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Multicenter Study
. 2024 May;17(5):e010477.
doi: 10.1161/CIRCOUTCOMES.123.010477. Epub 2024 Apr 3.

Impact of Local Tailoring on Acute Stroke Care in 21 Disparate Emergency Departments: A Prospective Stepped Wedge Type III Hybrid Effectiveness-Implementation Study

Kathleen E McKee #  1 , Andrew J Knighton #  2 , Kristy Veale  1 , Julie Martinez  1 , Cory McCann  1 , Jonathan W Anderson  1 , Doug Wolfe  2 , Robert Blackburn  3 , Marilyn McKasson  1 , Tyler Bardsley  4 , Blessing Ofori-Atta  4 , Tom H Greene  4 , Robert Hoesch  1 , H Adrian Püttgen  1 , Rajendu Srivastava  2   5
Affiliations
Multicenter Study

Impact of Local Tailoring on Acute Stroke Care in 21 Disparate Emergency Departments: A Prospective Stepped Wedge Type III Hybrid Effectiveness-Implementation Study

Kathleen E McKee et al. Circ Cardiovasc Qual Outcomes. 2024 May.

Abstract

Background: Faster delivery of tPA (tissue-type plasminogen activator) results in better health outcomes for eligible patients with stroke. Standardization of stroke protocols in emergency departments (EDs) has been difficult, especially in nonstroke centers. We measured the effectiveness of a centrally led implementation strategy with local site tailoring to sustain adherence to an acute stroke protocol to improve door-to-needle (DTN) times across disparate EDs in a multihospital health system.

Methods: Prospective, type III hybrid effectiveness-implementation cohort study measuring performance at 21 EDs in Utah and Idaho (stroke centers [4]/nonstroke centers [17]) from January 2018 to February 2020 using a nonrandomized stepped-wedge design, monthly repeated site measures and multilevel hierarchical modeling. Each site received the implementation strategies in 1 of 6 steps providing control and intervention data. Co-primary outcomes were percentage of DTN times ≤60 minutes and median DTN time. Secondary outcomes included percentage of door-to-activation of neurological consult times ≤10 minutes and clinical effectiveness outcomes. Results were stratified between stroke and nonstroke centers.

Results: A total of 855 474 ED patient encounters occurred with 5325 code stroke activations (median age, 69 [IQR, 56-79] years; 51.8% female patients]. Percentage of door-to-activation times ≤10 minutes increased from 47.5% to 59.9% (adjusted odds ratio, 1.93 [95% CI, 1.40-2.67]). A total of 615 patients received tPA of ≤3 hours from symptom onset (median age, 71 [IQR, 58-80] years; 49.6% female patients). The percentage of DTN times ≤60 minutes increased from 72.5% to 86.1% (adjusted odds ratio, 3.38, [95% CI, 1.47-7.78]; stroke centers (77.4%-90.0%); nonstroke centers [59.3%-72.1%]). Median DTN time declined from 46 to 38 minutes (adjusted median difference, -9.68 [95% CI, -17.17 to -2.20]; stroke centers [41-35 minutes]; nonstroke centers [55-52 minutes]). No differences were observed in clinical effectiveness outcomes.

Conclusions: A centrally led implementation strategy with local site tailoring led to faster delivery of tPA across disparate EDs in a multihospital system with no change in clinical effectiveness outcomes including rates of complication. Disparities in performance persisted between stroke and nonstroke centers.

Keywords: delivery of health care; hospital emergency services; implementation science; quality improvement; rural hospitals; stroke; tissue plasminogen activator.

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Conflict of interest statement

Disclosures Dr McKee consults for Ceraxis Health, Inc, Drs Knighton and Püttgen own shares in large publicly traded health/biotechnology companies not affiliated with this research. Dr Srivastava is a founder of the I-PASS Patient Safety Institute in which his employer, Intermountain Health owns his equity. Dr Srivastava has received monetary awards, honorariums, and travel reimbursement from multiple academic and professional organizations for teaching about pediatric hospitalist research networks and quality of care. The other authors report no conflicts.

Figures

Figure 1.
Figure 1.
Patient inclusion/exclusion diagram
See this image and copyright information in PMC

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