Quality Improvement

HomeStrokeVol. 52, No. 5Quality Improvement Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree ArticlePDF/EPUBQuality Monique F. Kilkenny, PhD Dawn M. BravataMD KilkennyMonique Kilkenny Correspondence to: PhD, Translational Public Health and Evaluation Division, Level 3 Hudson Institute Bldg, 27-31 Wright St, Clayton VIC 3168. Email E-mail Address: [email protected] https://orcid.org/0000-0002-3375-287X Stroke Ageing Research, Department of Medicine, School Clinical Sciences at Monash Health, University, Clayton, VIC, Australia (M.F.K.). The Florey Neuroscience Mental Heidelberg, Search for more papers by this author , BravataDawn Bravata Precision Monitoring Transform Care Quality Enhancement Research Initiative, Services Development, Veterans Affairs, Indianapolis, IN (D.M.B.). Development Center Information Communication, Richard L. Roudebush VA Medical Center, Medicine Service, Departments Neurology, Indiana University Indianapolis William Tierney Regenstrief Institute, Originally published8 Apr 2021https://doi.org/10.1161/STROKEAHA.121.033451Stroke. 2021;52:1866–1870Worldwide, there is a commitment ensure that all patients with stroke or transient ischemic attack (TIA) have access evidence-based therapies which optimize their survival recovery. learning health system1 provides framework (Figure) components (eg, evidence, data, implementation) are aligned continuous quality improvement (QI). This article summarizes advances made in QI within the last year.Download figureDownload PowerPointFigure. system.Learning SystemsThere increasing interest potential systems improve care. system one science (evidence), informatics (data), incentives (benchmarking), culture (clinicians) best practices embedded delivery process, new knowledge captured as important parts system. A cycle data collected analyzed address question then fed-back into drives QI. aligns plan, do, study, act model In recent published approach improving care has been deployed among TIA.2,3 integrates audit-and-feedback shown be an integral part support teams clinicians use performance care.4Impact COVID-19 on ActivitiesMany studies past year described severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) related stroke.5 pandemic resulted fewer hospitalizations TIA6–9 delays presentation time who do seek effect varied. Although lower rates thrombectomy reported,10 Canadian study successful modification standard treatment protocol increased efficiency while reducing frequency patient contacts.11 response pandemic, many services being delivered virtually. small, qualitative evaluation telerehabilitation program United States provided implementation virtual rehabilitation services.12 One promising during simulation; providing opportunity practice key elements protocols including some donning, doffing, disposal personal protective equipment).13Important Stakeholders QIThe World Organization committed outcomes after TIA ensuring worldwide get optimizes Since 2016, efforts Angels Initiative assisted hospitals around world increase number treated ready existing centers.14 Get With Guidelines–Stroke developed American Heart Association/American Association largest longest running integrated registry programs.15 Australia, engagement via Australian Coalition16 representatives from groups organizations working field clinical networks professional associations/colleges). These partners work together strengthen voice national state levels.Clinical Evidence From GuidelinesQI programs should based evidence trials meta-analyses systematic reviews. year, guidelines were about safe transfer stroke,17 reduction risk undergoing cardiac thoracic aortic surgery,18 organization specific recommendations QI19 need information ongoing monitoring). updated emerges world-first living guidelines.20Quality Data—Metrics, Process, Outcome MeasuresQI activities designed close gap between (what recommended guidelines) (evaluated provided). Around world, audit registries provide essential infrastructure reliably monitoring according guidelines.21 Over decade, implemented countries routine feedback registries.22–24Identifying gaps can serve targets fundamental Two focused methods identify outlier facilities. Kuhrij et al25 found funnel plots examining facility measure (ie, median door-to-needle time) complemented customary binary proportion above 90th percentile time); identified facilities opportunities not evident method. Wang al26 used cared greater than expected 4 processes had higher odds functional independence (modified Rankin Scale score 0–2). Similarly, Haas al27 associated 7-day in-hospital mortality (odds ratio: 3.39 [95% CI, 3.24–3.54]).All-or-none measurement—which assesses whether individual did (pass) (fail) receive they eligible—is increasingly poststroke mortality.2,27 Close Gap-Stroke Study Japan, tool was facilitate measurement indicators.28 Data insurance claims database electronic medical records combined test feasibility reliability developing indicators using these data. Of 8206 172 hospitals, target able obtained few missing but adherence low (<50%) 5 indicators.28Implementation InterventionsAuthors several evaluated effectiveness indicator measures. uses guide interventions hospital level.15 includes workshops, kits, feedback. multicomponent Queensland significantly improved indicators, primarily driven financial externally facilitated workshops.29In studies, various (Table); common include workshops. meta-analysis Siarkowski al30 96 combination strategies effective DTN approaches single intervention. Reduction times also longer duration each hospital.30 initiatives face-to-face workshops ten webinars) province Alberta (n=17 hospitals) led reduced (pre 89 minutes post 70 minutes) (discharged home: 46%–60%; home time: 43–54 days; mortality: 15%–11%).31Table. Interventions Used StudiesQI interventionBravata2Kamal31Levi32Sui33Chiu34Klingner35Hill36Droegemueller37Pines38Wharton39Kishore40Hospital engagementXXXXXFace-to-face workshopsXXXXXXXXHospital visitsXXXAudit-and-feedbackXXXXXXXXXPDSA cyclesXXXXQuality metricsXXXXXXXXXEducationXXXXXXXWebinarsXXRemindersXStaff meetingsXXXQI indicates improvement; PDSA, Plan-Do-Study-Act.In cluster-randomized controlled trial states (n=20 hospitals), multidisciplinary, intervention nursing education) no significant change thrombolysis.32 contrast, prepost 20 China, bundles thrombolysis 55% 65% 1.7 1.24–2.45]).33 multifaceted US Affairs (measured mean without-fail rate) 6 sites compared 36 matched control (36.7%–54.0% [17.3% absolute improvement] versus 38.6%–41.8% [3.2% improvement]; difference, 14%; P=0.008).2 multiple reduce (Table) Singapore34 assess sustainability Germany.35 States, collaborative door-to-groin puncture tertiary hospital.36 addressing communication barriers, systems, quickly implementing change.36Other identification hospitalized patients.37,38 Implementation pediatric over 7 years magnetic resonance imaging (68%–78%) National Institutes documentation (42%–82%).39 Kishore al40 educational (didactic session hands simulation) detection atrial fibrillation 112 early (20%–66%).ConclusionsIn marked systems.Nonstandard Abbreviations AcronymsCOVID-19coronavirus 2019QIquality improvementTIAtransient attackSources FundingDr acknowledges research fellowship Council (1109426).Disclosures Drs Section Editors Stroke.FootnotesThe opinions expressed necessarily those editors Association.For Sources Funding Disclosures, see page 1869.Correspondence monique.[email protected]eduReferences1. 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