Regional Learning Collaboratives Produce Rapid and Sustainable Improvements in Stroke Thrombolysis Times

Abstract

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...

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