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.
In response to the COVID-19 pandemic, affected countries implemented various public health measures to decrease viral transmission. An unintended consequence of these measures could be hospital avoidance by patients with medical emergencies, as observed during other outbreaks in the 2000s. 1,2 Some public health messaging specifically warned groups at high cardiovascular risk, such as older people or those with heart disease, that they were at elevated risk of severe COVID-19. 3 Physical distancing may also result in loss of services and support networks, impairing patients' ability to seek medical assistance. 4 Furthermore, pandemics generate new challenges of managing personal protective equipment and cleaning protocols, 5 and additional information bottlenecks, which could result in workflow delays for emergencies like stroke. 6 Previous studies have reported declines in patients presenting to hospital with stroke or acute coronary syndrome during the pandemic. 7,8 A World Stroke Organization survey of members in several countries indicated a sharp reduction in stroke admissions by 50%-80% in the first weeks of the pandemic. 9 A crosssectional study reported a global decline in hospital admissions ResearchHealth servicesChanges in ischemic stroke presentations, management and outcomes during the first year of the COVID-19 pandemic in Alberta: a population study
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