Association Between Adherence to Quality Indicators and 7-Day In-Hospital Mortality After Acute Ischemic Stroke

Background and Purpose: Quality indicators (QI) are an accepted tool to measure performance of hospitals in routine care. We investigated the association between quality of acute stroke care defined by overall adherence to evidence-based QI and early outcome in German acute care hospitals. Methods: Patients with ischemic stroke admitted to one of the hospitals cooperating within the ADSR (German Stroke Register Study Group) were analyzed. The ADSR is a voluntary network of 9 regional stroke registers monitoring quality of acute stroke care across 736 hospitals in Germany. Quality of stroke care was defined by adherence to 11 evidence-based indicators of early processes of stroke care. The correlation between overall adherence to QI with outcome was investigated by assessing the association between 7-day in-hospital mortality with the proportion of QI fulfilled from the total number of QI the individual patient was eligible for. Generalized linear mixed model analysis was performed adjusted for the variables age, sex, National Institutes of Health Stroke Scale and living will and as random effect for the variable hospital. Results: Between 2015 and 2016, 388 012 patients with ischemic stroke were reported (median age 76 years, 52.4% male). Adherence to distinct QI ranged between 41.0% (thrombolysis in eligible patients) and 95.2% (early physiotherapy). Seven-day in-hospital mortality was 3.4%. The overall proportion of QI fulfilled was median 90% (interquartile range, 75%–100%). In multivariable analysis, a linear association between overall adherence to QI and 7-day in-hospital-mortality was observed (odds ratio adherence <50% versus 100%, 12.7 [95% CI, 11.8–13.7]; P <0.001). Conclusions: Higher quality of care measured by adherence to a set of evidence-based process QI for the early phase of stroke treatment was associated with lower in-hospital mortality.

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Development and Implementation of Evidence-Based Indicators for Measuring Quality of Acute Stroke Care

Stroke ◽

10.1161/01.str.0000241086.92084.c0 ◽

2006 ◽

Vol 37 (10) ◽

pp. 2573-2551 ◽

Cited By ~ 69

Author(s):

Peter U. Heuschmann ◽

Marcel K. Biegler ◽

Otto Busse ◽

Susanne Elsner ◽

Armin Grau ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Evidence Based ◽

Acute Stroke Care

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FP22-TU-01 Quality of acute stroke care in Thailand, a prospective multicenter countrywide study

Journal of the Neurological Sciences ◽

10.1016/s0022-510x(09)70380-6 ◽

2009 ◽

Vol 285 ◽

pp. S91

Author(s):

Y. Nilanont ◽

S. Nidhinandana ◽

N. Suwanwela ◽

N. Poungvarin

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Acute Stroke Care

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Abstract W MP104: Quality of Acute Stroke Care at Primary Stroke Centers Before and After Certification in Comparison to Never-Certified Hospitals

Stroke ◽

10.1161/str.45.suppl_1.wmp104 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Nerses Sanossian ◽

May A Kim-Tenser ◽

David S Liebeskind ◽

Justina Breen ◽

Scott Hamilton ◽

...

Keyword(s):

