dayshift hour significantly decreased from 221 people to 160 people (28%, p < .001), and non-A&E related foot traffic decreased from 81.4% to 36.3% (45% decrease, p < .001). One hundred percent of the A&E patients have been formally triaged since the implementation of the newly established triage system. Our project used quality improvement principles to reduce the number of patients boarding in the hallways and to decrease unnecessary foot traffic in the A&E department with little investment from the hospital. Key success factors included a collaborative multidisciplinary project team, strong internal champions, data-driven analysis, evidence-based interventions, senior leadership support, and rapid application of initial implementation learnings. Results to date show the application of quality improvement principles can help hospitals in resource-limited settings improve quality of care at relatively low cost.

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Abstract 3446: Inpatient Code Stroke Protocol: A Quality Improvement and Knowledge Translation Strategy for a Challenging Scenario

Stroke ◽

10.1161/str.43.suppl_1.a3446 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Jacqueline D Willems ◽

Krsytyna Skrabka ◽

Roseane Nisenbaum ◽

Judith Barnaby ◽

Pawel Kostyrko ◽

...

Keyword(s):

Quality Improvement ◽

Acute Stroke ◽

Robust Regression ◽

Stroke Care ◽

Initial Assessment ◽

Stroke Severity ◽

Care Hospital ◽

Presenting Symptoms ◽

Number Of Patients ◽

Assessment And Treatment

Background: Stroke care faces a clinical challenge in treating inhospital strokes, which account for about 15% of all strokes. Prior studies showed an inequity in the assessment and treatment of inpatients who suffer a stroke versus out-of hospital. For example, inpatients have longer time to initial assessment, CT and are less likely (wait longer) to receive tissue plasminogen activator (t-PA). There is limited research evaluating the efficacy of inpatient code stroke protocols (ICSP) on access to and quality of hyper-acute stroke care. Objective: To evaluate the efficacy of the ICSP in a large tertiary care hospital. Methods: This prospective study evaluated a quality improvement strategy involving ICSP implementation at St Michael’s Hospital in 2009. The ICSP focuses on the identification of stroke symptoms and timely notification of most responsible physician, then leverages the Emergency Department code stroke process. A 3-month hospital-wide implementation period involved 60 min. education sessions with a minimum of 2 sessions per unit. Demographic factors, presenting symptoms, stroke severity, vascular risk factors as well as time of: symptoms onset, CT; and physician assessment were collected by chart abstraction after ethics approval. The primary outcomes was time from last seen normal (LSN) to CT scan. Secondary outcomes include time from LSN to initial assessment (IA), medical complications and number of patients receiving endovascular interventions or intravenous thrombolysis. The analysis was completed by comparing unadjusted and adjusted outcomes pre and post implementation of the ICSP. Descriptive statistics and robust regression was completed using SAS 9.0. Results: Overall, there were 245 inhospital strokes during the study period (152 pre and 93 post ICSP implementation). Mean age was 69.8 yrs, 60% were male. Most inpatient strokes occurred on cardiovascular services (42.9%). Main results summarized in table . There was no difference in the number of patients receiving thrombolysis or endovascular treatment. After adjustment for covariates, the ICS was associated with a significant reduction of 288 minutes (95%CI -566, -10) in time from LSN to CT. Similarly, there was significant reduction of 307 (95%CI -532, -82) in time from LSN to IA. Conclusions: Implementation of the ICSP resulted in improvements in the process indicators related to assessment and treatment of hyper-acute stroke. Similar quality improvement strategies can be implemented to ameliorate disparities between care for inpatients and outpatient presenting with an acute ischemic stroke.

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Use of a Structured Panel Process to Define Quality Metrics for Antimicrobial Stewardship Programs

Infection Control and Hospital Epidemiology ◽

10.1086/665324 ◽

2012 ◽

Vol 33 (5) ◽

pp. 500-506 ◽

Cited By ~ 62

Author(s):

Andrew M. Morris ◽

Stacey Brener ◽

Linda Dresser ◽

Nick Daneman ◽

Timothy H. Dellit ◽

...

