title: Thrombolysis for acute ischemic stroke in Joint Commission-certified and -noncertified hospitals in Michigan.
abstract: BACKGROUND
  The Joint Commission (JC) for Accreditation of Healthcare Organizations has devised disease specific certification programs for hospitals, including stroke. JC certification as a primary stroke center (PSC) suggests that the hospital has critical measures in place to ensure improving stroke outcomes over the long term. In this study, we focused on the delivery of care for patients with acute ischemic and compared differences in JC-certified and -noncertified centers in Michigan.
  
  
  METHODS
  We performed a systematic chart review of patients with acute ischemic stroke from 10 Michigan hospitals, half of whom were JC-certified PSCs. Sixty charts were randomly chosen from 1 calendar year from each hospital. An experienced nurse performed the data abstraction, and data analysis was performed with the Fisher exact test.
  
  
  RESULTS
  A total of 602 charts--of which 302 were from JC-certified PSCs--were chosen for the study. The 2 groups were similar with regard to stroke risk factors except that there were significantly more patients with atrial fibrillation in noncertified centers and there were more African American patients in JC-certified PSCs. Significantly more patients were considered for thrombolytic therapy in JC-certified PSCs compared to noncertified centers (90.4% v 66%; P = .0001). Overall, 3.8% of patients had received thrombolytic therapy without any significant difference between JC-certified PSCs and noncertified centers (4.6% v 3%; adjusted odds ratio 1.64; 95% confidence interval 0.64-4.19; P = .87). However, thrombolysis rates among eligible patients was significantly higher in the JC-certified PSCs (48.2% v 8.8%; P = .0001). The most common reason documented for not giving thrombolytic therapy was late arrival outside the therapeutic window, which was more common in JC-certified PSCs (72.8% v 55.6%; P = .0001) compared to noncertified centers. Seventy-four percent of patients from JC-certified PSCs were discharged home or to inpatient rehabilitation facility compared to 71% (P = .38) from noncertified hospitals. The mean length of stay was marginally shorter in JC-certified PSCs compared to noncertified centers (5.53 v 6.25 days; P = .08).
  
  
  CONCLUSIONS
  Rates of thrombolysis administration for acute stroke patients across Michigan were low in both JC-certified and noncertified hospitals, although better processes were in place in JC-certified PSCs. While there was no overall difference in the administration of thrombolytic treatment, a greater number of the eligible patients received thrombolysis in the certified centers. There was a tendency to shorter lengths of stay at JC-certified PSCs, but there was no significant difference in discharge to home, inpatient rehabilitation, or inpatient mortality in this study.
authors.affiliation: Comprehensive Stroke Program, Wayne State University School of Medicine, Detroit, MI 48201, USA. krajaman@med.wayne.edu
authors.forename: Kumar
authors.initials: K
authors.lastname: Rajamani
authors.forename: Scott
authors.initials: S
authors.lastname: Millis
authors.forename: Sam
authors.initials: S
authors.lastname: Watson
authors.forename: Flicia
authors.initials: F
authors.lastname: Mada
authors.forename: Leeza
authors.initials: L
authors.lastname: Salowich-Palm
authors.forename: Sabrina
authors.initials: S
authors.lastname: Hinton
authors.forename: Seemant
authors.initials: S
authors.lastname: Chaturvedi
mesh_terms: D002545:Brain Ischemia / Q000175:diagnosis / Q000188:drug therapy* / Q000208:ethnology / Q000401:mortality; D002568:Certification / Q000592:standards*; D015897:Comorbidity; D003695:Delivery of Health Care / Q000592:standards*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D054625:Healthcare Disparities / Q000592:standards; D006742:Hospital Bed Capacity; D017052:Hospital Mortality; D006761:Hospitals / Q000592:standards*; D006801:Humans; D007591:Joint Commission on Accreditation of Healthcare Organizations; D007902:Length of Stay; D008297:Male; D008824:Michigan / Q000453:epidemiology; D016017:Odds Ratio; D010351:Patient Discharge / Q000592:standards; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000188:drug therapy* / Q000208:ethnology / Q000401:mortality; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000401:mortality / Q000592:standards*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
chemical_list: D005343:Fibrinolytic Agents