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Quality improvement in acute stroke

The New York State Stroke Center Designation Project

From the Departments of Neurology (T.I.G.), Long Island College Hospital and State University of New York–Health Science Center at Brooklyn, IPRO (P.J.G., M.B.D.), Lake Success, Healthcare Quality Initiatives (C.A.B.), New York State Department of Health, New York, Departments of Neurology and Epidemiology (R.L.S.), Columbia University Medical Center, New York, Department of Emergency Medicine (T.K.) and Division of Cerebrovascular Disease (R.L.), Long Island Jewish Medical Center, New Hyde Park, Department of Neurology (D.L.), North Shore University Hospital, Manhasset, Department of Neurology (D.L.), Weill Medical College of Cornell University–New York Presbyterian Hospital, New York, and Stroke Center (S.A.), Lutheran Medical Center, Brooklyn, NY; and New York City Fire Department and Louisville Metro EMS (N.J.R.), Louisville, KY.

Address correspondence and reprint requests to Dr Gropen, Neurology Department, Long Island College Hospital, 339 Hicks St., Brooklyn, NY 11201; e-mail: tgropen{at}chpnet.org

Background: Many hospitals lack the infrastructure required to treat patients with acute stroke. The Brain Attack Coalition (BAC) published guidelines for the establishment of primary stroke centers.

Objective: To determine if stroke center designation and selective triage of acute stroke patients improve quality of care.

Methods: Baseline chart abstraction was performed on all stroke patients admitted to 32 hospitals serving Brooklyn and Queens, NY, from March to May 2002. Hospitals were invited to meet BAC guideline-based criteria. Adherence was verified by on-site visits. After designation, acute stroke patients were selectively triaged. Remeasurement data were collected from August to October 2003.

Results: The authors abstracted 1,598 charts at baseline and 1,442 charts at remeasurement. From baseline to remeasurement, median times decreased for door to physician contact (25 vs 15 minutes, p = 0.001), CT performance for potential tissue plasminogen activator (t-PA) candidates (68 vs 32 minutes, p < 0.001), and t-PA administration (109 vs 98 minutes (p = NS). IV t-PA utilization increased from 2.4 to 5.2% (p < 0.005), select t-PA protocol violations decreased from 11.1 to 7.9% (p = NS), and the stroke unit admission rate increased from 16 to 39% (p < 0.001). In stroke centers (n = 14) vs nondesignated hospitals (n = 18), there were shorter median times from door to physician contact (10 vs 25 minutes, p < 0.001), CT performance for potential t-PA candidates (31 vs 40 minutes, p = NS), and t-PA administration (95 vs 115 minutes, p < 0.05). Stroke centers, compared with nondesignated centers, admitted acute stroke patients to stroke units more often (55.9 vs 10.9%, p < 0.001).

Conclusions: Stroke center designation and selective triage of acute stroke patients improved the quality of care, including access to timely thrombolytic therapy and stroke units.

Additional material related to this article can be found on the Neurology Web site. Go to www.neurology.org and scroll down the Table of Contents for the July 11 issue to find the title link for this article.

IPRO was supported by the New York State Department of Health. Stroke centers were supported by institutional funds of participating hospitals.

Disclosure: The authors report no conflicts of interest.

Received November 9, 2005. Accepted in final form March 13, 2006.

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