Keyword(s):

Quality Improvement ◽

Antimicrobial Stewardship ◽

Bloodstream Infections ◽

The United States ◽

Community Acquired Pneumonia ◽

Public Reporting ◽

Modified Delphi ◽

Number Of Patients ◽

Days Of Therapy ◽

The Impact

Introduction.Antimicrobial stewardship programs are being implemented in health care to reduce inappropriate antimicrobial use, adverse events, Clostridium difficile infection, and antimicrobial resistance. There is no standardized approach to evaluate the impact of these programs.Objective.To use a structured panel process to define quality improvement metrics for evaluating antimicrobial stewardship programs in hospital settings that also have the potential to be used as part of public reporting efforts.Design.A multiphase modified Delphi technique.Setting.Paper-based survey supplemented with a 1-day consensus meeting.Participants.A 10-member expert panel from Canada and the United States was assembled to evaluate indicators for relevance, effectiveness, and the potential to aid quality improvement efforts.Results.There were a total of 5 final metrics selected by the panel: (1) days of therapy per 1000 patient-days; (2) number of patients with specific organisms that are drug resistant; (3) mortality related to antimicrobial-resistant organisms; (4) conservable days of therapy among patients with community-acquired pneumonia (CAP), skin and soft-tissue infections (SSTI), or sepsis and bloodstream infections (BSI); and (5) unplanned hospital readmission within 30 days after discharge from the hospital in which the most responsible diagnosis was one of CAP, SSTI, sepsis or BSI. The first and second indicators were also identified as useful for accountability purposes, such as public reporting.Conclusion.We have successfully identified 2 measures for public reporting purposes and 5 measures that can be used internally in healthcare settings as quality indicators. These indicators can be implemented across diverse healthcare systems to enable ongoing evaluation of antimicrobial stewardship programs and complement efforts for improved patient safety.

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Impact of COVID-19 Pandemic on the Incidence, Prehospital Evaluation, and Presentation of Ischemic Stroke at a Nonurban Comprehensive Stroke Center

Stroke Research and Treatment ◽

10.1155/2021/6624231 ◽

2021 ◽

Vol 2021 ◽

pp. 1-5

Author(s):

Cesar Velasco ◽

Brandon Wattai ◽

Scott Buchle ◽

Alicia Richardson ◽

Varun Padmanaban ◽

...

Keyword(s):

Urban Areas ◽

Stroke Care ◽

Final Diagnosis ◽

Medical Attention ◽

Presenting Symptoms ◽

Number Of Patients ◽

Community Transmission ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

The Impact

Introduction. Many reports have described a decrease in the numbers of patients seeking medical attention for typical emergencies during the COVID-19 pandemic. These reports primarily relate to urban areas with widespread community transmission. The impact of COVID-19 on nonurban areas with minimal community transmission is less well understood. Methods. Using a prospectively maintained prehospital quality improvement database, we reviewed our hospital EMS transports with a diagnosis of stroke from January to April 2019 (baseline) and January to April 2020 (pandemic). We compared the volume of patients, transport/presentation times, severity of presenting symptoms, and final diagnosis. Results. In January, February, March, and April 2019, 10, 11, 17, and 19 patients, respectively, were transported in comparison to 19, 14, 10, and 8 during the same months in 2020. From January through April 2019, there was a 53% increase in transports, compared to a 42% decrease during the same months in 2020, constituting significantly different trend-line slopes (3.30; 95% CI 0.48–6.12 versus -3.70; 95% CI -5.76–-1.64, p = 0.001 ). Patient demographics, comorbidities, and symptom severity were mostly similar over the two time periods, and the number of patients with a final diagnosis of stroke was also similar. However, the median interval from EMS dispatch to ED arrival for patients with a final diagnosis of stroke was significantly longer in January to April 2020 ( 50 ± 11.7 min ) compared to the same time period in 2019 ( 42 ± 8.2 min , p = 0.01 ). Discussion/Conclusion. Our data indicate a decrease in patient transport volumes and longer intervals to EMS activation for suspected stroke care. These results suggest that even in a nonurban location without widespread community transmission, patients may be delaying or avoiding care for severe illnesses such as stroke. Clinicians and public health officials should not ignore the potential impact of pandemic-like illnesses even in areas of relatively low disease prevalence.

