QI Initiative Reduces Door-to-Needle Times For tPA Administration in Stroke Patients

Since its approval in the U.S. in 1996, intravenous tissue plasminogen activator (tPA) has remained the only level 1A treatment for acute ischemic stroke. Already battling against a lack of public recognition of stroke symptoms and a general urgency to seek care, hospitals and other emergency centers have consistently struggled to administer this life-saving treatment in an appropriate timeframe, with only 30 percent of U.S. patients treated within the recommended door-to-needle window of 60 minutes or less.

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Revealing substantial progress in solving this problem, a new report shows that the American Heart Association/American Stroke Association’s 2010 quality improvement initiative Target:Stroke, has made great strides since its implementation, and that "hospital participation in a multidimensional quality initiative was associated with improvement in the timeliness of tPA administration."

The study was published April 22 in the Journal of the American Medical Association, and led by Gregg Fonarow, MD, FACC, University of California, and compared 27,319 patients treated with tPA from 2003-2009 to 43,850 treated from 2010-2013. Data showed that the median door-to-needle time decreased to 67 minutes (from 77 minutes pre-intervention), with the percentage of patients with door-to-needle times of 60 minutes or less increasing from 29.6 percent to 53.3 percent. Clinical outcomes also improved, with in-hospital mortality falling to 8.25 percent (versus 9.93 percent pre-intervention), and symptomatic hemorrhage rates declining to 4.68 percent (versus 5.68 percent pre-intervention). Treatment of all patients with ischemic stroke rose from 5.7 percent to 8.1 percent post-intervention.

The investigators conclude that "there was also a more than 4-fold increase in the annual rate of improvement in the proportion of patients with door-to-needle times of 60 minutes or less after initiation of the intervention. Importantly, the improvement in timeliness in tPA administration following the start of the program was associated with improved clinical outcomes including lower in-hospital mortality, more frequent discharge to a more independently functioning environment, and lower rates of tPA complications, including symptomatic intracranial hemorrhage."

In a related editorial comment, James Grotta, MD, Memorial Hermann Hospital, writes "Although these types of observational uncontrolled studies have certain important limitations, including quality and consistency of data input before and after the intervention, and the contribution of secular trends toward improved tPA treatment metrics nationally, the study by Fonarow et al has many strengths, such as the very large sample size, the sharp positive inflection in the improvement curve seen immediately after the quality improvement initiative began, the observation that overall improvement in stroke care for patients not treated with tPA in the same hospitals was much less than tPA-related gains, and adjusted analysis for patient and hospital variables associated with stroke center performance and clinical outcomes. Further analyses will be helpful in identifying which factors of the quality improvement program were most important in contributing to the outcomes observed."

Keywords: Quality Improvement, Stroke, Intracranial Hemorrhages, Hospital Mortality, Tissue Plasminogen Activator, Needles

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