Quality initiative helps lower risk of bleeding, death after stroke

Dr Fonarow

Implementation of a quality initiative has been linked to improvement in the time to treatment and a lower risk of in-hospital death, intracranial hemorrhage (bleeding in the brain), and an increase in the portion of patients discharged to their home, according to a study in the April 23/30 issue of JAMA.

Intravenous tissue plasminogen activator (tPA) reduces long-term disability when administered early to eligible patients with acute ischemic stroke. These benefits, however, are highly time dependent. Because of the of the importance of rapid treatment, national guidelines recommend that hospitals complete the evaluation of patients with acute ischemic stroke and initiate intravenous tPA therapy within 60 minutes of patient arrival in eligible patients.

However, prior studies demonstrate that less than 30% of patients presenting with acute ischemic stroke in the United States were treated within the guideline recommended door-to-needle (DTN) time for tPA administration and this measure had improved minimally over time.

Gregg C. Fonarow, MD, of the University of California, Los Angeles, and colleagues examined the results of a national quality improvement initiative (Target: Stroke), which aims to increase the number of stroke patients treated with clot-busting drugs for ischemic stroke within 60 minutes or less after hospital arrival. Initiated nationwide in 2010, Target: Stroke provided 10 key strategies as well as tools to facilitate timely tPA administration, as well as additional approaches to improve stroke care and outcome. Data from 71,169 tPA-treated stroke patients at 1,030 hospitals participating in Target: Stroke were analyzed to compared the time to treatment and incidence of complications before implementation, from 2003 to 2009, to the post-implementation years, from 2010 to 2013.

The study found that the multidimensional Target: Stroke initiative resulted in all measures of door-to-needle times for administration of tPA significantly improving; a 4-fold acceleration in the annual rate of patients with DTN times within 60 minutes; achieving the goal of at least 50% of tPA treated patients in Get With the Guidelines-Stroke (GWTG-Stroke) having DTN times within 60 minutes; equitable improvement in stroke care by age, sex, and all race/ethnic groups; marked increase in eligible acute ischemic stroke patients being treated with tPA in the 3-hour window, 4.5-hour window, and overall; significant reductions in in-hospital death and disability due to acute ischemic stroke; and enhanced patient safety with reductions in symptomatic intracranial hemorrhage and overall complications from tPA.

“There were notable achievements in all 6 Institute of Medicine quality-of-care domains,” according to Dr Fonarow.

The median (midpoint) DTN time for tPA administration for the pre-intervention period was 77 minutes, which decreased to 67 minutes for the entire post-intervention period. DTN times for tPA administration of 60 minutes or less increased from 26.5% to 41.3% (and from 29.6% to 53.3% at the end of each intervention period). Other improvements included in-hospital deaths (9.9% to 8.3%); discharge to home (38% to 43%); independence with walking (42% to 45%); and symptomatic intracranial hemorrhage within 36 hours (5.7% to 4.7%).

“By applying the 10 Target: Stroke evidence-based strategies for improving the timeliness of intravenous tPA administration for acute ischemic stroke hospital teams can improve stroke care, reduce disability from stroke, and improve survival,” Dr Fonarow said. “These findings are applicable to all hospitals that care for patients with acute ischemic stroke.”

The Target: Stroke quality improvement initiative was highly successful in improving stroke care and clinical outcomes at the national level, according to Dr Fonarow.

“These findings also further reinforce the importance and clinical benefits of faster administration of intravenous tPA,” he said. “By showing that the timeliness of tPA administration can be improved at the national level, these findings also support further expansion of the Target: Stroke initiative.”