title: Total quality improvement method for reduction of delays between emergency department admission and treatment of acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group.
abstract: OBJECTIVE
  To develop an approach for reducing time between emergency department (ED) admission and treatment in patients with acute ischemic stroke to meet the challenge of providing tissue plasminogen activator treatment within 180 minutes.
  
  
  METHODS
  An observational study.
  
  
  METHODS
  Forty trial-affiliated hospitals, including 30 community hospitals.
  
  
  METHODS
  A total of 17,324 consecutive patients admitted to trial-affiliated hospital EDs within 24 hours of possible stroke, from January 1991 through October 1994.
  
  
  METHODS
  Appraisal of the process of triage, evaluation, diagnosis, and treatment by means of total quality improvement techniques in each hospital. Staff participating in the process identified sources of variation and modifications by flow charting the process.
  
  
  METHODS
  Time between ED admission and treatment with study medication.
  
  
  RESULTS
  Total quality improvement methods identified hospital-specific process improvements. Many improvements were administrative, requiring no additional resources. More than 50% of screened patients arrived too late to be treated. Only 1268 patients were admitted between 0 and 125 minutes from stroke onset with no other trial exclusion criteria; 48% were treated. Of 243 patients admitted between 126 and 170 minutes from stroke onset with no exclusion criteria, 4% were treated. Mean time from ED admission to treatment was similar in teaching and community hospitals.
  
  
  CONCLUSIONS
  Total quality improvement methods identified ED-specific sources of process variability and reduced time between ED admission and treatment. Therefore, these methods should be considered in developing and monitoring emergent stroke treatment protocols.
authors.affiliation: Division of Biostatistics and Research Epidemiology, Henry Ford Health Sciences Center, Case Western Reserve University, Detroit, Mich., USA. btilley1@biostat.hfh.edu
authors.forename: B C
authors.initials: BC
authors.lastname: Tilley
authors.forename: P D
authors.initials: PD
authors.lastname: Lyden
authors.forename: T G
authors.initials: TG
authors.lastname: Brott
authors.forename: M
authors.initials: M
authors.lastname: Lu
authors.forename: S R
authors.initials: SR
authors.lastname: Levine
authors.forename: K M
authors.initials: KM
authors.lastname: Welch
mesh_terms: D000208:Acute Disease; D002545:Brain Ischemia / Q000188:drug therapy*; D002561:Cerebrovascular Disorders / Q000188:drug therapy*; D004311:Double-Blind Method; D004636:Emergency Service, Hospital; D005246:Feedback; D006801:Humans; D009316:National Institutes of Health (U.S.); D010343:Patient Admission; D010960:Plasminogen Activators / Q000627:therapeutic use*; D011994:Recombinant Proteins; D012985:Software Design; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D017749:Total Quality Management / Q000379:methods*; D014218:Triage / Q000379:methods*; D014481:United States
chemical_list: D011994:Recombinant Proteins; D010960:Plasminogen Activators; D010959:Tissue Plasminogen Activator