Exploring clinical outcomes of acute ischemic stroke following a door-to-needle quality improvement project
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Date
2017
Authors
Alcock, Susan
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Abstract
Background: The incidence of stroke is increasing; therefore, ongoing strategies to improve patient outcomes are needed. Timely care is an essential component of hyperacute stroke care. The earlier eligible stroke patients receive intravenous recombinant tissue plasminogen activator (rt-PA) in the narrow 4.5-hour window, the greater the likelihood of a good clinical outcome. In 2011, based on sub-optimal performance results, our centre invested in a door-to-needle (DTN) quality improvement initiative, which focused on performance feedback, stroke education, and improved workflow processes. The primary aim of this thesis study was to determine if clinical outcomes in stroke patients improved following the DTN quality improvement initiative.
Methods: Guided by the Donabedian framework, we retrospectively reviewed charts of all consecutive patients (N=324) who presented to Health Sciences Centre Adult Emergency and received rt-PA pre [January 1st, 2008 to December 31st, 2010; n= 102] and post [January 1st, 2012 to December 31st, 2014; n= 224] quality improvement initiative. The washout year was 2011. Demographic and clinical patient data, and process and outcome measures were collected. Primary study outcomes included mortality, discharge location, ambulation upon discharge, and adverse events. SPSS software was used for statistical analysis, with the level of significance of .05.
Results: Patients in the two groups were similar, except that in the post-intervention period more patients were rural (p <.001), arrived by ambulance (p <.001) and had longer onset-to-door times (p <.001). Median door-to-needle (DTN) time (49 vs. 70.5 min, p <.001), and the percentage of cases with a DTN ≤ 60 minute (77.9 vs. 31.4%, p <.001) improved dramatically post-intervention. Outcomes, including a reduction in in-hospital mortality, (p = .013) and an increase in the proportion of favorable (i.e., home, rehab, community hospital) versus unfavorable discharge locations (i.e., long term care, death), p=.005, were also significant. Mortality rates in all study patients with DTN ≤ 60 minutes compared to those with DTN > 60 minutes were also significantly lower (p =.004).
Conclusion: This research addressed an existing gap at our hospital regarding the impact of structural and process improvements on clinical outcomes in acute stroke. Our quality improvement initiative resulted in timelier care, and likely influenced the improved clinical outcomes. This study highlights the key role of nursing as part of the multidisciplinary team, in lessening the impact of stroke. The findings also provide institutional and governmental organizations with evidence to support investing in hyperacute stroke care. Furthermore, this study will foster increased uptake and compliance with best practice stroke care. Ultimately, all stroke patients in Manitoba may benefit, as it may increase the adherence to time-driven hyperacute stroke protocols. Thus, this study has provided valuable insights and reasons for optimism in the future of stroke care at HSC, in the Province of Manitoba, and beyond.
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Keywords
Stroke, Door-to-Needle, Quality improvement initiative