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  • Differential Protocol Adherence Affects Rates of TPA Delivery

    Final Number:

    Richard Donald Fessler MD; Chiu To DO; Robert Dunne MD; Paul Cullis MD; Omar M. Qahwash DO; Boyd Richards DO; Vickie Gordon NP-C, PhD; Carrie Stover NP-C

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2012 Annual Meeting

    Introduction: Multiple factors influence a given institution's capacity to deliver intravenous tpa to eligible stroke patients. We have previously described a system of care which delivered intravenous tpa to nearly 9% of eligible stroke patients presenting to one of our system institutions. We present contrasting results from a system-wide stroke process in which hospitals had markedly different tpa delivery rates for stroke patients based on adherence to agreed upon processes.

    Methods: The St. John Providence Health System (SJPHS) treats more than 1600 stroke victims annually. Of 6 system hospitals, 4 are certified primary stroke centers. We have previously described an integrated system of care involving triage, CT algorithms, as well as physician benchmarks which elevated the delivery rate of tpa to nearly 100% of eligible patients. Our ongoing prospective data collection reveals trends in delivery rates related to deviation from agreed upon treatment protocols at specific institutions.

    Results: All data was collected from our 4 primary certified stroke centers, 3 of which have neuroendovascular coverage 24/7. Two sites routinely activated code stroke alerts upon patient arrival in the emergency room; alerting CT, neurology, and the neuroendovascular team. This activation occurred uniformly for nearly 100% of all patients. Two institutions had diffential protocol adherence: Hospital 1 failed to routinely activate the code stroke until after ER physician evaluation and image acquisition. Hospital 2 altered the code stroke activation to an evaluation by resident staff and mid-level providers rather than immediate alerts to neurology and neuroendovascular specialists. The hospitals in the compliant cohort delivered tpa at an 11% rate to all patients triaged as stroke victims during 2011. Patients in the non-compliant cohort delivered tpa at a rate of less than 4%. In addition, the non-compliant cohort obtained significantly greater numbers of imaging studies per patient.

    Conclusions: Adherence to multidisciplinary evaluation and treatment algorithms has a positive influence on tpa delivery rates.

    Patient Care: Our work has shown that strict adherence to agreed upon care protocols results in markedly improved delivery of tpa to patients presenting with symptoms of stroke.

    Learning Objectives: Participants will understand the impact that adherence to process protocols and multidisciplinary evaluation can have on treatment delivery.


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