Improving stroke alert response time: Applying quality improvement methodology to the inpatient neurologic emergency

Cumbler, Ethan; Zaemisch, R.; Graves, Andrew; Brega, Kerry E.; Jones, William J.

doi:10.1002/jhm.984

Cited by 22 publications

(14 citation statements)

References 16 publications

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“…However, with explicit quality improvement efforts, there is evidence that response times can be reduced. [24][25][26] Our findings suggest in-hospital stroke time to thrombolytic treatment requires targeted attention.…”

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confidence: 80%

Quality of Care and Outcomes for In-Hospital Ischemic Stroke

Cumbler

Wald

Bhatt

et al. 2014

Stroke

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Background and Purpose-Analysis of quality of care for in-hospital stroke has not been previously performed at the national level. This study compares patient characteristics, process measures of quality, and outcomes for in-hospital strokes with those for community-onset strokes in a national cohort. Methods-We performed a retrospective cohort study of the Get With The Guidelines-Stroke (GWTG-Stroke) database ofThe American Heart Association from January 2006 to April 2012, using data from 1280 sites that reported ≥1 in-hospital stroke. Patient characteristics, comorbid illnesses, medications, quality of care measures, and outcomes were analyzed for 21 349 in-hospital ischemic strokes compared with 928 885 community-onset ischemic strokes. Results-Patients with in-hospital stroke had more thromboembolic risk factors, including atrial fibrillation, prosthetic heart valves, carotid stenosis, and heart failure (P<0.0001), and experienced more severe strokes (median National Institutes of Health Stroke Score 9.0 versus 4.0; P<0.0001). Using GWTG-Stroke achievement measures, the proportion of patients with defect-free care was lower for in-hospital strokes (60.8% versus 82.0%; P<0.0001). After accounting for patient and hospital characteristics, patients with in-hospital strokes were less likely to be discharged home (adjusted odds ratio 0.37; 95% confidence intervals [0.35-0.39]) or be able to ambulate independently at discharge (adjusted odds ratio 0.42; 95% confidence intervals [0.39-0.45]). In-hospital mortality was higher for in-hospital stroke (adjusted odds ratio 2.72; 95% confidence intervals [2.57-2.88]). Conclusions-Compared with community-onset ischemic stroke, patients with in-hospital stroke experienced more severe strokes, received lower adherence to process-based quality measures, and had worse outcomes. These findings suggest there is an important opportunity for targeted quality improvement efforts for patients with in-hospital stroke.

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confidence: 80%

Quality of Care and Outcomes for In-Hospital Ischemic Stroke

Cumbler

Wald

Bhatt

et al. 2014

Stroke

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“…This phenomenon can actually be harnessed in QI projects to sustain positive changes in practice by committing to continuous and ongoing provider feedback. 15 The reliability of the reception of individual prescribing information and the individual interpretation of this data was not measured.…”

Section: Limitationsmentioning

confidence: 99%

A Quality Improvement Initiative to Decrease Variability of Emergency Physician Opioid Analgesic Prescribing

