Advances in Stroke: Quality Improvement

HomeStrokeVol. 53, No. 5Advances in Stroke: Quality Improvement Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBAdvances in Stroke: Quality Improvement Dawn M. Bravata, Tara Purvis and Monique F. Kilkenny Dawn M. BravataDawn M. Bravata Correspondence to: Dawn M. Bravata, MD, Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 W 10th St, Indianapolis, IN 46202. Email E-mail Address: [email protected] https://orcid.org/0000-0002-3048-2536 Health Services Research and Development Center for Health Information and Communication, Department of Veterans Affairs and Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B.). Expanding Expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Health Services Research and Development, Department of Veterans Affairs (VA), Indianapolis, IN (D.M.B.). Departments of Medicine and Neurology, Indiana University School of Medicine, Indianapolis (D.M.B.). William M. Tierney Center for Health Services Research, Regenstrief Institute, Indianapolis, IN (D.M.B.). , Tara PurvisTara Purvis Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (T.P., M.F.K.). The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (T.P., M.F.K.). and Monique F. KilkennyMonique F. Kilkenny https://orcid.org/0000-0002-3375-287X Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (T.P., M.F.K.). The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (T.P., M.F.K.). Originally published4 Apr 2022https://doi.org/10.1161/STROKEAHA.122.037450Stroke. 2022;53:1767–1771Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 4, 2022: Ahead of Print In 2021, studies evaluated a variety of quality improvement (QI) interventions targeting processes of care across the continuum of care (ie, prehospital, acute hospital, and posthospital discharge) for patients with stroke or transient ischemic attack (TIA). Commonalities among the programs that effectively improved quality of care included: multidisciplinary/interprofessional teams which set policy and provided facilitation; order sets, clinical pathways, and protocols; clearly articulating guideline-concordant care elements that became the focus of QI activities and that were subject to ongoing measurement and audit-and-feedback; process mapping; Plan-Do-Study-Act (PDSA) cycles; and multifaceted education programs. Future studies should seek to include patients and caregivers in QI, examine approaches to sustaining QI after active implementation has ended, focus on reducing health care disparities, and evaluate interventions to improve care in the posthospital period. Studies of QI interventions should not only examine whether average quality of care is improved but also if heterogeneity across patients or hospitals is reduced; seeking to ensure that all patients across all hospitals receive the stroke care for which they are eligible.Globally, there is a commitment to ensuring that all patients with stroke or TIA have access to evidence-based treatments to improve survival and recovery. Across the stroke continuum of care from preadmission through acute hospital admission to postdischarge (Figure), the learning health system provides a model of continuous QI (eg, clinical evidence, guidelines, data, and implementation).1 Studies published in 2021 describe advances in stroke QI across local, regional and national systems of care, as well as within components of the stroke continuum of care, and are summarized following.Download figureDownload PowerPointFigure. Quality improvement initiatives to improve stroke care.Systems of Care QIStudies sought to understand or support existing stroke system of care in the United States2 and Canada3 and to develop new stroke systems of care in China,4,5 Chile,6 and Panamá.7 For example, Zusevics et al2 used development evaluation to examine the stroke system of care for the Wisconsin Coverdell Stroke Program. Through process mapping and stakeholder interviews, quality practices were identified, including areas requiring improvement. The development evaluation methodology provided opportunities for stakeholders to strategize together and to identify opportunities to collaborate.Process mapping was also used in a province-wide stroke system improvement initiative (Saskatchewan Acute Stroke Pathway) in 9 Canadian hospitals which identified QI priorities and resource gaps focused on hyperacute stroke care.3 The comprehensive QI program included: performance monitoring with audit-and-feedback; standardized order sets; educational workshops; discipline-specific interventions (eg, radiology) to improve timeliness, communication, and documentation; and PDSA cycles. The implementation of this initiative led to improvements for door-to-imaging, door-to-needle, and