Stroke treatment: metrics and processes

Tratamento do AVC: métrica e processos

The proportion of cerebral infarct patients receiving intravenous thrombolysis is a sensible and logic marker of stroke care quality. A high number of treated patients reflects fast collaborative work in acute stroke-ready hospitals¹. Tipically, these hospitals have structured acute stroke teams, carefully studied and written protocols, fast laboratory and neuroimaging testing, and exhibit major involvement of emergency medical services and personnel².

Increasing the number of IV rT-PA treated patients should be considered a high priority for acute stroke hospitals. This depends on a coordinated effort of policy makers, Health insurance companies and local facilities. Federal, State and local Government should be responsible for adequate funding of public services, human and technological resources (e.g., telethrombolysis, immediate rescue of patients in remote areas); coordinate different public and private agents (e.g., primary or comprehensive stroke centers and more simple facilities benefiting from effective telemedicine use and drip and ship strategies); legislate and supervise the adequacy of services provided, and improve public education about stroke signs and symptoms, preparedness and effective action^1,3.

Any hospital dealing with a significant number of acute stroke patients should carefully develop and control the processes involved. Ideally, this should include all evaluation and treatment phases - from pre-hospital management to post- discharge care and rehabilitation⁴. Such comprehensive approach leads to a higher proportion of patients treated with rT-PA¹, better results, and cost savings⁵. International societies have developed criteria to certificate institutions involved in stroke care and provide guidance on how to prove excellence in care^6,7.

The processes involved in the initial evaluation and treatment of acute stroke patients is the object of the article by Li and Johnson published in the present number of Arquivos de Neuropsiquiatria⁸. The authors focus on the hyperacute phase assessment and management. They emphasize the need of a critical evaluation of the chain of steps that may constitute barriers to speed the use of IV rT-PA. Improvement of those steps, gaining more time and leading to a higher number of patients treated within the golden 90 minutes-window is suggested. They provide references from institutions that have achieved a significant decrease in average onset-to-treatment time (OTT) to IV thrombolysis. Unfortunately, this does not necessarily result in better outcomes. These somewhat deceiving final results could be due to a non-significant increase in the proportion of patients treated within the 90-minute frame.

Constant effort to improve workflow metrics should be part of the institution’s commitment to high-quality stroke management. It should be acknowledged, however, that mean or median OTT cannot tell us the whole story^9,10. Central tendency measures may represent a final result of divergent forces: greater symptom recognition by the public and more efficient hospital processes, and, on the other hand, the parallel inclusion of more patients in the extended 3 to 4.5 hour-window.

Li and Johnson also propose the use of a specific approach – Lean-Six-Sigma – to rationally speed the management processes emphasizing on-site observation of the entire chain of steps⁸. This is followed by preferential intervention on those steps that can add most value – i.e., speed – to the process. The method has already been applied to hospital processes¹¹. Unfortunately, we are left without any details of the proposed approach in the setting of hyperacute stroke, as the only reference cited – from the same authors – is yet to be published¹². The general idea of improving the steps with greater impact on OTT is of course reasonable and the authors should be acknowledged for highlighting this. Pre-hospital and in-hospital processes are not equally sensitive to intervention effects¹³.

Some specific interventions are known to speed processes. Increasing the availability of emergency ambulance transport can very be effective in reducing time to admission after stroke onset^14,15. Using CT instead of MRI may also have a great impact on time to intravenous as well as intra-arterial treatment delivery¹⁶. Simple text-messaging interventions directed to residents leading stroke teams have been associated with reduced door-to-needle time¹⁷. Sometimes, the consistent provision of available resources can reduce time-related differences in care received by patients admitted off-hours^18,19.

Keeping in agreement with key Brazilian and International guidelines is a logical way to improve the quality of care in acute stroke. Costs may be reduced by this approach⁵, helping managers to direct funding to additional improvements. A number of publications help to set standards of care in different settings². Reliability and consistency in all treatment phases is the key to quality, and it is considered the main institutional goal by International accreditation programs as mentioned before^7,8. The whole chain of processes (from pre-hospital to rehabilitation and secondary prevention) should be constantly monitored in any hospital willing to provide excellent treatment to stroke patients.