Los Angeles ◽

Acute Stroke ◽

Stroke Care ◽

Care Quality ◽

Acute Stroke Care ◽

Phase 3 ◽

Before And After ◽

Beneficial Impact ◽

Mean Time

Background: Primary Stroke Centers (PSC) provide better acute stroke care than non-PSC hospitals, including faster times to imaging and lytic treatment, and higher rates of lytic delivery. Nationwide less than 1 in 3 hospital has achieved this designation. We aimed to determine the extent to which the better performance at PSC is driven by improvements within hospitals after PSC designation versus better baseline hospital care among facilities seeking PSC certification. Methods: From 2005 to 2012, the NIH Field Administration of Stroke Therapy -Magnesium (FAST-MAG) Phase 3 clinical trial enrolled subjects with likely stroke within 2 hours of onset in a study of prehospital start of a neuroprotective agent. Subjects were routed to 59 community and academic centers in Los Angeles and Orange Counties. Of the original 59 centers, 39 eventually achieved PSC status during the study period. Each subject was classified as enrolled at a PSC before certification (pre-PSC), at a PSC post certification (post-PSC), or at a hospital that never achieved PSC (non-PSC). Results: Of 1700 cases, 529 (31%) were enrolled at pre-PSC, 856 (50%) at post-PSC, and 315 (19%) at non-PSC hospitals. Mean time in minutes from ED arrival to first scan was 33 minutes at post-PSC, 47 minutes at pre-PSC and 49 at non-PSCs [p<0.001 by Mann-Whitney]. Among cases of cerebral ischemia (CI) [N=1223], rates of TPA utilization were 43% at post-PSC, 27% at pre-PSC and 28% at non-PSC hospitals [p<0.001 by X2]. Time in minutes from ED arrival to thrombolysis in treated cases was 71 at post-PSC, 98 at pre-PSC, and 95 at non-PSC hospitals [p<0.001 by Mann-Whitney]. Hospitals that achieved PSC showed improvements in pre-PSC and post-PSC performance on door to imaging time, from 47 to 33 minutes [p=0.014]; percent TPA use in CI, from 27% to 43% [p<0.001], and reduced door-to-needle times, from 98 to 71 minutes [p=0.003]. There was no difference in time to imaging [47 vs. 49 minutes], time to thrombolysis [98 vs. 95 minutes] and percent TPA use [27% vs. 28%] between pre-PSC hospitals and non-PSC hospitals. Conclusions: Better performance of Primary Stroke Centers on acute care quality metrics is primarily driven by a beneficial impact of the PSC-certification process, and not better performance prior to seeking PSC status.

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Ten Years of Improving Acute Stroke Management in a Metropolitan Area: A Population-Based Quantification of Quality Indicators

European Neurology ◽

10.1159/000518428 ◽

2021 ◽

pp. 1-11

Author(s):

Anna Alegiani ◽

Michael Rosenkranz ◽

Leonie Schmitz ◽

Susanne Lezius ◽

Günter Seidel ◽

...

Keyword(s):

Acute Stroke ◽

Quality Indicators ◽

Metropolitan Area ◽

Stroke Care ◽

Care Quality ◽

Acute Stroke Care ◽

Stroke Units ◽

Stroke Treatment ◽

Acute Stroke Treatment ◽

Over Time

Background and Purpose: Rapid access to acute stroke treatment improves clinical outcomes in patients with ischemic stroke. We aimed to shorten the time to admission and to acute stroke treatment for patients with acute stroke in the Hamburg metropolitan area by collaborative multilevel measures involving all hospitals with stroke units, the Emergency Medical Services (EMS), and health-care authorities. Methods: In 2007, an area-wide stroke care quality project was initiated. The project included mandatory admission of all stroke patients in Hamburg exclusively to hospitals with stroke units, harmonized acute treatment algorithms among all hospitals, repeated training of the EMS staff, a multimedia educational campaign, and a mandatory stroke care quality monitoring system based on structured data assessment and quality indicators for procedural measures. We analyzed data of all patients with acute stroke who received inhospital treatment in the city of Hamburg during the evaluation period from the quality assurance database data and evaluated trends of key quality indicators over time. Results: From 2007 to 2016, a total of 83,395 patients with acute stroke were registered. During this period, the proportion of patients admitted within ≤3 h from symptom onset increased over time from 27.8% in 2007 to 35.2% in 2016 (p < 0.001). The proportion of patients who received rapid thrombolysis (within ≤30 min after admission) increased from 7.7 to 54.1% (p < 0.001). Conclusions: Collaborative stroke care quality projects are suitable and effective to improve acute stroke care.

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Effects of centralizing acute stroke services

Neurology ◽

10.1212/wnl.0000000000005822 ◽

2018 ◽

Vol 91 (3) ◽

pp. e236-e248 ◽

Cited By ~ 6

Author(s):

Sidsel Hastrup ◽

Soren P. Johnsen ◽

Thorkild Terkelsen ◽

Heidi H. Hundborg ◽

Paul von Weitzel-Mudersbach ◽

...