door-to-groin times across the province.The China Stroke Prevention Project Committee established a stroke center network including a national stroke data center.4 This comprehensive program included screening and stroke prevention elements, prehospital rapid response systems, construction of 380 stroke centers, and a network establishment. This stroke system of care improved care provision (eg, decreased median door-to-needle time from 50 to 48 minutes; P<0.05). Another study from China described the Chinese Stroke Center Alliance which evaluated a multifaceted acute stroke and TIA QI program that included web-based data collection and performance feedback, and a series of collaborative workshops and webinars led by clinical and QI experts.5 Their cohort included over a million patients with stroke or TIA from 1476 volunteer hospitals. Although improvements in several quality metrics (eg, anticoagulants for atrial fibrillation) were observed over time, substantial opportunities for improvement remained (eg, the defect-free care rate remained well below 40%); heterogeneity in quality existed across cerebrovascular event types (eg, ischemic stroke versus subarachnoid hemorrhage) and across hospitals.A new stroke care network was also developed in Chile, with a single mechanical thrombectomy-capable stroke center and five primary stroke centers, which improved access to mechanical thrombectomy.6 Likewise, the first stroke program in Central America was implemented in Panamá using an evidence-based 7 step process that could serve as a model for program development and implementation across the spectrum of resource availability contexts (eg, emerging high-income countries).7Prehospital Care QISix QI studies reported ambulance and emergency department processes to improve systems of prehospital care. A study from 4 hospitals in Houston, TX, examined an integrated stroke system of care model.8 This included physician coverage shared across hospitals, nursing protocols, order sets, and centralized QI data collection. The objective of the program was to improve endovascular therapy for patients with large vessel occlusion acute ischemic stroke at low-volume hospitals. The initiative successfully decreased interfacility transfers (46%–37%; P<0.05), median door-to-groin puncture time (111–89 minutes; P<0.0001), and median door-to-recanalization time (153–129 minutes; P<0.0001) but no change was observed in the 90-day modified Rankin Scale score. These data suggest that QI is possible at low-volume hospitals which enhances access to acute stroke services.Kapoor et al9 found that most patients at their large, academic medical center in Canada with suspected TIA or minor ischemic stroke had computed tomography (CT) of the head with outpatient carotid Dopplers. An electronic decision support tool for use by emergency department clinicians was implemented, to increase the use of CT angiography instead of noncontrast CT of the head. The multidisciplinary QI project successfully improved CT angiography in the emergency department (13.1%–65.9%; P<0.0001) among patients with high-risk events.A report from a single hospital in Melbourne, Australia, described a series of QI activities that targeted door-to-needle time including: changes in workflow, protocols, and augmented staffing.10 The direct-to-CT protocol and additional acute stroke nursing staffing were identified as keys to reducing door-to-needle times. This study also provides a reminder that it is not only imperative that hospitals seek to reduce mean door-to-needle times but that the variation across patients should also be minimized.A systems redesign approach (ie, process mapping, identification of failure modes, intervention development, action planning) was used successfully in one hospital in Connecticut to reduce emergency department length of stay (300–149 minutes; P<0.01) and improve interdisciplinary communication for patients requiring neurocritical care.11Implementation of a StrokeWatch at an academic stroke center in Germany provided a mechanism to measure key stroke-related procedures in real-time (ie, door-to-needle, door-to-groin, and door-to-recanalization).12 Although no significant differences in times were observed, this study demonstrated the feasibility of implementing real-time measurement and was helpful in identifying sources of delay (eg, intrahospital patient transport).In a tertiary care hospital in Japan, the development and implementation of a stroke code protocol and educational workshops resulted in decreased time from stroke recognition to neurologist assessment (91–35 minutes; P=0.002) and to neuroimaging (123–74 minutes; P=0.013), but no changes in thrombolysis or