Target: Stroke hits a bull’s eye with timely care, improved outcomes

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 - Emergency Department

A pre-post analysis of a national stroke initiative found patients were more likely to receive timely treatment and have better outcomes after the launch of the quality improvement program. The results were published in the April 23/30 issue of JAMA.

American Heart Association/American Stroke Association guidelines recommend eligible patients with acute ischemic stroke be treated with intravenous tissue plasminogen activator (tPA) within 60 minutes of arrival at an emergency department. In 2010, the associations launched Target: Stroke, a national program to increase the number of stroke patients who receive tPA in the recommended door-to-needle time frame.

All Get With The Guidelines-Stroke (GWTG-Stroke) hospitals were invited to participate in Target: Stroke. Participating hospitals had the goal of administering tPA in at least half of patients with acute ischemic stroke within 60 minutes. They received a tool kit that included 10 key evidence-based strategies they could adopt as well as educational support, clinical decision support tools and feedback.  

Gregg C. Fonarow, MD, of the Ahmanson-University of California, Los Angeles Cardiomyopathy Center, and colleagues analyzed data from GWTG-Stroke hospitals to assess the effectiveness of Target: Stroke and to determine if improvements in door-to-needle time translated into improvements in clinical outcomes. The study period spanned April 1, 2003, to Dec. 31, 2009, for the preintervention period and Jan. 1, 2010, to Sept. 30, 2013, for the postintervention period.

They analyzed data on 71,169 patients treated with tPA at 1,030 hospitals. Patient characteristics were mostly similar in the pre and post groups.

The median door-to-needle time in the pre group was 77 minutes vs. 67 minutes in the post group. Comparing the last quarter of the pre group with the last quarter of the post group showed an even more dramatic change of 74 minutes to 59 minutes.

The proportion of patients who received tPA treatment within 60 minutes increased from 26.5 percent in the pre group to 41.3 percent in the post group. In a last quarter analysis, the percentage increased from 29.6 percent to 53.3 percent.    

Inhospital all-cause mortality was lower in the post group (8.25 percent vs. 9.93 percent in the pre group). A greater proportion of patients in the post group were discharged to home (42.7 percent vs. 37.6 percent for the pre group). The post group also had lower rates for overall tPA complications and symptomatic intracranial hemorrhage.

“Our new findings suggest that the significant decline in door-to-needle times along with acceleration in the percentage of patients meeting guideline-recommended times within 60 minutes during the postintervention period were associated with substantial improvement in short-term clinical outcomes,” Fonarow and colleagues wrote.

The results may put to rest concerns that hospitals may compromise care in efforts to achieve shorter door-to-needle times, they added.