Guidelines for Inpatient Treatment of Stroke Improve Quality of Care

Paula Moyer, MA

February 03, 2005

Feb. 3, 2005 (New Orleans) — The quality of care for stroke patients improves dramatically within a year when hospitals use an electronic prompting program developed by the American Stroke Association (ASA), according to Lee H. Schwamm, MD, who presented his group's findings here at the 30th International Stroke Conference.

The study, which focused on the use of intravenous tissue plasminogen activator (tPA), showed that participating hospitals increased their use of these agents in stroke patients, as well as their documentation of the reasons that such agents were not used, after the ASA program was implemented. The study period was one calendar year, from April 2003 to April 2004.

The findings show that a program like this can serve as a "gentle reminder" to physicians and reduce their reliance on their own memories of stroke management guidelines, Dr. Schwamm said.

"We need to move to models where how we document our work helps us know how we're doing," Dr. Schwamm, the study's principal investigator, told Medscape in an interview. "This program makes it easier for us to do our job well." He is associate director of acute stroke services at Massachusetts General Hospital in Boston, where he is an associate professor of neurology at Harvard Medical School.

The program, known as Get With The Guidelines-Stroke, consists of an electronic checklist of evidence-based standards of stroke care. Dr. Schwamm and colleagues conducted the study to determine if implementation of the ASA's guidelines would improve hospital care in patients admitted with acute ischemic stroke or transient ischemic attack.

The study investigators reviewed care given to 21,563 stroke patients in 99 participating hospitals. Data on the patients' care were collected from interhospital collaborative meetings, best-practice sharing, and an Internet tool used for data collection, reporting, and decision support.

The investigators compared the hospitals' baseline practices with their practices for the four consecutive quarters that made up the study period. The study protocol allowed the investigators to include patients from three acute stroke registry prototypes that were funded by the Centers for Disease Control and Prevention, provided that the hospitals at which the patients were treated used the ASA's program for data entry and quality improvement throughout the study period.

The investigators examined the hospitals' use of intravenous tPA or documentation of why it was not used in patients who arrived in the emergency department less than two hours after the onset of symptoms, as well as those who arrived less than three hours after the onset of symptoms. The study emphasized the importance of initiating tPA within 60 minutes of admission, monitoring symptomatic systemic or intracranial hemorrhage, and the use of antithrombotic therapy within 48 hours after admission, when appropriate.

The investigators recorded the institutions' compliance rates at each quarter of the study period, compared them to baseline rates, and analyzed trends over time.

At baseline, tPA was used in 32.3% of cases of the 804 patients admitted within two hours of onset. That rate increased each quarter so that by the fourth quarter the rate of use was 61.1% ( P < .0001). In the 1,033 patients admitted within three hours of onset, 26.9% received tPA at baseline compared with 44.5% of patients by the fourth quarter ( P < .0001). In the 3,504 patients who did not receive tPA, the justification for not using it was documented in 62.9% of cases at baseline compared with 85.2% by the study's end ( P < .0001).

At baseline, the staff started tPA within 60 minutes in 23.4% of cases and in 13.8% of cases by the fourth quarter. The investigators documented tPA-related complications in 4.4% of patients at baseline compared with 3.6% at the study's end. Antithrombotic treatment was started within 48 hours in 85.3% of cases at baseline and in 95.3% of cases by the study's end. None of these changes were statistically significant. The investigators noted that increased use of tPA was not associated with a higher rate of complications.

Participating physicians have been satisfied with the program, Dr. Schwamm said. They see the preprinted order sets and the documentation of reasons not to give evidence-based treatments as tools that help them do their job well with less effort. "When a patient has atrial fibrillation and I don't give warfarin, it should ask me why not," he said. "The system should be prompting you to do what the evidence base suggests, rather than relying on us to remember."

Physicians should not be concerned that the program intrudes onto their clinical judgment, Dr. Schwamm stressed. "The system is not replacing the doctor's judgment," he said. "It's a gentle reminder at your elbow."

30th International Stroke Conference: Abstract 93. Presented Feb. 4, 2005.

Reviewed by Gary D. Vogin, MD