What’s New in the Patient Safety World
September 2015
Stroke: Doing Less Well Than You Think?
It’s human nature to
think we are doing better at something than we really are when we don’t know
the data. A number of years ago we asked caregivers at a community hospital how
well they provided care for patients with acute MI. They weren’t really sure
because they sent most of their acute MI patients to a tertiary hospital. But
they thought most of their patients would have received percutaneous coronary
angioplasty within the prescribed timeframes. When they finally got around to
requesting the data from the tertiary hospital it turned out that almost none
of the patients got the angioplasty within the recommended timeframe, mainly
because of transport delays and delays on arrival. Their patient population
would have been much better off receiving thrombolytic therapy at the community
hospital before being transported to a tertiary hospital. Once the hospital
recognized this problem they began initiating thrombolytic therapy on-site and
did a good job achieving this therapy within the prescribed timeframes for most
acute MI patients. The problem was clearly one of lack of data availability and
lack of timely feedback on performance.
The same applies to
acute stroke care. A recent study from hospitals participating in the American
Heart Association’s “Get With The Guidelines” (GWTG)
program found that hospitals often overestimate their ability to deliver timely
tPA to patients treated with tPA
(Lin 2015).
Less than one third of all hospitals responding to a survey accurately
identified their door-to-needle (DTN) time performance. Respondents from
hospitals in middle- and low-performing hospitals in particular overestimated
their DTN performance.
The key message is
that to improve care you need to provide comparative provider performance data
routinely to caregivers.
There are many
factors that go into running successful stroke programs. We’ve discussed those
in the several prior columns listed at the end of today’s column. But there are
a few new considerations.
One important factor
is coming to a correct diagnosis of stroke. Prior to administering tPA we need to exclude certain
stroke “look-alikes” or “mimics” (eg. migraine,
post-ictal Todd’s paralysis, etc.). However, we may also fail to diagnosis
acute strokes in some patients. A recent study (Richoz 2015)
looked at acute stroke “chameleons” presenting to a university hospital
emergency department. They found that 2.1% of strokes were missed initially.
These were either misdiagnosed as other neurologic diseases (42%) or
non-neurologic diseases (17%) or as unexplained decreased level of
consciousness (21%) or as concomitantly present disease (19%). These strokes
tended to be either very mild or very severe. At 12 months patients with these
“chameleons” tended to have less favorable outcomes and higher mortality.
Another problem in
thrombolytic therapy for acute stroke was recently noted by Bordoehl
and colleagues (Brodoehl
2015). Because of the short
half-life of tPA, it should
be administered as a bolus followed by an immediate infusion. However, they
note that in clinical practice there are sometimes delays between the
application of the bolus and the start of the infusion. In addition,
interruptions of the infusion may occur. They found that even 1-minute delays
before the infusion is begun or interruptions of the infusion for more than
1-minute may affect serum tPA
concentrations. Their results strongly suggest avoiding bolus-infusion delays
by giving the bolus only when the infusion is ready. They went on to estimate
the dosing of a potential second bolus depending on the duration of the
delay/interruption to allow for the achievement of appropriate serum tPA concentrations. However, they
stress that clinical safety data are needed to recommend the application of a
second bolus.
Sustaining improvement is often difficult and another recent study illustrates the
difficulties encountered in sustaining some components of good stroke care.
Perhaps just as important as getting thrombolytic therapy to those eligible
acute stroke patients is prevention of complications of stroke, such as UTI’s,
pneumonia, and DVT. Williams and colleagues (Williams
2015) conducted a
cluster-randomized quality improvement trial, randomizing hospitals to quality
improvement training plus indicator feedback versus indicator feedback alone to
improve deep vein thrombosis (DVT) prophylaxis and dysphagia screening. DVT
prophylaxis improved more during the intervention period in the active
intervention group but this improvement was not sustained afterward. For
improving dysphagia screening quality improvement training was no better than
feedback alone.
So, while we
encourage you to make the major changes noted in our columns below, we also use
the above examples to remind you that some of the other issues in stroke care
also impact the outcomes for your patients.
Some of our previous columns on improving stroke care:
November 6,
2012 “Using
LEAN to Improve Stroke Care”
March 18, 2014 “Systems
Approach Improving Stroke Care”
September 23,
2014 “Stroke
Thrombolysis: Need to Focus on Imaging-to-Needle Time”
January 27, 2015 “The
Golden Hour for Stroke Thrombolysis”
May 12, 2015 “More
on Delays for In-Hospital Stroke”
June 2015 “Too
Much of a Good Thing? Very Early Mobilization in Stroke”
References:
Lin CB, Cox M, Olson DM, et al. Perception versus actual performance in timely tissue plasminogen activation administration in the management of acute ischemic stroke. Journal of the American Heart Association 2015; DOI: 10.1161/JAHA.114.001298
http://jaha.ahajournals.org/content/4/7/e001298.abstract
Richoz B, Hugli O, Dami F, et al. Acute stroke chameleons in a university hospital: Risk factors, circumstances, and outcomes. Neurology 2015; 85: 505-511; published ahead of print July 15, 2015
http://www.neurology.org/content/85/6/505.abstract?etoc
Brodoehl S, Günther A, Witte OW, Klingner CM. How to Manage Thrombolysis Interruptions in Acute Stroke? Clinical Neuropharmacology 2015; 38(3): 85-88
Williams L, Daggett V, Slaven JE, et al. A cluster-randomised quality improvement study to improve two inpatient stroke quality indicators. BMJ Qual Saf 2015; published online 24 August 2015 doi:10.1136/bmjqs-2015-004188
http://qualitysafety.bmj.com/content/early/2015/08/24/bmjqs-2015-004188.short?g=w_qs_ahead_tab
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