No abstract

stroke triage is a public policy intervention that can have an immediate impact on acute stroke care in a region.OBJECTIVE To evaluate the impact that a citywide policy recommending prehospital triage of patients with suspected stroke to the nearest primary stroke center had on intravenous tissue plasminogen activator (tPA) use in Chicago, Illinois.

Background and Purpose-We evaluated the impact that duration as a primary stroke center (PSC) had on tissue-type plasminogen activator (tPA) utilization for acute ischemic stroke. Methods-A retrospective analysis of the Illinois Hospital Association CompData was performed identifying those patients with primary discharge diagnosis of acute ischemic stroke based on International Classification of Diseases version 9 codes. We assessed utilization of tPA by International Classification of Diseases version 9 procedure code (99.10). We categorized patients as cared for at non-PSC, PSC Ͼ1 year before, Յ1 year before, Յ1 year after, and Ͼ1 year after certification. We used generalized estimating equations to calculate adjusted odds ratios for tPA utilization by PSC category. Results-Among 119 539 acute ischemic stroke patients (mean age, 72 years; 55.2% women), tPA use was 1.9% but increased by PSC category (PϽ0.001): (1) non-PSC 0.9%; (2) Ͼ1 year before PSC certification 1.4%; (3) Յ1 year before certification 3.2%; (4) Յ1 year after certification 4.3%; and (5) Ͼ1 year after certification 6.5%. Adjusting for age, insurance status, admission source, year of study, region of Illinois, and hospital bed size, the odds of tPA utilization increased with advancing stage of PSC certification (highest category: adjusted odds ratio, 2.37; 95% confidence interval, 1.52-3.71). Conclusions-Although increasing over time, stroke thrombolysis is strongly impacted by the PSC certification process.Rather than waning or stagnating, tPA utilization increases at PSC from the earliest phases of preparation through certification and subsequent maintenance. (Stroke. 2012;43:875-877.)

Background-Reduction in door-to-needle (DTN) times in patients with acute ischemic stroke treated with tissue-type plasminogen activator is associated with improved outcomes. We hypothesized that a learning collaborative would rapidly reduce DTN times at Chicago's primary stroke centers. Methods and Results-We analyzed data from all adult patients with out-of-hospital ischemic stroke hospitalized between January 1, 2010 and March 31, 2015 and who received tissue-type plasminogen activator in the emergency department at 15 primary stroke centers in Chicago and 15 primary stroke centers in St. Louis. We implemented a structured learning collaborative in Chicago in quarter 1 of 2013 that included (1) a quality improvement leader, (2) stroke content expert, (3) multidisciplinary teams from each site, (4) a targeted goal for the program (DTN time <60 minutes in >50% of patients treated with tissue-type plasminogen activator), and (5) face-to-face meetings with on-site visits. We used interrupted time-series analysis to compare the impact of the learning collaborative on DTN times in Chicago pre-and post implementation and also concurrently versus St. Louis. We prespecified adjustment for mode of arrival, emergency medical services prenotification, and onset-to-arrival times. P values less than 0.05 were considered significant. In adjusted analysis, the reduction in DTN time within 1 quarter of implementation was 15. MethodsThere are nearly 3 million residents in Chicago (45% white, 33% black, and 29% Hispanic; http://www.census.gov/; accessed July 15, 2015). The Chicago Fire Department is the sole public emergency medical services (EMS) provider for the emergent transportation of patients with stroke. In 2009, Illinois passed a law permitting regional preferential transportation of suspected stroke patients to the nearest PSC. Chicago implemented a stroke triage policy in March 2011. We previously published on the impact of this policy on tPA treatment rates at Chicago PSCs. 20During the study period, 15 PSCs within city limits received suspected stroke patients by EMS ( Figure I in the Data Supplement). All centers use the (GWTG-S) Get With The Guidelines-Stroke registry for quality improvement and aggregate regional data reporting and analysis. Each hospital expressed agreement with the AHA/ASA to share data and report results in aggregate form. We required the following data to be entered in the GWTG-S database for analysis: demographics (age, sex, race, and ethnicity), medical history (hypertension, diabetes mellitus, prior stroke, hyperlipidemia, and atrial fibrillation/flutter), mode of hospital arrival, EMS prenotification, times of symptom onset, CT imaging completed, and thrombolytic administration, initial stroke severity using the NIHSS (National Institutes of Health Stroke Scale), complications of thrombolytic therapy, and discharge outcomes. All data were entered by local site coordinators without central adjudication, interpretation, or review. All participating institutions were required to comply wit...