Clinical Performance Measures for Adults Hospitalized With Acute Ischemic Stroke

Self Cite

Introduction— Dysphagia screening protocols have been recommended to identify patients at risk for aspiration. The American Heart Association convened an evidence review committee to systematically review evidence for the effectiveness of dysphagia screening protocols to reduce the risk of pneumonia, death, or dependency after stroke. Methods— The Medline, Embase, and Cochrane databases were searched on November 1, 2016, to identify randomized controlled trials (RCTs) comparing dysphagia screening protocols or quality interventions with increased dysphagia screening rates and reporting outcomes of pneumonia, death, or dependency. Results— Three RCTs were identified. One RCT found that a combined nursing quality improvement intervention targeting fever and glucose management and dysphagia screening reduced death and dependency but without reducing the pneumonia rate. Another RCT failed to find evidence that pneumonia rates were reduced by adding the cough reflex to routine dysphagia screening. A smaller RCT randomly assigned 2 hospital wards to a stroke care pathway including dysphagia screening or regular care and found that patients on the stroke care pathway were less likely to require intubation and mechanical ventilation; however, the study was small and at risk for bias. Conclusions— There were insufficient RCT data to determine the effect of dysphagia screening protocols on reducing the rates of pneumonia, death, or dependency after stroke. Additional trials are needed to compare the validity, feasibility, and clinical effectiveness of different screening methods for dysphagia.

Section: Strokementioning

confidence: 99%

Effect of Dysphagia Screening Strategies on Clinical Outcomes After Stroke: A Systematic Review for the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Smith¹,

Kent²,

Bulsara³

et al. 2018

Self Cite

“…Our findings have important implications for the interpretation of DTN quality performance measures that exclude patients with reasons for delays, as the National Quality Forum (NQF) and American Heart Association/ American Stroke Association endorsed Time to Intravenous Thrombolytic Therapy does. 15,16 More than a fifth of all alteplase-treated patients are excluded from the denominator of this measure based on documentation of eligibility or medical reasons for slower treatment. The result is an inflation bias in the reported proportion of patients treated within 60 minutes of arrival according to the measure, and it is important to recognize that the proportion of rapidly treated cases is actually lower if all alteplase-treated patients were to be included in the denominator, as is the approach that has been used in Target: Stroke.…”

Section: Discussionmentioning

confidence: 99%

“…If DTN time was >60 minutes, then reasons for delays were collected based on 3 categories (eligibility, medical, and hospital reasons) in the case report form ( Table I in the online-only Data Supplement), matching definitions used in the National Quality Forum Time to Intravenous Thrombolysis performance measure, which has also been endorsed by the American Heart Association. 15 Hospital reasons are further subdivided into delay in diagnosis, inhospital delay, equipment-related delay, and other.…”

Section: Methodsmentioning

confidence: 99%

Delays in Door-to-Needle Times and Their Impact on Treatment Time and Outcomes in Get With The Guidelines-Stroke

Kamal

Sheng

Xian

et al. 2017

Self Cite

T he benefit of intravenous alteplase (tissue-type plasminogen activator) is time dependent 1,2 with no average benefit beyond ≈4.5 hours from time of onset. [3][4][5] The recommended time from patient arrival at hospital to treatment (door-to-needle [DTN] time) is ≤60 minutes.6 Even though the American Heart Association/American Stroke Association Target Stroke initiative has greatly increased the number of patients that are treated with DTN times within 60 minutes in the United States, 7 a substantial portion of patients are still treated later than 60 minutes from arrival. Modifiable delays have been related to hospital factors, which may be successfully redesigned to lower DTN times, [8][9][10] and patient factors such as hypertension or other concomitant emergency conditions that need to be managed before treatment. 11 Finally, there are several eligibility criteria including the confirmation that ischemic stroke is the underlying cause of the acute onset of neurological symptoms that need to be met before starting treatment. 12However, the reasons for treatment delay have not been well described in the literature. Furthermore, the extent to which reasons for delays may impact DTN times and outcomes has not been examined.We analyzed data from the Get With The Guidelines-Stroke database to describe the reasons for delays. We examine the association of DTN times and documented reason(s) for delay, Background and Purpose-Despite quality improvement programs such as the American Heart Association/American Stroke Association Target Stroke initiative, a substantial portion of acute ischemic stroke patients are still treated with tissue-type plasminogen activator (alteplase) later than 60 minutes from arrival. This study aims to describe the documented reasons for delays and the associations between reasons for delays and patient outcomes. Methods-We analyzed the characteristics of 55 296 patients who received intravenous alteplase in 1422 hospitals participating in Get With The Guidelines-Stroke from October 2012 to April 2015, excluding transferred patients and inpatient strokes. We assessed eligibility, medical, and hospital reasons for delays in door-to-needle time. Results-There were 27 778 patients (50.2%) treated within 60 minutes, 10 086 patients (18.2%) treated >60 minutes without documented delays, and 17 432 patients (31.5%) treated >60 minutes with one or more documented reasons for delay. Delayed door-to-needle times were associated with delayed diagnosis (36 minutes longer than those without delay in diagnosis) and hypoglycemia or seizure (34 minutes longer than without those conditions). The presence of documented delays was associated with higher odds of in-hospital mortality (odds ratio, 1.2; 95% confidence interval, 1.1-1.3) and symptomatic intracranial hemorrhage (odds ratio, 1.2; 95% confidence interval, 1.1-1.3) and lower odds of independent ambulation at discharge (odds ratio, 0.92; 95% confidence interval, 0.9-1.0) after adjusting for patient and hospital characteristics. Conclusions-Hospita...

“…The Stroke Performance Measures Oversight Committee recently published its first report on quality measures for inpatient management of acute ischemic stroke. 79 The expert panel acknowledged that because performance measurement is, by definition, dynamic, it must continuously evolve with the accumulating scientific evidence on best practice.…”

Section: Prior Experience With the Use Of Quality Measures In Strokementioning

confidence: 99%

Telemedicine Quality and Outcomes in Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

Wechsler¹,

Demaerschalk²,

Schwamm³

et al. 2017

Self Cite

207

153

e3T elestroke is one of the most successful applications of telemedicine, bringing the experience of stroke experts to hospitals lacking appropriate stroke expertise. The number and extent of telestroke networks continue to grow in the United States and throughout the world. As telestroke matures, monitoring practice quality and outcomes becomes essential to Purpose-Telestroke is one of the most frequently used and rapidly expanding applications of telemedicine, delivering much-needed stroke expertise to hospitals and patients. This document reviews the current status of telestroke and suggests measures for ongoing quality and outcome monitoring to improve performance and to enhance delivery of care. Methods-A literature search was undertaken to examine the current status of telestroke and relevant quality indicators.The members of the writing committee contributed to the review of specific quality and outcome measures with specific suggestions for metrics in telestroke networks. The drafts were circulated and revised by all committee members, and suggestions were discussed for consensus. Results-Models of telestroke and the role of telestroke in stroke systems of care are reviewed. A brief description of the science of quality monitoring and prior experience in quality measures for stroke is provided. Process measures, outcomes, tissue-type plasminogen activator use, patient and provider satisfaction, and telestroke technology are reviewed, and suggestions are provided for quality metrics. Additional topics include licensing, credentialing, training, and documentation. (Stroke. 2017;48:e3-e25.