endovascular therapy were observed.13Acute Hospital Care QISeveral studies described in-hospital care QI initiatives including in Nova Scotia (Canada),14 Australia,15 and in single institutions in Denmark,16 and East Kent (United Kingdom).17 The studies varied in terms of the QI intervention; some were multifaceted,14 whereas others focused on a single QI strategy (eg, PDSA cycles,16,17 external facilitation15).For example, a Canadian report describes a 14-year effort to improve stroke care in the province of Nova Scotia which initially included 33 hospitals. The comprehensive QI program was multicomponent and multidisciplinary and included: identification of a stroke coordinator and physician champion who led local QI efforts, clustering stroke patients into inpatient stroke units, continuous data collection, audit-and-feedback, local development of QI plans based on gaps in care quality, education, interviews with stakeholders, and sharing of lessons learned.14 The hospitals implemented a broad range of QI activities including order sets, policies, and changes in work flow. From this QI program, an interim demonstration project indicated that the minimum patient-volume to maintain high quality of care was 115 patients per year in a ≥6-bed unit which led to an effort to consolidate care within geographic regions.14 In reflecting upon their experience, the authors attributed the many improvements in quality of care to the stroke physician and stroke coordinators who provided facilitation, knowledge brokering, and knowledge transfer.A study from 19 hospitals in Queensland (Australia) evaluated the effectiveness of external facilitation for stroke QI.15 Neither the amount nor type of external facilitation (eg, face-to-face, telephone, and email) was associated with development of a site-specific action plan or change in quality of care.PDSA cycles are commonly used in stroke QI projects. For example, they were used successfully to improve the proportion of stroke patients receiving glucose and cholesterol measurement on admission at a hospital in East Kent (United Kingdom).17 PDSA cycles were also used successfully to reduce the number of potentially avoidable night-time tasks in a Danish stroke unit.16 The project included education, knowledge sharing, checklists, and feedback over a period of 17 weeks and 5 PDSA cycles. The number of avoidable tasks for on-call junior doctors reduced from a median of 11 to a median of 3 per week.Posthospital Discharge Care QIFew studies evaluated QI initiatives to improve quality of stroke care following discharge from the acute in-patient stay (either in rehabilitation or primary care settings). A study from Germany sought to develop and pilot-test quality metrics that could be used in future studies to evaluate the possible benefits of poststroke neuropsychological therapy in the outpatient setting including a variety of domains (eg, involvement of relatives in the therapeutic process, standardized assessment of depression, time to initiating therapy, and counseling on fitness to drive).18QI Studies Spanning the Continuum of CareTwo articles reported content relevant to the entire continuum of stroke care. A systematic review of stroke QI collaboratives included 20 studies from 5 countries which included studies that spanned the continuum of care (eg, prehospital care, acute care, rehabilitation care, and primary care).19 QI collaboratives involve participants from different organizations (eg, different hospitals) joining together in QI-related activities over time.20–22 The greater the complexity of the collaborative intervention, the less likely it was to be effective; in contrast, interventions that focused on simple processes that were under control of the stroke team were more effective. The review described barriers of stroke QI collaboratives, such as structural changes during the intervention, lack of organizational support within the hospital for QI, insufficient resources and time to participate, as well as facilitators, including networking, feedback tools, and engagement by leaders.A systematic review of patient-reported experience measures of stroke care included 18 studies of 13 metrics (2 were stroke-specific and 11 were generic patient-reported experience measures).23 The existing measures either included many items and, therefore, had limited feasibility for implementation in routine practice or had not been validated in patients with stroke.Economic Evaluations of QITwo studies undertook economic evaluations of QI interventions and both found that implementation of QI programs was cost-effective. Ajmi et al24 reported on the cost-effectiveness of implementing a multifaceted QI project that included process