Cooperative efforts improve compliance with acute stroke guidelines. (Original Article).Objective: Guidelines for emergency treatment of stroke are not always known or followed. Florida Medical Quality Assurance, Inc. collaborated with hospitals to determine how closely the current American Heart Association American Heart Association (AHA), n.pr a national voluntary health agency that has the goal of increasing public and medical awareness of cardiovascular diseases and stroke, and thereby reducing the number of associated deaths and disabilities. (ABA Aba (ä`bä), city (1991 est. pop. 264,000), SE Nigeria. It is an important regional market, a road and rail hub, and a manufacturing center for cement, textiles, pharmaceuticals, processed palm oil, shoes, plastics, soap, and beer. ) and the Florida Agency for Health Care Administration (AHCA AHCA Agency for Health Care Administration AHCA American Health Care Association AHCA American Hockey Coaches Association AHCA American Highland Cattle Association AHCA Australian Health Care Agreement AHCA Austin Healey Club of America ) guidelines were being followed and to improve compliance with these guidelines. Methods: Medical records of patients admitted for acute stroke to 32 hospitals were retrospectively reviewed for compliance with six quality indicators (QIs) on the basis of AHA and AHCA guidelines. Hospitals were provided feedback on their levels of guideline compliance, and they subsequently implemented measures to improve compliance. After 6 months, the records of patients admitted after the provision of feedback were reviewed for compliance with the same six QIs. Results: Compliance improved with regard to all QIs and was statistically significant for three of them. Conclusion: Feedback on performance, coupled with proactive collaboration with emergency department staff, resulted in improved compliance with the stroke guidelines. ********** Stroke is predominantly a disease of the elderly. Approximately 88% of deaths attributed to stroke are among people older than 65 years of age. (1) With Florida's large elderly population, the optimal treatment of stroke is a particularly important issue in the state, which in 1996 alone recorded 25,218 stroke admissions, representing 3.7% of all statewide Medicare admissions. More than 77% of these stroke patients were admitted through the emergency department (ED). Florida Medical Quality Assurance, Inc., the Florida peer review organization peer review organization Professional review organization, qualilty improvement organization Managed care An independent or sponsored group of physicians or other appropriate peers–eg, allied health professionals who conduct pre-admission, continued stay, charged with improving the quality of care of Medicare patients, collaborated with 32 acute care hospitals statewide with the dual objectives of determining how closely current guidelines for the emergency treatment of stroke were being followed and of improving compliance with these guidelines. After acute ischemic Ischemic An inadequate supply of blood to a part of the body, caused by partial or total blockage of an artery. Mentioned in: Antiangiogenic Therapy, Subarachnoid Hemorrhage, Ventricular Fibrillation ischemic or hemorrhagic stroke hemorrhagic stroke Neurology An ischemic stroke in which blood enters necrotic brain tissue, which may not be accompanied by a worsening clinical status Risks for HS Hemophilia, thrombocytopenia, sickle cell anemia, DIC, anticoagulants, HTN. See Stroke. , an increase in systemic blood pressure (BP) is a common phenomenon. Transient elevated BP may protect stroke patients by preserving cerebral blood flow Cerebral blood flow, or CBF, is the blood supply to the brain in a given time.[1] In an adult, CBF is 750 mls/min or 15% of the cardiac output. On a weight basis, this is 50 to 54 milllitres/100grams/minute. to viable tissue around the infarct infarct /in·farct/ (in´fahrkt) a localized area of ischemic necrosis produced by occlusion of the arterial supply or the venous drainage of the part. or hemorrhage hemorrhage (hĕm`ərĭj), escape of blood from the circulation (arteries, veins, capillaries) to the internal or external tissues. The term is usually applied to a loss of blood that is copious enough to threaten health or life. . Thus, lowering moderately elevated BP may result in greater isohemic damage to the brain. When hypertension is treated, sublingual sublingual /sub·lin·gual/ (-ling´gwal) hypoglossal; beneath the tongue. sub·lin·gual adj. Abbr. SL Below or beneath the tongue; hypoglossal. calcium antagonists antagonists, n muscles that counterbalance agonists during specific movements. opioid Neurology A pain-attenuating peptide that occurs naturally in the brain, which induces analgesia by mimicking endogenous opioids at opioid are to be avoided because their rapid absorption can precipitate precipitate /pre·cip·i·tate/ (-sip´i-tat) 1. to cause settling in solid particles of substance in solution. 2. a deposit of solid particles settled out of a solution. 3. occurring with undue rapidity. a rapid decline in BP. (2) Because the treatment of stroke in the ED can have a major effect on patient outcomes, guidelines pertaining per·tain intr.v. per·tained, per·tain·ing, per·tains 1. To have reference; relate: evidence that pertains to the accident. 