”Time=Brain”: A healthcare system collaboration to improve stroke care

Stroke is the third leading cause of death in the United States, killing approximately 150,000 people annually. In 2003, in response to the Brain Attack Coalition guidelines, Joint Commission Stroke Certification guidelines, and the New York State Department of Health Level 1 Stroke Center program outlining the development of coordinated stroke systems as a model for improving the quality of stroke care, the NewYork-Presbyterian Healthcare System (NYPHS) initiated a System-wide Stroke Initiative. This initiative aimed to: 1) Assess, standardize and improve stroke care at its 27 acute care hospitals through compliance with national and state stroke center designation standards; and 2) Identify and monitor stroke care quality process and outcome indicators, including timely evaluation and brain imaging (CT Scan) and administration of intravenous thrombolytic therapy (t-PA), construct benchmarking reports and share unblinded data across the System.

Methods: A Stroke Directors Council, consisting of stroke directors and clinical experts from each System hospital as well as representatives from the American Stroke Association, and the New York State Department of Health, was convened and meets on a bi-monthly basis. Clinical guidelines, protocols and standardized order sets were developed and disseminated system-wide. Consensus was achieved on a data collection methodology using the American Heart Association's Get With The Guidelines Stroke Patient Management Tool. Process and outcome quality measure performance are presented and discussed at the bi-monthly meetings. An annual curriculum of CME Educational Programs was developed by NewYork-Presbyterian Hospital and open to all System hospital staff. Institutions have developed and participate in Community Outreach and Education programs throughout the year and annually during Stroke Awareness Month.

Results and Discussion:

• Since 2004, 20 hospitals have achieved State Level 1 Stroke Center Designation and 3 have achieved Joint Commission certification.

• Data comparisons from 2005 indicate statistically significant improvements in median door to CT Scan Completion and median door to t-PA administration (decreases from 40 minutes to 28 minutes and 80 minutes to 73.5 minutes respectively).

• Improvement trends observed in hemorrhagic complications and mortality after t-PA administration.

The System Stroke Initiative has been successful as it has provided a structure conducive to sharing of expertise and resources resulting in improvement of stroke care across a diverse healthcare system. The initiative continues and has been expanded to include other aspects of inpatient and outpatient care of stroke patients.