References

• ¹
  Ganesh A, Camden M, Lindsay P, Kapral MK, Coté R, Fang J et al. The quality of treatment of hyperacute ischemic stroke in Canada: a retrospective chart audit. CMAJ Open. 2014;2(4):E233-9. http://dx.doi.org/10.9778/cmajo.20140067
  » https://doi.org/10.9778/cmajo.20140067
• ²
  Alberts MJ, Wechsler LR, Jensen ME, Latchaw RE, Crocco TJ, George MG et al. Formation and function of acute stroke-ready hospitals within a stroke system of care recommendations from the brain attack coalition. Stroke. 2013;44(12):3382-93. http://dx.doi.org/10.1161/STROKEAHA.113.002285
  » https://doi.org/10.1161/STROKEAHA.113.002285
• ³
  Boden-Albala B, Edwards DF, St Clair S, Wing JJ, Fernandez S, Gibbons MC et al. Methodology for a community-based stroke preparedness intervention: the Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities Study. Stroke. 2014;45(7):2047-52. http://dx.doi.org/10.1161/STROKEAHA.113.003502
  » https://doi.org/10.1161/STROKEAHA.113.003502
• ⁴
  Katzan I, Speck M, Uchino K, Frey J. The stroke 8: a daily checklist for inpatient stroke management. Crit Pathw Cardiol. 2015; 14(1):1-6. http://dx.doi.org/10.1097/HPC.0000000000000037
  » https://doi.org/10.1097/HPC.0000000000000037
• ⁵
  Svendsen ML, Ehlers LH, Hundborg HH, Ingeman A, Johnsen SP. Processes of early stroke care and hospital costs. Int J Stroke. 2014;9(6):777-82. http://dx.doi.org/10.1111/ijs.12221
  » https://doi.org/10.1111/ijs.12221
• ⁶
  Accreditation Canada. Stroke distinction. Ontario; 2013 [cited 1015 Apr 24]. Available from: http://www.accreditation.ca/stroke-distinction
  » http://www.accreditation.ca/stroke-distinction
• ⁷
  American Heart Association. Get with the Guidelines®-Stroke recognition criteria. Dallas; 2015 [cited 1015 Apr 24]. Available from: http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelines/GetWithTheGuidelines-Stroke/Get-With-The-Guidelines-Stroke-Recognition-Criteria_UCM_310337_Article.jsp
  » http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelines/GetWithTheGuidelines-Stroke/Get-With-The-Guidelines-Stroke-Recognition-Criteria_UCM_310337_Article.jsp
• ⁸
  Li Min Li, Johnson S. Lean thinking turns ‘time is brain’ into reality. Arq Neuropsiquiatr. 2015;73(6):526-30; http://dx.doi.org/10.1590/0004-282X20150047
  » https://doi.org/10.1590/0004-282X20150047
• ⁹
  Moro CH, Gonçalves AR, Longo AL, Fonseca PG, Harger R, Gomes DB et al. Trends of the incidence of ischemic stroke thrombolysis over seven years and one-year outcome: a population-based study in Joinville, Brazil. Cerebrovasc Dis Extra. 2013;3(1):156-66. http://dx.doi.org/10.1159/000356984
  » https://doi.org/10.1159/000356984
• ¹⁰
  McMeekin P, Wildman J, Ford GA, Vale L, Price CI. Relative distributions: a novel method for examining trends between stroke onset and thrombolysis time. Stroke. 2015;46:1381-3. http://dx.doi.org/10.1161/STROKEAHA.115.008724
  » https://doi.org/10.1161/STROKEAHA.115.008724
• ¹¹
  Arthur J. Lean six sigma for hospitals: simple steps to fast, affordable, and flawless healthcare. New York: McGraw-Hill; 2011.
• ¹²
  Li LM, Johnson S. Stroke care within the golden hour. JAMA Neurol. 2015;72(4):475.
• ¹³
  Power M, Tyrrell PJ, Rudd AG, Tully MP, Dalton D, Marshall M et al. Did a quality improvement collaborative make stroke care better? A cluster randomized trial. Implement Sci. 2014;9(1):40. http://dx.doi.org/10.1186/1748-5908-9-40
  » https://doi.org/10.1186/1748-5908-9-40
• ¹⁴
  Minnerup J, Wersching H, Unrath M, Berger K. Effects of emergency medical service transport on acute stroke care. Eur J Neurol. 2014;21(10):1344-7. http://dx.doi.org/10.1111/ene.12367
  » https://doi.org/10.1111/ene.12367
• ¹⁵
  Neil WP, Raman R, Hemmen TM, Ernstrom K, Meyer BC, Meyer DM et al. Association of Hispanic ethnicity with acute ischemic stroke care processes and outcomes. Ethn Dis. 2015;25(1):19-23.
• ¹⁶
  Menon BK, Almekhlafi MA, Pereira VM, Gralla J, Bonafe A, Davalos A et al. Optimal workflow and process-based performance measures for endovascular therapy in acute ischemic stroke: analysis of the Solitaire FR thrombectomy for acute revascularization study. Stroke. 2014;45(7):2024-9. http://dx.doi.org/10.1161/STROKEAHA.114.005050
  » https://doi.org/10.1161/STROKEAHA.114.005050
• ¹⁷
  Burnett MM, Zimmermann L, Coralic Z, Quon T, Whetstone W, Kim AS. Simple text-messaging intervention is associated with improved door-to-needle times for acute ischemic stroke. Stroke. 2014;45(12):3714-6. http://dx.doi.org/10.1161/STROKEAHA.114.007294
  » https://doi.org/10.1161/STROKEAHA.114.007294
• ¹⁸
  Kristiansen NS, Mainz J, Nørgård BM, Bartels PD, Andersen G, Johnsen SP. Off-hours admission and acute stroke care quality: a nationwide study of performance measures and case-fatality. Stroke. 2014;45(12):3663-9. http://dx.doi.org/10.1161/STROKEAHA.114.005535
  » https://doi.org/10.1161/STROKEAHA.114.005535
• ¹⁹
  Campbell JT, Bray BD, Hoffman AM, Kavanagh SJ, Rudd AG, Tyrrell PJ. The effect of out of hours presentation with acute stroke on processes of care and outcomes: analysis of data from the Stroke Improvement National Audit Programme (SINAP). PLoS One. 2014;9(2):e87946. http://dx.doi.org/10.1371/journal.pone.0087946
  » https://doi.org/10.1371/journal.pone.0087946

Publication Dates

• Publication in this collection
  June 2015

History

• Received
  29 Apr 2015
• Accepted
  06 May 2015