mapping and redesign, engaging stakeholders, education, and simulation-based training at a large stroke center in Norway to improve thrombolysis care. The fixed costs of implementing the QI program was US$44 802 (2019 prices); the estimated costs per minute reduction in door-to-needle time per patient ranged from US$13 to US$29 and the estimated costs per death averted ranged from US$4679 to US$10 543; cost-effectiveness increased over time.Marquina et al25 constructed a decision analysis model to predict the cost-effectiveness of the Quality in Acute Stroke Care protocol which has been implemented 36 units in New South Wales (Australia). Over a 5-year period, implementation of the QI program nationwide was predicted to prevent 1154 deaths, gain 3180 quality-adjusted life-years, at an estimated net savings of Australian dollar 65.2 million in health care costs (AUD247 per stroke).ConclusionsIn 2021, the QI interventions targeted processes of stroke care across the continuum of care. Many interventions reviewed were successful and numerous effective programs were multicomponent and multidisciplinary. In the future, studies should include patients and caregivers in QI and evaluate interventions to improve care in the posthospital period.Article InformationSources of FundingM.F. Kilkenny was supported by a Future Leader Fellowship (#105737) from the National Heart Foundation of Australia and National Health and Medical Research Council (NHMRC) of Australia (#1141848).Nonstandard Abbreviations and AcronymsCTcomputed tomographyPDSAPlan-Do-Study-ActQIquality improvementTIAtransient ischemic attackDisclosures None.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Sources of Funding and Disclosures, see page 1770.Correspondence to: Dawn M. Bravata, MD, Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 W 10th St, Indianapolis, IN 46202. Email dawn.[email protected]govReferences1. Budrionis A, Bellika JG. The learning healthcare system: where are we now? A systematic review.J Biomed Inform. 2016; 64:87–92. doi: 10.1016/j.jbi.2016.09.018CrossrefGoogle Scholar2. Zusevics KL, Kaemmerer NN, Lang J, Link J, Bluma DD. A unique approach to quality improvement within the stroke system of care utilizing developmental evaluation.Health Promot Pract. 2021; 22:224–235. doi: 10.1177/1524839919894305CrossrefGoogle Scholar3. Holodinsky JK, Onaemo VN, Whelan R, Hunter G, Graham BR, Hamilton J, Schwartz L, Latta L, Peeling L, Kelly ME. Implementation of a provincial acute stroke pathway and its impact on access to advanced stroke care in Saskatchewan.BMJ Open Qual. 2021; 10:e001214. doi: 10.1136/bmjoq-2020-001214CrossrefGoogle Scholar4. Chao BH, Yan F, Hua Y, Liu JM, Yang Y, Ji XM, Peng B, Zhao GG, Wang YJ, Kang DZ, et al. Stroke prevention and control system in China: CSPPC-stroke program.Int J Stroke. 2021; 16:265–272. doi: 10.1177/1747493020913557CrossrefGoogle Scholar5. Gu HQ, Yang X, Wang CJ, Zhao XQ, Wang YL, Liu LP, Meng X, Jiang Y, Li H, Liu C, et al. Clinical characteristics, management, and in-hospital outcomes in patients with stroke or transient ischemic attack in China.JAMA Netw Open. 2021; 4:e2120745. doi: 10.1001/jamanetworkopen.2021.20745CrossrefGoogle Scholar6. Rivera R, Amudio C, Brunetti E, Catalan P, Sordo JG, Badilla L, Echeverria D, Cruz JP, Ojeda H, Bravo L, et al. Breaking the breach in Latin America: A pilot study of mechanical thrombectomy in the public healthcare system in Chile.Interv Neuroradiol. 2021; 27:114–118. doi: 10.1177/1591019920956405CrossrefGoogle Scholar7. Novarro-Escudero N, Moon YJ, Olmedo A, Ferguson T, Caballero I, Onodera E, Effio E, Klein LM, Zink EK, Johnson B, et al. Organization and implementation of a stroke center in panamá, a model for implementation of stroke centers in low and middle income countries.Front Neurol. 2021; 12:684775. doi: 10.3389/fneur.2021.684775CrossrefMedlineGoogle Scholar8. Lopez-Rivera V, Salazar-Marioni S, Abdelkhaleq R, Savitz SI, Czap AL, Alderazi YJ, Chen PR, Grotta JC, Blackburn SL, Jones W, et al. Integrated stroke system model expands availability of endovascular therapy while maintaining quality outcomes.Stroke. 