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Driving stroke quality improvement at scale in EDs across a nationwide network of hospitals: strategies and interventions
  1. Max Shpak1,2,
  2. Kimberly Korwek3,
  3. Zoltan Nadasdy2,
  4. Anurekha Ramakrishnan2,
  5. Matthew Cowperthwaite1,
  6. Kristen Ankrom3,
  7. Jon Jennings3,
  8. Ashley Moody3,
  9. Kevin Orndorff3,
  10. Christopher Fanale4
  1. 1 Neuroscience and Spine Institute, St. David’s Medical Center, Austin, Texas, USA
  2. 2 Neuroscience Division, Sarah Cannon Research Institute, Nashville, Tennessee, USA
  3. 3 Neuroscience Division, HCA Healthcare, Nashville, Tennessee, USA
  4. 4 Department of Neurosciences, HealthOne Swedish Medical Center, Denver, Colorado, USA
  1. Correspondence to Dr Max Shpak, St. David’s Medical Center, Austin, TX 78705, USA; maxim.shpak{at}


Objectives Reducing the treatment time while increasing the proportion of eligible stroke patients who receive intravenous tissue plasminogen activator (tPA) has been a priority for many quality improvement efforts. Recent studies have primarily focused on identifying interventions that reduce door-to-needle (DTN) time, while comparatively little has been done to determine whether these interventions also improve tPA rates.

Methods In order to investigate interventions related to process improvements, an electronic dashboard serving as a stroke performance tool was implemented to store and retrieve patient outcome data. These data were used to study the efficacy of interventions designed to facilitate triage of stroke patients in the ED, and determine the individual interventions associated with the most significant improvements in the fraction of patients receiving tPA and in reducing the DTN time. Stroke performance data from the dashboard collected over a 2-year period (2015–2017) from 89 US hospitals were analysed with respect to interventions implemented by individual facilities, as verified by a hospital survey.

Results A statistically significant association was found between increases in the fraction of patients receiving tPA and reductions in DTN time over the study period. These improvements in outcomes were most strongly associated with process interventions that allocate stroke-specific physical and human resources in the ED, most notably a designated emergency room space for stroke, and with workflows that decrease the time to key checkpoints for determining a patient’s eligibility for tPA.

Conclusions Data from the stroke performance tool was leveraged to identify the programmes and process interventions that lead to improved patient outcomes and allow EDs to better prioritise process interventions and resources.

  • stroke
  • thrombolysis
  • management, quality assurance

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  • Contributors Statistical analyses were performed by MS, ZN and AR. The manuscript was primarily written by MS, apart from some sections describing the stroke dashboard that were prepared by KK. Both KK and MC assisted in editing the manuscript into its final form. The stroke dashboard was created (and data from the dashboard were provided) by KA, JJ and AM. The study was suggested by CF and KO. MC also contributed to the specifics of the study design.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The views expressed in this publication represent those of the authors and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.