Quality improvement in acute stroke: the New York State Stroke Center Designation Project.
BACKGROUND
Many hospitals lack the infrastructure required to treat patients with acute stroke. The Brain Attack Coalition (BAC) published guidelines for the establishment of primary stroke centers.


OBJECTIVE
To determine if stroke center designation and selective triage of acute stroke patients improve quality of care.


METHODS
Baseline chart abstraction was performed on all stroke patients admitted to 32 hospitals serving Brooklyn and Queens, NY, from March to May 2002. Hospitals were invited to meet BAC guideline-based criteria. Adherence was verified by on-site visits. After designation, acute stroke patients were selectively triaged. Remeasurement data were collected from August to October 2003.


RESULTS
The authors abstracted 1,598 charts at baseline and 1,442 charts at remeasurement. From baseline to remeasurement, median times decreased for door to physician contact (25 vs 15 minutes, p = 0.001), CT performance for potential tissue plasminogen activator (t-PA) candidates (68 vs 32 minutes, p < 0.001), and t-PA administration (109 vs 98 minutes (p = NS). IV t-PA utilization increased from 2.4 to 5.2% (p < 0.005), select t-PA protocol violations decreased from 11.1 to 7.9% (p = NS), and the stroke unit admission rate increased from 16 to 39% (p < 0.001). In stroke centers (n = 14) vs nondesignated hospitals (n = 18), there were shorter median times from door to physician contact (10 vs 25 minutes, p < 0.001), CT performance for potential t-PA candidates (31 vs 40 minutes, p = NS), and t-PA administration (95 vs 115 minutes, p < 0.05). Stroke centers, compared with nondesignated centers, admitted acute stroke patients to stroke units more often (55.9 vs 10.9%, p < 0.001).


CONCLUSIONS
Stroke center designation and selective triage of acute stroke patients improved the quality of care, including access to timely thrombolytic therapy and stroke units.
Gropen
T I
TI
Department of Neurology, Long Island College Hospital and State University of New York-Health Science Center at Brooklyn, 11201, USA. tgropen@chpnet.org
Gagliano
P J
PJ
Blake
C A
CA
Sacco
R L
RL
Kwiatkowski
T
T
Richmond
N J
NJ
Leifer
D
D
Libman
R
R
Azhar
S
S
Daley
M B
MB
D000368:Aged; D003710:Demography; D005260:Female; D019983:Guideline Adherence; D006748:Hospital Departments; D006801:Humans; D008297:Male; D009518:New York / Q000453:epidemiology; D017063:Outcome Assessment, Health Care; D010960:Plasminogen Activators / Q000627:therapeutic use*; D011635:Public Health Administration; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D020521:Stroke / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D013997:Time Factors
D010960:Plasminogen Activators