2021; 52:1022–1029. doi: 10.1161/STROKEAHA.120.032710LinkGoogle Scholar9. Kapoor A, Verma A, Kim IJ, Kujbid N, Si K, Casaubon LK, Kapral MK, Fang J, Symons S, Swartz RH, et al. Multidisciplinary quality improvement initiative to optimize acute neurovascular imaging for transient ischemic attack or minor stroke.CJEM. 2021; 23:820–827. doi: 10.1007/s43678-021-00180-1CrossrefGoogle Scholar10. Park PSW, Frost T, Tan S, Wong J, Pope A, Dewey HM, Choi PMC. The quest to reduce stroke treatment delays at a melbourne metropolitan primary stroke centre over the last two decades [published online June 18, 2021].Intern Med J. 2021. doi: 10.1111/imj.15429CrossrefGoogle Scholar11. Chilakamarri P, Finn EB, Sather J, Sheth KN, Matouk C, Parwani V, Ulrich A, Davis M, Pham L, Chaudhry SI, et al. Failure mode and effect analysis: engineering safer neurocritical care transitions.Neurocrit Care. 2021; 35:232–240. doi: 10.1007/s12028-020-01160-6CrossrefGoogle Scholar12. Kröger H, Nikoubashman O, Dimitrov I, Yousefian Jazi E, Schürmann K, Wiesmann M, Schulz JB, Reich A. StrokeWatch: an instrument for objective standardized real-time measurement of door-to-needle times in acute ischemic stroke treatment.J Stroke Cerebrovasc Dis. 2021; 30:105962. doi: 10.1016/j.jstrokecerebrovasdis.2021.105962CrossrefGoogle Scholar13. Kawano H, Ebisawa S, Ayano M, Kono Y, Saito M, Johno T, Maruoka H, Ryoji N, Yamashita H, Nakanishi K, et al. Improving acute in-hospital stroke care by reorganization of an in-hospital stroke code protocol.J Stroke Cerebrovasc Dis. 2021; 30:105433. doi: 10.1016/j.jstrokecerebrovasdis.2020.105433CrossrefGoogle Scholar14. Phillips SJ, Stevens A, Cao H, Simpkin W, Payne J, Gill N. Improving stroke care in Nova Scotia, Canada: a population-based project spanning 14 years.BMJ Open Qual. 2021; 10:e001368. doi: 10.1136/bmjoq-2021-001368CrossrefGoogle Scholar15. Thayabaranathan T, Andrew NE, Grimley R, Stroil-Salama E, Grabsch B, Hill K, Cadigan G, Purvis T, Middleton S, Kilkenny MF, et al. Understanding the role of external facilitation to drive quality improvement for stroke care in hospitals.Healthcare (Basel). 2021; 9:1095. doi: 10.3390/healthcare9091095CrossrefGoogle Scholar16. Tireli D, Jensen MB. Reducing potentially avoidable tasks in a hyperacute stroke unit.BMJ Open Qual. 2021; 10:e001482. doi: 10.1136/bmjoq-2021-001482CrossrefGoogle Scholar17. Khan AR, Dorai S, Serry Y. Optimising the measurement of blood glucose and cholesterol in patients who had an acute stroke: a quality improvement project.BMJ Open Qual. 2021; 10:e001237. doi: 10.1136/bmjoq-2020-001237CrossrefGoogle Scholar18. Padberg I, Heel S, Thiem P, Diebel A, Mordhorst E, Strohmeyer U, Meisel A. Quality measurement of out-patient neuropsychological therapy after stroke in Germany: definition of indicators and retrospective pilot study.BMC Neurol. 2021; 21:76. doi: 10.1186/s12883-021-02092-0CrossrefGoogle Scholar19. Lowther HJ, Harrison J, Hill JE, Gaskins NJ, Lazo KC, Clegg AJ, Connell LA, Garrett H, Gibson JME, Lightbody CE, et al. The effectiveness of quality improvement collaboratives in improving stroke care and the facilitators and barriers to their implementation: a systematic review.Implement Sci. 2021; 16:95. doi: 10.1186/s13012-021-01162-8CrossrefGoogle Scholar20. Boushon B, Provost L, Gagnon J, Carver P. Using a virtual breakthrough series collaborative to improve access in primary care.Jt Comm J Qual Patient Saf. 2006; 32:573–584. doi: 10.1016/s1553-7250(06)32075-2CrossrefGoogle Scholar21. Katzelnick DJ, Von Korff M, Chung H, Provost LP, Wagner EH. Applying depression-specific change concepts in a collaborative breakthrough series.Jt Comm J Qual Patient Saf. 2005; 31:386–397. doi: 10.1016/s1553-7250(05)31052-xCrossrefGoogle Scholar22. Thies K, Schiessl A, Khalid N, Hess AM, Harding K, Ward D. Evaluation of a learning collaborative to advance team-based care in Federally Qualified Health Centers.BMJ Open Qual. 2020; 9:e000794. doi: 10.1136/bmjoq-2019-000794CrossrefGoogle Scholar23. Cornelis C, den Hartog SJ, Bastemeijer CM, Roozenbeek B, Nederkoorn PJ, Van den Berg-Vos RM. Patient-reported experience measures in stroke care: a systematic review.Stroke. 2021; 52:2432–2435. doi: 10.1161/STROKEAHA.120.034028LinkGoogle Scholar24. Ajmi SC, Kurz MW, Ersdal H, Lindner T, Goyal M, Issenberg SB, Vossius C. Cost-effectiveness of a quality improvement project, including simulation-based training, on reducing door-to-needle times in stroke thrombolysis [published online October 1, 2021].BMJ Qual Saf. 2021. doi: 10.1136/bmjqs-2021-013398CrossrefGoogle Scholar25. Marquina C, Ademi Z, Zomer E, Ofori-Asenso R, Tate R, Liew D. Cost burden and cost-effective analysis of the nationwide implementation of the quality in acute stroke care protocol in Australia.J Stroke Cerebrovasc Dis. 2021; 30:105931. doi: 10.1016/j.jstrokecerebrovasdis.2021.105931CrossrefGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByMoore K, Summers D and Wilson S (2023) Improving Stroke Measure Compliance and Outcomes Through Hospital Collaboration, Stroke, 54:4, (1160-1170), Online publication date: 1-Apr-2023. May 2022Vol 53, Issue 5 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.122.037450PMID: 35369717 Originally publishedApril 4, 2022 Keywordsquality improvementstrokequality of carePDF download Advertisement