Keyword(s):

Hospital Stay ◽

Acute Stroke ◽

Stroke Care ◽

Acute Hospital ◽

Acute Stroke Care ◽

Difference In Differences ◽

Stroke Units ◽

Before And After ◽

Stroke Services

ObjectiveTo investigate the effects of centralizing the acute stroke services in the Central Denmark Region (CDR).MethodsThe CDR (1.3 million inhabitants) centralized acute stroke care from 6 to 2 designated acute stroke units with 7-day outpatient clinics. We performed a prospective “before-and-after” cohort study comparing all strokes from the CDR with strokes in the rest of Denmark to discover underlying general trends, adopting a difference-in-differences approach. The population comprised 22,141 stroke cases hospitalized from May 2011 to April 2012 and May 2013 to April 2014.ResultsCentralization was associated with a significant reduction in length of acute hospital stay from a median of 5 to 2 days with a length-of-stay ratio of 0.53 (95% confidence interval 0.38–0.75, data adjusted) with no corresponding change seen in the rest of Denmark. Similarly, centralization led to a significant increase in strokes with same-day admission (mainly outpatients), whereas this remained unchanged in the rest of Denmark. We observed a significant improvement in quality of care captured in 11 process performance measures in both the CDR and the rest of Denmark. Centralization was associated with a nonsignificant increase in thrombolysis rate. We observed a slight increase in readmissions at day 30, but this was not significantly different from the general trend. Mortality at days 30 and 365 remained unchanged, as in the rest of Denmark.ConclusionsCentralizing acute stroke care in the CDR significantly reduced the length of acute hospital stay without compromising quality. Readmissions and mortality stayed comparable to the rest of Denmark.

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Quality of Acute Stroke Care at Primary Stroke Centers Before and After Certification in Comparison to Never-Certified Hospitals

Frontiers in Neurology ◽

10.3389/fneur.2019.01396 ◽

2020 ◽

Vol 10 ◽

Author(s):

Kristina Shkirkova ◽

Theodore T. Wang ◽

Lily Vartanyan ◽

David S. Liebeskind ◽

Marc Eckstein ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Acute Stroke Care ◽

Before And After

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Variations in Quality Indicators of Acute Stroke Care in 6 European Countries

Stroke ◽

10.1161/strokeaha.111.628396 ◽

2012 ◽

Vol 43 (2) ◽

pp. 458-463 ◽

Cited By ~ 26

Author(s):

Silke Wiedmann ◽

Bo Norrving ◽

Tim Nowe ◽

Sònia Abilleira ◽

Kjell Asplund ◽

...

Keyword(s):

Acute Stroke ◽

Quality Indicators ◽

Stroke Care ◽

European Countries ◽

Acute Stroke Care

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The Dutch Acute Stroke Audit: Benchmarking acute stroke care in the Netherlands

European Stroke Journal ◽

10.1177/2396987318787695 ◽

2018 ◽

Vol 3 (4) ◽

pp. 361-368 ◽

Cited By ~ 8

Author(s):

Laurien S Kuhrij ◽

Michel WJM Wouters ◽

Renske M van den Berg-Vos ◽

Frank-Erik de Leeuw ◽

Paul J Nederkoorn

Keyword(s):

Acute Stroke ◽

Best Practice ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Favourable Outcome ◽

Hospital Level ◽

Acute Stroke Care ◽

Related Factors ◽

Variation In Care

Introduction In the nationwide Dutch Acute Stroke Audit (DASA), consecutive patients with acute ischaemic stroke (AIS) and intracranial haemorrhage (ICH) are prospectively registered. Acute stroke care is a rapidly evolving field in which intravenous thrombolysis (IVT) and intra-arterial thrombectomy (IAT) play a crucial role in increasing odds of favourable outcome. The DASA can be used to assess the variation in care between hospitals and develop ‘best practice’ in acute stroke care. Patients and methods: We describe the initiation and design of the DASA as well as the results from 2015 and 2016. Results In 2015 and 2016, 55,854 patients with AIS and 7727 patients with ICH were registered in the DASA. Treatment with IVT was administered to 10,637 patients (with an increase of 1.3% in 2016) and 1740 patients underwent IAT (with an increase of 1% in 2016). Median door-to-needle time for IVT and median door-to-groin time for IAT have decreased from 27 to 25 min and 66 to 64 min, respectively. Mortality during admission was 4.9% in patients with AIS, whereas 26% of patients with ICH died. Modified Rankin Scale score at three months was registered in 49% of AIS patients and 45% of ICH patients. Discussion During the nationwide DASA, time to treatment is reduced for IVT as well as IAT. With the rapidly evolving treatment of acute stroke care, the DASA can be used to monitor the quality provided on patient- and hospital level. Conclusion Increasing completeness of registration of the outcome, in combination with adjustment for patient-related factors, is necessary to define and further improve the quality of the acute stroke care.