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Epidemiological Surveillance of the Impact of the COVID-19 Pandemic on Stroke Care Using Artificial Intelligence

Stroke ◽

10.1161/strokeaha.120.031960 ◽

2021 ◽

Author(s):

Raul G. Nogueira ◽

Jason M. Davies ◽

Rishi Gupta ◽

Ameer E. Hassan ◽

Thomas Devlin ◽

...

Keyword(s):

Artificial Intelligence ◽

Acute Stroke ◽

Systems Of Care ◽

Ct Perfusion ◽

Stroke Care ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Number Of Patients ◽

The Impact

Background and Purpose: The degree to which the coronavirus disease 2019 (COVID-19) pandemic has affected systems of care, in particular, those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence platform. Methods: Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke across 97 hospitals in 20 US states were collected in real time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23 223 patients were included. The incidence of large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (−22.8%; 1.39–1.07 patients/day per hospital, P <0.001) and CT perfusion (−26.1%; 0.50–0.37 patients/day per hospital, P <0.001) as well as in the incidence of large vessel occlusion (−17.1%; 0.15–0.13 patients/day per hospital, P <0.001) and severe strokes on CT perfusion (−16.7%; 0.12–0.10 patients/day per hospital, P <0.005). The sampled cohort showed similar declines in the rates of large vessel occlusions versus thrombectomy (18.8% versus 19.5%, P =0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, P =0.4). Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.

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A System-Based Intervention to Improve Access to Hyperacute Stroke Care

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2017.40 ◽

2017 ◽

Vol 44 (5) ◽

pp. 475-482 ◽

Cited By ~ 2

Author(s):

Richard H. Swartz ◽

Elizabeth Linkewich ◽

Shelley Sharp ◽

Jacqueline Willems ◽

Chris Olynyk ◽

...

Keyword(s):

Patient Flow ◽

Stroke Care ◽

Hyperacute Stroke ◽

Greater Toronto Area ◽

Number Of Patients ◽

Tissue Plasminogen ◽

Incident Reports ◽

The Impact ◽

Mean Time ◽

Improve Access

AbstractBackground:Hyperacute stroke is a time-sensitive emergency for which outcomes improve with faster treatment. When stroke systems are accessed via emergency medical services (EMS), patients are routed to hyperacute stroke centres and are treated faster. But over a third of patients with strokes do not come to the hospital by EMS, and may inadvertently arrive at centres that do not provide acute stroke services. We developed and studied the impact of protocols to quickly identify and move “walk-in” patients from non-hyperacute hospitals to regional stroke centres (RSCs).Methods and Results:Protocols were developed by a multi-disciplinary and multi-institutional working group and implemented across 14 acute hospital sites within the Greater Toronto Area in December of 2012. Key metrics were recorded 18 months pre- and post-implementation. The teams regularly reviewed incident reports of protocol non-adherence and patient flow data. Transports increased by 80% from 103 to 185. The number of patients receiving tissue plasminogen activator (tPA) increased by 68% from 34 to 57. Total EMS transport time decreased 17 minutes (mean time of 54.46 to 37.86 minutes,p<0.0001). Calls responded to within 9 minutes increased from 34 to 59%.Conclusions:A systems-based approach that included a multi-organizational collaboration and consensus-based protocols to move patients from non-hyperacute hospitals to RSCs resulted in more patients receiving hyperacute stroke interventions and improvements in EMS response and transport times. As hyperacute stroke care becomes more centralized and endovascular therapy becomes more broadly implemented, the protocols developed here can be employed by other regions organizing patient flow across systems of stroke care.

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American Heart Association COVID-19 CVD Registry Powered by Get With The Guidelines

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.120.006967 ◽

2020 ◽

Vol 13 (8) ◽

Cited By ~ 1

Author(s):

Heather M. Alger ◽

Christine Rutan ◽

Joseph H. Williams ◽

Jason G. Walchok ◽

Michele Bolles ◽

...

