title: Quality assurance monitoring of a citywide transportation protocol improves clinical indicators of intravenous tissue plasminogen activator therapy: a community-based, longitudinal study.
abstract: BACKGROUND
  Stroke-bypass transportation to the stroke center by paramedics is important to maximize the efficiency of intravenous tissue plasminogen activator (iv-tPA) therapy. To improve access to stroke thrombolysis, a citywide protocol was launched on January 2007 in Kawasaki City (population 1.4 million) using the Maria Prehospital Stroke Scale (MPSS), and quality assurance monitoring has been performed every 6 months. The aim was to identify whether the citywide quality assurance monitoring improves the process and outcome of iv-tPA therapy.
  
  
  METHODS
  All of the MPSS-based transportation data prospectively recorded by the Kawasaki City Fire Department and the associated clinical data in the 11 hospitals that accept stroke-bypass transfers were merged every 6 months for the quality assurance monitoring. Clinical indicators such as ambulance call-to-door time, onset-to-needle time, door-to-needle time, frequency of thrombolytic use, and outcome of thrombolytic therapy were analyzed. These clinical indicators were also compared between patients transferred on weekdays and on weekends.
  
  
  RESULTS
  A total of 2049 patients was registered from April 2009 to March 2013. Their mean age was 70.4 ± 13.2 (range, 24-98) years, and 64.3% were male. Ambulance call-to-door time decreased gradually from 37.5 ± 12.5 minutes to 33.9 ± 11.7 minutes over 4 years (P = .000, analysis of variance with the post hoc Dunnett test). Onset-to-needle time and door-to-needle time were similar over the 4 years. Good outcome (modified Rankin Scale score <2) after iv-tPA therapy increased from 24.1% to 35.3% (P = .045, 2010 vs. 2012). No deleterious effect of weekend admission was observed based on these clinical indicators.
  
  
  CONCLUSIONS
  A citywide MPSS-based transportation protocol significantly decreased the delay in the ambulance call-to-door time. The implementation of standardized cross-institutional quality assurance programs for acute stroke therapy may improve the process and outcome of iv-tPA therapy in the community.
authors.affiliation: Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan.
authors.forename: Chihiro
authors.initials: C
authors.lastname: Atsumi
authors.affiliation: Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan. Electronic address: shinnai@marianna-u.ac.jp.
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Hasegawa
authors.affiliation: Department of Neurosurgery & Neurovascular Center, Kawasaki Saiwai Hospital, Kawasaki, Japan.
authors.forename: Kohtaro
authors.initials: K
authors.lastname: Tsumura
authors.affiliation: Department of Strokology, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan.
authors.forename: Toshihiro
authors.initials: T
authors.lastname: Ueda
authors.affiliation: Department of Neurosurgery, Ohta General Hospital, Kawasaki, Japan.
authors.forename: Kazunari
authors.initials: K
authors.lastname: Suzuki
authors.affiliation: Department of Neurosurgery, Kanto Rosai Hospital, Kawasaki, Japan.
authors.forename: Makoto
authors.initials: M
authors.lastname: Sugiyama
authors.affiliation: Department of Neurology, Kawasaki City Hospital, Kawasaki, Japan.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Nozaki
authors.affiliation: Department of Neurosurgery, Asao General Hospital, Kawasaki, Japan.
authors.forename: Shinichi
authors.initials: S
authors.lastname: Suzuki
authors.affiliation: Department of Neurosurgery, Teikyo University School of Medicine, University Hospital Mizonokuchi, Kawasaki, Japan.
authors.forename: Makoto
authors.initials: M
authors.lastname: Nakane
authors.affiliation: Department of Neurosurgery, Municipal Tama Hospital, Kawasaki, Japan.
authors.forename: Goro
authors.initials: G
authors.lastname: Nagashima
authors.affiliation: Department of Neurosurgery, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan.
authors.forename: Takayuki
authors.initials: T
authors.lastname: Kitamura
authors.affiliation: Department of Neurosurgery, Daiichi Hospital, Kawasaki, Japan.
authors.forename: Hirofumi
authors.initials: H
authors.lastname: Nikaido
authors.affiliation: Department of Neurosurgery, Shinyurigaoka General Hospital, Kawasaki, Japan.
authors.forename: Jinichi
authors.initials: J
authors.lastname: Sasanuma
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000552:Ambulances; D004632:Emergency Medical Services; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D007564:Japan; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011785:Quality Assurance, Health Care / Q000379:methods*; D020521:Stroke / Q000188:drug therapy; D015912:Thrombolytic Therapy / Q000379:methods*; D061665:Time-to-Treatment; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D014187:Transportation of Patients / Q000458:organization & administration*; D016896:Treatment Outcome; D014505:Urban Population; D055815:Young Adult
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Stroke-bypass transportation; alteplase; plan-do-study-act cycle; stroke scale