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Abstract 90: Nursing Education: A Critical Need in the Delivery of High Quality Stroke Care

Stroke ◽

10.1161/str.45.suppl_1.90 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Virginia Daggett ◽

Linda Williams ◽

Nicholas Burrus ◽

Jennifer Myers ◽

Laura Plue ◽

...

Keyword(s):

Acute Stroke ◽

Quality Indicators ◽

Stroke Care ◽

Training Needs ◽

Release Time ◽

Multidisciplinary Teams ◽

Care Providers ◽

Acute Stroke Care ◽

High Quality ◽

And Training

Objectives: High quality stroke care is complex, and requires strong multidisciplinary teams, including nurses, to ensure care processes are timely and appropriate. The purpose of this study was to identify training needs of nurses who deliver care to patients who present with acute stroke and are admitted to inpatient units. Methodology: Using semi-structured interviews, we conducted a qualitative study for a formative evaluation in 12 Department of Veterans Affairs Medical Centers (VAMCs) that had ≥ 50 acute ischemic stroke admissions a year and were diverse in the structure of stroke care. The interviews focused on current context and structure of stroke care, including educational practices and training needs. Secondary analyses were conducted, targeting frontline nurse and physician respondents (N = 113) in emergency, acute care and rehabilitation units. Results: Respondents across the sites reported insufficient nurse education and training for acute stroke care as an overarching theme. Moreover, themes related to the acute stroke care quality indicators emerged as areas of competencies that nurses needed training on a continuum: a) timely recognition of acute stroke and transient ischemic attacks, b) NIH Stroke Scale and neurological exams, c) dysphagia screening, d) administration of tissue plasminogen activator and management post treatment, and e) deep vein thrombosis prophylaxis. Themes that were related to structure of stroke care and/or context also emerged and attributed to training challenges across the sites, listed in order of prevalence: a) centralized care versus decentralized care, b) low volume of acute strokes, c) nurse engagement, d) structured acute stroke care education, and e) release time. Conclusions: VA stroke care providers identify educational needs around specific stroke quality indicators, but also describe key barriers including lower volume, time for training and engagement of nursing staff in acute stroke care. Future programs to improve VA stroke care need to address these barriers to optimally support high quality multidisciplinary stroke care.

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Abstract MP22: Sex Differences in the Delivery of Acute Telestroke Care

Stroke ◽

10.1161/str.52.suppl_1.mp22 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Johanna L Morton ◽

Suraj Didwania ◽

Eric Anderson ◽

Jason Hallock

Keyword(s):

Sex Differences ◽

Ischemic Stroke ◽

Acute Stroke ◽

Patient Population ◽

Functional Outcomes ◽

Stroke Care ◽

Stroke Severity ◽

Acute Stroke Care ◽

Presenting Symptoms ◽

Suspected Stroke

Background: Sex differences are encountered in many aspects of ischemic stroke, including risk factors, presenting symptoms, stroke mechanism, acute interventions and functional outcomes. As telestroke services continue to expand, many patients utilize telestroke for the evaluation and treatment of suspected stroke symptoms. To date, the existence of such differences between sexes has not been identified in the patient population having utilized telestroke for acute stroke care. Methods: A retrospective observational study of the experience of a single teleneurology practice serving 340 hospitals from April 2018 to June 2020 was performed. Patients seen in the emergency department (ED) with a diagnosis of suspected stroke were included. Data from the acute stroke encounter was reported through the current medical record platform. Results: Within the queried period, there were 11,454 male and 11,794 female patients identified as having received ED telestroke evaluation for suspected acute stroke. Males were younger than females (67 vs 70, P <0.01). Males had higher rates of prior stroke, hypertension, diabetes, hyperlipidemia, and coronary disease than females ( P <0.01), while females had higher rates of atrial fibrillation ( P =0.03) and TIA ( P <0.01). Rates of antiplatelet and anticoagulants were higher in males ( P <0.01) than females. There were no differences in time to ED presentation, time to request consult or make a thrombolysis decision, or length of consult. Females had higher stroke severity ( P <0.01) and door-to-needle times ( P <0.01), but lower alteplase rates ( P =0.02) compared to males. Conclusion: This review of a national heterogeneous telestroke patient population is indicative of sex differences in multiple aspects of acute ischemic stroke, most notably in thrombolysis delivered via telestroke. Further investigation into the etiology of such differences is warranted, as well as a survey of functional outcomes. As telemedicine continues to expand in the era of the COVID-19 pandemic, it is imperative that the reasons behind this disparity are investigated.

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