Available online 5 December 2023

Author links open overlay panel, , , , , , , , ABSTRACTBackground

Despites guidelines and strong evidence supporting intravenous thrombolysis and endovascular thrombectomy for acute stroke, access to these interventions remains a challenge. The objective of the IMPROVE stroke care program was to accelerate acute stroke care delivery by implementing best practices and improving the regional systems of care within comprehensive stroke networks.

Methods

The IMPROVE Stroke Care program was a prospective quality improvement program based on established models used in acute coronary care. Nine hub hospitals (comprehensive stroke centers), their 52 regional/community referral hospitals (spokes), and over 100 emergency medical service agencies participated. Through 6 regional meetings, 49 best practices were chosen for improvement by the participating sites. Over a two-year period, progress was tracked and discussed weekly and performance reviews were disseminated quarterly.

Results

Data were collected on 21,647 stroke code activations of which 8502 (39.3%) activations had a final diagnosis of stroke. There were 7226 (85.0%) ischemic strokes, and thrombolytic therapy was administered 2814 times (38.9%). There was significant overall improvement in the proportion that received lytic therapy within 45 minutes (baseline of 44.6% to 60.4%). The hubs were more frequently achieving this at baseline, but both site types improved. A total of 1455 (17.1%) thrombectomies were included in the data of which 401 (27.6%) were transferred from a spoke. There was no clinically significant change in door-to-groin times for hub-presenting thrombectomy patients, however significant improvement occurred for transferred cases, 46 minutes (interquartile range (IQR) 36, 115.5) at baseline to 27 minutes (IQR 10, 59).

Conclusion

The IMPROVE program approach was successful at improving delivery of thrombolytic intervention across the consortium at both spoke and hub sites through collaborative efforts to operationalize guideline-based care through iterative sharing of performance and best practices for implementation. Our approach allowed identification of both opportunities for improvement and operational best practices providing guidance on how best to create a regional stroke care network and operationalize the published acute stroke care guidelines.

Section snippetsINTRODUCTION

Stroke is a time-sensitive emergency and is the fifth leading cause of death and a major cause of chronic disability in the United States.1 Despite excellent data to support the use of thrombolytics and endovascular intervention in acute stroke,2, 3, 4, 5, 6 access to these interventions remains a challenge. The American Heart Association Guidelines for the management of acute stroke now recommend that stroke care systems be established to address these barriers to access, though no guidance is

Program Overview

The IMPROVE stroke care program has been described in detail previously9 and was reviewed and approved by the Duke IRB and site IRBs as appropriate as an exempt quality assurance program. The analysis and presentation of the data conform to the SQUIRE 2.0 criteria for reporting results from a quality assurance program. A ‘systems of care’ quality improvement effort was conducted in the Southeastern United States among nine comprehensive stroke centers (hubs) and fifty-two community-based

The Consortium and their patients

As summarized in Table 1, a total of 21,647 stroke code activations from our consortium of 9 comprehensive (Hub) centers and 52 (spoke) referral hospitals were captured in the database, of which 8502 (39.3%) had a final diagnosis of stroke. There were 7226 (85.0%) ischemic strokes and 1217 (14.3%) transient ischemic attacks (TIAs). A stroke type could not be determined for the remaining 3868 (45.5%) events. Thrombolytic therapy was administered 2814 (38.9%) times and 1650 (19.4%) cases were

DISCUSSION

We undertook the IMPROVE Stroke Care project in order to adapt the regional care system model proven to be effective for STEMI and cardiac arrest to stroke care systems.25 The model of Regionalized Stroke Systems of Care utilized in IMPROVE Stroke Care was highly successful in improving the delivery of acute stroke care based on the significant improvement in the proportion of thrombolytic administrations given in under 45 minutes across all site types.

The program led to the identification and

Conclusions

The AHA/ASA gave a Level 1A recommendation that Stroke Systems of Care should be developed in order to improve the acute treatment of ischemic stroke. We leveraged an established model of systems of care development and optimized 9 regional stroke systems in the Southeastern United States. Our result demonstrated that collaborative efforts to share anonymized performance metrics across all providers in the chain of care within a region can lead to rapid, sustainable improvements in delivery of

Author Contribution Statement

Brad J Kolls: Conceptualization, Methodology, Writing - Original Draft, Writing - Review & Editing, Project administration and operationalization, Funding acquisition.

Matthew E Ehrlich: Methodology, Writing - Review & Editing, Project administration and operationalization

Lisa Monk: Methodology, Writing - Original Draft for portions of the methods section, Writing - Review & Editing, Project administration and operationalization

Shreyansh Shah: Methodology, Writing - Review & Editing, Project

Sources of funding

This work was supported by several industry partners. The industry partners were not involved in the design, conductance, data collection or analysis of the IMPROVE program. Funding and service support for this work included (in no specific order):Financial support
Medtronic Foundation
Daiichi Sankyo
Chiesi USAVolunteer services
Pulsara
AmWell
Corazon

Supplemental material

Tables S1–S3Atrium Heath Main
Dr. Andre Asimos
Jeremy Rhoten and Nicole BrandonNovant Forsyth Medical Center
Dr. Colin Timothy McDonald
Karen NormanAtrium Health Cabarrus
Dr. Jeffrey Bodle
Chelsea DunstonNovant New Hanover Regional Medical Center
Dr. James McKinney
Erika Yourkiewicz and Ruth MarescalcoDuke Health
Drs. Brad Kolls and Carmelo Graffagnino
Melissa FreemanPrisma Health
Dr. Anil Yallapragada
Laura HammondsMission Health
Dr. Reid Taylor
Robin Jones and Joshua LewisWake Forest Medical Center
Dr. Amy

CRediT authorship contribution statement

Brad J Kolls: Conceptualization, Data curation, Formal analysis, Investigation, Project administration, Writing – original draft, Writing – review & editing. Matthew E Ehrlich: Investigation, Writing – review & editing. Lisa Monk: Conceptualization, Data curation, Funding acquisition, Investigation, Project administration, Writing – original draft. Shreyansh Shah: Investigation, Writing – review & editing. Mayme Roettig: Conceptualization, Funding acquisition, Methodology, Resources,

Declaration of Competing Interest

None.

Acknowledgements

The authors would like to acknowledge the efforts of Jeremiah Reed, the primary data analyst, for all of his work in automating the data collection and curation process, Dr. Kowsalya Ragavan, Ph.D., the lead statistical data analyst who developed and provided the quarterly anonymized performance reports used in the weekly calls. The authors are grateful for the thoughtful review and feedback on the manuscript prior to submission from Dr Wayne Feng, Dr. Daniel Laskowitz, and Dr. Brian Mac Grory.

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