2. to the emergency treatment of stroke recommend close monitoring of BP, cardiac monitoring, early computed tomography Computed tomography (CT scan) X rays are aimed at slices of the body (by rotating equipment) and results are assembled with a computer to give a three-dimensional picture of a structure. (CT) or magnetic resonance imaging magnetic resonance imaging (MRI), noninvasive diagnostic technique that uses nuclear magnetic resonance to produce cross-sectional images of organs and other internal body structures. (MRI 1. (application) MRI - Magnetic Resonance Imaging. 2. MRI - Measurement Requirements and Interface. ) to determine the type of stroke (le, ischemic, hemorrhagic Hemorrhagic A condition resulting in massive, difficult-to-control bleeding. Mentioned in: Hantavirus Infections hemorrhagic pertaining to or characterized by hemorrhage. ), and treatment of hypertension only if systolic Systolic The phase of blood circulation in which the heart's pumping chambers (ventricles) are actively pumping blood. The ventricles are squeezing (contracting) forcefully, and the pressure against the walls of the arteries is at its highest. BP is above 220 mm Hg or mean BP is higher than 130 mm HG. (2-5) However, it is not always the case that treatment guidelines are known or followed when known. (6) Patients and Methods Florida Medical Quality Assurance, Inc., followed the Health Care Financing Administration's Health Care Quality Improvement Program cooperative project method of measuring well-accepted, evidence-based QIs before and after implementing provider interventions.7 Thirty-two Florida hospitals agreed to participate in this project and provided records for a retrospective review retrospective review, a posttreatment assessment of services on a case-by-case or aggregate basis after the services have been performed. of a random sample of 1,019 stroke patient admissions between July 1, 1996, and March 31, 1997. These 32 hospitals admitted 24% of all Florida Medicare stroke patients in 1996 and 25.2% of them in 1997. These admissions were selected using ICD-9-CM ICD-9-CM International Classification of Disease, 9th edition, Clinical Modification A standardized classification of disease, injuries, and causes of death, by etiology and anatomic localization and codified into a 6-digit number, which allows 430.xx, 431.xx, 433.xx, 434.xx, and 436.xx, excluding the 433.xO and 434.x0 codes. Record reviews focused on six QIs on the basis of AHA guidelines for the management of patients with acute ischemic stroke Noun 1. ischemic stroke - the most common kind of stroke; caused by an interruption in the flow of blood to the brain (as from a clot blocking a blood vessel) ischaemic stroke , (2) as well as AHCA guidelines. (3) The following QIs were used: * QI 1: Percentage of presenting patients with three or more BP measurements [less than or equal to]30 minutes after presentation. * QI 2. Percentage of treated patients with three or more BP measurements [less than or equal to]30 minutes after first antihypertensive antihypertensive /an·ti·hy·per·ten·sive/ (-ten´siv) counteracting high blood pressure, or an agent that does this. an·ti·hy·per·ten·sive adj. Reducing high blood pressure. n. treatment. * QI 3: Percentage of patients with systolic BP >220 mm Hg or mean BP >130 mm Hg who were treated for hypertension. * QI 4: Percentage of all patients who had an initial brain imaging study (CT/MRI) [less than or equal to]2 hours after presentation. * QI 5: Percentage of patients who underwent cardiac monitoring in the ED. * QI 6: Percentage of patients treated for hypertension who did not receive calcium channel blockers Calcium Channel Blockers Definition Calcium channel blockers are medicines that slow the movement of calcium into the cells of the heart and blood vessels. (sublingual or oral) in the ED. After data had been gathered and analyzed for each QI, the facilities were informed of their individual and aggregate results. This feedback was presented either in face-to-face meetings or by mail. Written feedback material presented to all hospitals included a project overview, the definition of the QIs, the methodology of case review, results, discussion, conclusions, and a suggested format for developing an improvement plan. On the basis of the information received, QI staff at collaborating hospitals were free to implement individual facility interventions designed to improve the emergency treatment of stroke patients. Many collaborating hospitals developed new standing orders, critical pathways, protocols, educational seminars, and documentation tools for managing acute stroke patients in the ED. Some also conducted educational activities aimed at physicians and ED staff. Others changed the physical layout of EDs or purchased new equipment. After a period of 6 months of implementation, the medical records of all stroke patients admitted from June 1, 1998, through September 30, 1998, were reviewed according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. the same criteria (n = 684), and the results were compared with preintervention values. Simple percentages with