Introduction: Across the United States, delivery of thrombolytic therapy to acute stroke victims occurs in fewer than 2% of patients. Barriers to therapy include a lack of community awareness, limited access to specialists, and inability to rapidly evaluate and deliver care at the local level. In an effort to improve stroke care to the nearly 1400 patients presenting to their facilities on a yearly basis, the St. John Providence Health System (SJPHS) initiated a process improvement program.

Methods: A series of multi-disciplinary teams were created at local facilities and at the system level to integrate stroke related critical care pathways, order sets, and care algorithms. Multi-disciplinary conferences, peer review, and code stroke teams were created. Mandatory competency training modules and simulations were created for nurses and mid-level providers. Neuroscience, rapid response, ER, and ICU physicians were required to maintain NIHSS certification. Physician bench marking was initiated and weekly process improvement meetings evaluated the stroke process for every patient presenting to the emergency room with stroke signs and symptoms.

Results: Preimplementation, in 2008, fewer than 2% of all patients received thrombolytic therapy. Stroke response times averaged greater than 20 minutes. In 2010, participating hospitals had code stroke response times of under 2 minutes for stroke neurologists and neuroendovascular specialists. Delivery of thrombolytic therapy increased form 1.6% to 8.8% for all patients presenting to the ER with signs and symptoms of stroke. NIHSS documentation improved from 72% to greater than 98%.

Conclusions: Delivery of thrombolytic therapy for stroke improved nearly 5 fold with standardization of care, benchmarking of physician performance, and dedication to continuous process improvement.

Patient Care: Our work has improved patient care through a nearly 5 fold increase in our delivery rate of thrombolytic therapy across a geographic region at multiple hospital sites.

Learning Objectives: Participants will be able to describe common barriers to delivery of efficient stroke care. Participants will be able to discuss several common approaches to enhancing delivery of stroke care at an institutional level.

References: Schumacher HC, Bateman BT, Boden-Albala B, et al. Use of thrombolysis in acute ischemic stroke: analysis of the Nationwide Inpatient Sample 1999 to 2004. Ann Emerg Med. 2007;50(2):99-107