A multifaceted initiative from the American Heart Association (AHA) and the American Stroke Association (ASA) has generated marked improvements in the rate of patients suffering a stroke who receive a critical drug within an all-important treatment window. Those improved treatment rates have resulted in reduced in-hospital mortality, more frequent ambulation at discharge, and more frequent discharge to home, according to a study recently published in JAMA, the journal of the American Medical Association (AMA).
The drug, tissue plasminogen activator (tPA),has been long known to significantly reduce long-term disability for patients with acute ischemic stroke; however, to work effectively it has to be administered early—within 60 minutes of patient arrival. The problem, according to study authors, is that less than one-third of patients who could receive the treatment have been getting it within the 60-minute "door-to-needle" timeframe.
That low rate was the target of a treatment initiative called Target: Stroke created by the AHA and ASA in 2010. The goal was to get hospitals to employ combinations of 10 evidence-based strategies to increase door-to-needle rates. The strategies included prenotification of hospitals by emergency medical services personnel, the creation of a single call system that could activate an entire stroke team, premixing of tPA for likely candidates, and a faster process for getting and reading brain imaging, among other approaches.
The initiative was accompanied by an extensive educational and public relations effort that included webinars, interactive video, case studies of successful approaches used by hospitals, and the publication of an "honor roll" of hospitals that raised door-to-needle rates to 50% or higher.
Authors of the JAMA report analyzed 71,169 patients treated with tPA from 1,030 hospitals participating in the Target: Stroke program. Median age of the patient population was 72, with a median onset-to-arrival time of 51 minutes. Just over 50% of patients were women.
The bottom line, according to authors, is that the initiative worked: the number of patients receiving tPA within the 60-minute door-to-needle time increased from 29.6% to 53.3%, with related decreases in hospital mortality, intracranial hemorrhages, and fewer overall tPA complications (an initial worry among some experts). The improved treatment times also resulted in more frequent ambulation at discharge and a greater number of patients being discharged to home. "These findings suggest that the 10 best practice strategies used with this initiative may have contributed to the benefits observed," the authors write.
"There was a prompt improvement in the percentage of patients meeting guideline-recommended door-to-needle times once this quality improvement initiative was implemented," the report states. Authors attribute the effective strategies to the reductions but also acknowledge the importance of the hospital staff environment in making the initiative a success. "Prior experiences of hospitals successful in improving the quality of cardiovascular care suggest that improvement is most effective when integrated into an environment that includes explicit goals; collaborative, interdisciplinary teams; a patient-focused organizational culture; engaged clinical leaders and senior management; and detailed data feedback," they write.
APTA offers resources to physical therapists including a podcast, around care of patients with limitations in functioning after a stroke, and has created a PT's "guide to stroke" and pocket guide to physical fitness for survivors of stroke at its Move Forward website. In addition, PTNow contains tests and measures used in the examination of patients with stroke and provides access to full text of relevant clinical practice guidelines and Cochrane systematic reviews. PTNow’s search engine searches across several stroke-related evidence sites, such as StrokEngine and Evidence-Based Review of Stroke Rehabilitation (EBRSR).
Research-related stories featured in News Now are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.
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