exact binomial binomial (bī'nō`mēəl), polynomial expression (see polynomial) containing two terms, for example, x+y. The binomial theorem, or binomial formula, gives the expansion of the nth power of a binomial (x+ 95% confidence intervals confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. were used to measure individual facility and overall measures for each quality indicator. Only aggregate measures are reported in this article, because of facility confidentiality requirements. A Mantel-Haenszel analysis was performed to determine whether there were significant differences in QI rates. Individual and aggregate odds ratios with 95% confidence intervals were computed. The Breslow-Day test was used to test the odds ratios' homogeneity Homogeneity The degree to which items are similar. . Informed consent was not required, because data were collected with regard to the administration of the Medicare program, not for research, and access to these data is granted to the program by law. Results The characteristics of patients reviewed before intervention were similar to those of patients seen after QI feedback was given to hospitals (Table 1). The major differences observed were a slightly smaller percentage of men (39.6 versus 45.5%) and fewer patients transported to the hospital by the Emergency Medical System (62.0 versus 68.5%). None of the patient characteristics were significantly different (P > 0.05 in all cases). The preintervention rates of compliance with specific guideline recommendations ranged from 11.9 to 75.9% (Table 2). The QIs pertaining to blood pressure measurement (QI1-QI3) had the lowest rates of compliance, but it should be noted that these indicators depended on the accurate recording of dates and times, which was a weakness of many records. During abstraction, it was noted that the time when the physician first saw the patient was missing in 47.4% of the cases overall. Although not a QI, it seems reasonable to assume that there is a correlation between how quickly a physician saw a patient and how soon tests and treatments were ordered and performed. After receiving feedback on their levels of compliance with key elements of the AHA/AHCA guidelines, hospital ED staff improved their performance on all measures. Three QIs showed strong statistical significance, with P < 0.001 (QI1, QI4, and QI6; Table 2). A fourth (QI5) showed marked improvement, but the improvement was not significant (P = 0.06). The recommendation against administration of rapid-acting calcium channel blockers, QI6, was especially stressed in the presentations to the hospitals. Although there was already reasonably high compliance with this measure, it improved significantly, from 68 to 94% (P < 0.001), representing a 38% relative improvement. There was a similarly large increase in compliance with QI4, calling for imaging studies. However, there was little change in QI3, pertaining to the treatment of patients whose hypertension was sufficiently high to warrant intervention. Discussion This study measured the improvement in guideline compliance and patient care after acute care facilities and EDs were informed of their levels of care, and had implemented various measures to better treat stroke patients. The design of the study does not allow a strong inference Strong Inference is the title of a paper by John R. Platt, published in Volume 146, Number 3642 of the journal Science on 1964-10-16. The paper sets out an efficient experimental method which the paper's author finds missing in some areas of science in his time. of causality causality, in philosophy, the relationship between cause and effect. A distinction is often made between a cause that produces something new (e.g., a moth from a caterpillar) and one that produces a change in an existing substance (e.g. to be made, and it is possible that the improvements seen resulted entirely or in part from causes other than the facilities' making efforts to provide better emergency care. Such potential causes are numerous and include the publication of guidelines, changes in the standards of practice regarding nifedipine nifedipine /ni·fed·i·pine/ (ni-fed´i-pen) a calcium channel blocking agent used as a coronary vasodilator in the treatment of coronary insufficiency and angina pectoris; also used in the treatment of hypertension. , and changes in physician attitudes regarding guidelines. In this study, EDs were proactively recruited for a voluntary effort to improve compliance with guidelines for the emergency care of stroke patients. The key components of the effort were increasing physician awareness of guideline recommendations and providing feedback on compliance. This approach seems to have been successful, significantly improving performance on three of the six chosen QIs (P < 0.001). The effort was particularly effective in increasing ED staff awareness of the importance of not rapidly decreasing BP by using sublingual calcium channel blockers, a measure that was stressed in presentations to hospital staff, but it had virtually no effect on increasing the treatment of patients with hypertension when treatment was warranted. A relatively short time was allotted al·lot tr.v. al·lot·ted, al·lot·ting, al·lots 1. To parcel out; distribute or apportion: allotting land to homesteaders; allot blame. 