Burton¹,

Hoppe²,

Echternach³

et al. 2016

WestJEM

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IntroductionAddressing pain is a crucial aspect of emergency medicine. Prescription opioids are commonly prescribed for moderate to severe pain in the emergency department (ED); unfortunately, prescribing practices are variable. High variability of opioid prescribing decisions suggests a lack of consensus and an opportunity to improve care. This quality improvement (QI) initiative aimed to reduce variability in ED opioid analgesic prescribing.MethodsWe evaluated the impact of a three-part QI initiative on ED opioid prescribing by physicians at seven sites. Stage 1: Retrospective baseline period (nine months). Stage 2: Physicians were informed that opioid prescribing information would be prospectively collected and feedback on their prescribing and that of the group would be shared at the end of the stage (three months). Stage 3: After physicians received their individual opioid prescribing data with blinded comparison to the group means (from Stage 2) they were informed that individual prescribing data would be unblinded and shared with the group after three months. The primary outcome was variability of the standard error of the mean and standard deviation of the opioid prescribing rate (defined as number of patients discharged with an opioid divided by total number of discharges for each provider). Secondary observations included mean quantity of pills per opioid prescription, and overall frequency of opioid prescribing.ResultsThe study group included 47 physicians with 149,884 ED patient encounters. The variability in prescribing decreased through each stage of the initiative as represented by the distributions for the opioid prescribing rate: Stage 1 mean 20%; Stage 2 mean 13% (46% reduction, p<0.01), and Stage 3 mean 8% (60% reduction, p<0.01). The mean quantity of pills prescribed per prescription was 16 pills in Stage 1, 14 pills in Stage 2 (18% reduction, p<0.01), and 13 pills in Stage 3 (18% reduction, p<0.01). The group mean prescribing rate also decreased through each stage: 20% in Stage 1, 13% in Stage 2 (46% reduction, p<0.01), and 8% in Stage 3 (60% reduction, p<0.01).ConclusionED physician opioid prescribing variability can be decreased through the systematic application of sharing of peer prescribing rates and prescriber specific normative feedback.

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“…Thus, reductions at different stages of the care pathway are possible, and are in concurrence with generating a more favorable outcome. Also, the HERMES analysis (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) reported a linear reduction in chances of good outcome with increasing time between onset and MT (17).…”

Section: Discussionmentioning

confidence: 99%

“…Studies have demonstrated that modifications and improvements are potentially attainable at every stage of the care workflow, where considerable emphasis has been placed to reduce transport times (4,(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16). The quality of care in AIS has been shown to be influenced by operational modifications such as the implementation of evidence-based stroke protocols, improved staff education and training, and prioritization of hospital resources (17,18). The accumulation of these findings is in agreement with the necessity to improve efficiencies at individual stages of the care workflow, which is achievable through a methodologically incorporated alteration of the whole care pathway.…”

Section: Introductionmentioning

confidence: 99%

STEPS-T Program Improves Endovascular Treatment Outcomes of Acute Ischemic Stroke; A 6-Year Study

et al. 2020

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Background: Early endovascular recanalization of occluded vessels in acute ischemic stroke (AIS) is a major contributor to good clinical outcome. We report the analysis of all AIS patients throughout a 6-year experience following the deployment of a quality initiative aiming at improving care, speed and maintaining quality for AIS treatment.Methods: Using a prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2017, workflow/outcomes were recorded. There were no exclusion criteria. During the first year, a quality program employing "digital-object" technology, staff education, and workflow improvement was implemented to reduce time-to-treatment. Using electronic recording, workflow times were collected for onset Results: Analysis of 382 patients (aged 71.3 ± 12.9) undergoing mechanical thrombectomy for AIS (206 male and 176 female) was performed. Recanalization time was significantly reduced from 82 min in 2012 to 34 min by 2017 (IQR 52-117 min and 23-49 min), a 59% reduction (P < 0.001). Further, consistent year-over-year reductions in setup time (T A -T G ) (44% improvement) and T CT to T A times were observed. During the same period, clinical outcome significantly improved year-over-year as measured with the modified Rankin Scale 0-2 (33, 37, 38, 41, 53, and 58%).Conclusions: Significant improvements were observed following the deployment of a quality initiative enabling iterative evidence-based process improvements, thereby sustaining significant reductions in time-to-treat and improved clinical outcomes for AIS patients.

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Improving stroke alert response time: Applying quality improvement methodology to the inpatient neurologic emergency

Cited by 22 publications

References 16 publications

Quality of Care and Outcomes for In-Hospital Ischemic Stroke

Quality of Care and Outcomes for In-Hospital Ischemic Stroke

A Quality Improvement Initiative to Decrease Variability of Emergency Physician Opioid Analgesic Prescribing

STEPS-T Program Improves Endovascular Treatment Outcomes of Acute Ischemic Stroke; A 6-Year Study

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