Keyword(s):

Quality Improvement ◽

American Heart Association ◽

American Heart ◽

Heart Association ◽

Research Community ◽

Improvement Program ◽

Data Resource ◽

Clinical Records ◽

Get With The Guidelines ◽

The Impact

Background: In response to the public health emergency created by the coronavirus disease 2019 (COVID-19) pandemic, American Heart Association volunteers and staff aimed to rapidly develop and launch a resource for the medical and research community to expedite scientific advancement through shared learning, quality improvement, and research. In <4 weeks after it was first announced on April 3, 2020, AHA’s COVID-19 CVD Registry powered by Get With The Guidelines received its first clinical records. Methods and Results: Participating hospitals are enrolling consecutive hospitalized patients with active COVID-19 disease, regardless of CVD status. This hospital quality improvement program will allow participating hospitals and health systems to evaluate patient-level data including mortality rates, intensive care unit bed days, and ventilator days from individual review of electronic medical records of sequential adult patients with active COVID-19 infection. Participating sites can leverage these data for onsite, rapid quality improvement, and benchmarking versus other institutions. After 9 weeks, >130 sites have enrolled in the program and >4000 records have been abstracted in the national dataset. Additionally, the aggregate dataset will be a valuable data resource for the medical research community. Conclusions: The AHA COVID-19 CVD Registry will support greater understanding of the impact of COVID-19 on cardiovascular disease and will inform best practices for evaluation and management of patients with COVID-19.

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Using Quality Improvement Methods and Time-Driven Activity-Based Costing to Improve Value-Based Cancer Care Delivery at a Cancer Genetics Clinic

Journal of Oncology Practice ◽

10.1200/jop.2015.007765 ◽

2016 ◽

Vol 12 (3) ◽

pp. e320-e331 ◽

Cited By ~ 12

Author(s):

Ryan Y.C. Tan ◽

Marie Met-Domestici ◽

Ke Zhou ◽

Alexis B. Guzman ◽

Soon Thye Lim ◽

...

Keyword(s):

Quality Improvement ◽

Cancer Care ◽

Cancer Genetics ◽

Care Delivery ◽

Genetic Counselor ◽

Activity Based Costing ◽

Improvement Project ◽

Personnel Costs ◽

Number Of Patients ◽

The Impact

Purpose: To meet increasing demand for cancer genetic testing and improve value-based cancer care delivery, National Cancer Centre Singapore restructured the Cancer Genetics Service in 2014. Care delivery processes were redesigned. We sought to improve access by increasing the clinic capacity of the Cancer Genetics Service by 100% within 1 year without increasing direct personnel costs. Methods: Process mapping and plan-do-study-act (PDSA) cycles were used in a quality improvement project for the Cancer Genetics Service clinic. The impact of interventions was evaluated by tracking the weekly number of patient consultations and access times for appointments between April 2014 and May 2015. The cost impact of implemented process changes was calculated using the time-driven activity-based costing method. Results: Our study completed two PDSA cycles. An important outcome was achieved after the first cycle: The inclusion of a genetic counselor increased clinic capacity by 350%. The number of patients seen per week increased from two in April 2014 (range, zero to four patients) to seven in November 2014 (range, four to 10 patients). Our second PDSA cycle showed that manual preappointment reminder calls reduced the variation in the nonattendance rate and contributed to a further increase in patients seen per week to 10 in May 2015 (range, seven to 13 patients). There was a concomitant decrease in costs of the patient care cycle by 18% after both PDSA cycles. Conclusion: This study shows how quality improvement methods can be combined with time-driven activity-based costing to increase value. In this paper, we demonstrate how we improved access while reducing costs of care delivery.

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Evaluating the Effectiveness of Concurrent Review

10.28971/532013mc65 ◽

2013 ◽

Author(s):

Celia McGillivray

Keyword(s):

Quality Improvement ◽

Performance Feedback ◽

Practice Patterns ◽

Standards Of Care ◽

Stroke Patients ◽

Improvement Strategy ◽

Quality Improvement Strategy ◽

Actual Performance ◽

And Performance ◽

The Impact

Concurrent review may be seen as a relatively new quality improvement strategy or an improvement over an existing quality improvement strategy, but research is scant. This strategy incorporates several key elements of performance feedback, which may be broadly defined as sharing non-judgmental information to professionals regarding discrepancies between their actual performance and standards of care. The distinction between concurrent review and performance feedback is the timing of information provided. Concurrent review incorporates the provision ofmedical information regarding a provider's performance during the patient's hospitalization, so that the plan ofcare is altered. This study evaluated concurrent review by examining the impact on stroke measures and whether physician and nurse practice patterns in managing stroke patients were altered.

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