2. to facilities to implement new processes, and the second review of patient records included patients who may have been admitted before the EDs had had an opportunity to make any changes. Thus, the present results may underestimat e the degree of actual improvement in patient care that resulted. Although many evidence-based guidelines have been promulgated prom·ul·gate tr.v. prom·ul·gat·ed, prom·ul·gat·ing, prom·ul·gates 1. To make known (a decree, for example) by public declaration; announce officially. See Synonyms at announce. 2. , their full impact on general medical care is yet to be fully realized. Methods of ensuring physician awareness and adherence to recommendations continue to be elucidated. (6) The combination of providing hospital ED staff with knowledge of the best practices for the emergency treatment of stroke, coupled with the knowledge that future practice would be monitored, seemed in this study to be capable of effecting clinically important and statistically significant changes in the care provided to stroke patients. In this study, each facility was free to make structural, systemic, or process changes in any way desired, and there was great heterogeneity het·er·o·ge·ne·i·ty n. The quality or state of being heterogeneous. heterogeneity the state of being heterogeneous. in facility-specific interventions. Thus, it is not certain that the results seen were due to any particular facility-level intervention. Hospital EDs often made structural, systemic, or procedural changes (eg, changes in standing orders, critical pathways, physical facilities) to improve performance, and physician knowledge that the results would be monitored may not have been the major motivation for improvement. Instead, the favorable results may be attributable to the facilities' providing an environment in which staff were committed to and supportive of changes in practice. Other studies have shown that concerted efforts to improve guideline compliance can elicit a favorable response from ED physicians, independent of their attitudes toward guidelines in general, (8) and that the provision of feedback alone to practitioners can improve stroke management. (9) Although no explicit survey of ED staff attitudes was conducted in this study, informal responses indicated a favorable opinion of the process on the part of hospital staff, and it is likely that this also played a major role in the improvements seen. These results would then be consistent with those of Solberg et al, (10) whose poll of leaders in clinical guideline implementation found that the external environment of medical practice and the organizational capabilities for change were major factors in guideline compliance, as much as or more than the guideline content itself. The present study of the early management of acute stroke suggests that providing emergency room physicians and facilities with information on their performance can lead to a commitment to improve the environment of care and to increase compliance with acute stroke guidelines. Knowing and following these guidelines are crucial to improving the outcome of stroke. Disclaimer The analyses on which this publication is based were performed under Contract 500-96-P710, titled "Utilization and Quality Control Peer Review Organization for the State of Florida," sponsored by the Health Care Financing Administration Health Care Financing Administration, n.pr department in the U.S. agency of Health and Human Services responsible for the oversight of the Medicaid and Medicare benefit programs, including guidelines, payment, and coverage policies. , U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979 Health and Human Services, HHS . The content of this publication does not necessarily reflect the views or policies of the U.S. Department of Health and Human Services, and the mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Health Care Financing Administration, which has encouraged the identification of quality improvement projects derived from analysis of patterns of care, and therefore no special funding on the part of this contractor was required.
Table 1
Patient characteristics (a)
Before
intervention Follow-up
Characteristic (n = 1,019) (n = 684)
Median age (yr) 78.5 80.0
Men (%) 45.5% 39.6%
Arrived via EMS (%) 68.5% 62.0%
Principal diagnosis of hemorrhagic 12.4% 15.8%
stroke (%)
History of hypertension (%) 47.5% 50.4%
Stroke history (%) 29.8% 29.5%
TIA history (%) 9.2% 11.5%
Atrial fibrillation history (%) 10.1% 14.5%
Atrial fibrillation on 18.1% 14.3%
electrocardiogram at admission (%)
Systolic BP >220 or mean BP >130 (%) 23.1% 23.5%
(a) EMS, emergency medical system
TIA, transient ischemic attack
BP, blood pressure.
Table 2
Quality indicators (a)
Before intervention Follow-up
Quality indicator (95% CI) (95% CI)
QI1: Percentage of presenting 11.9% 21.5%
patients with three or more BP (10.0%, 14.0%) (18.5%, 24.8%)
measurements n = 1,019 (c) n = 684
[less than or equal to]30 minutes
after presentation.
QI2: Percentage of treated patients 13.4% 19.6%
with three or more BP measurements (8.7%, 19.4%) (12.2%, 28.9%)
[less than or equal to]30 minutes n = 172 n = 97
after first antihypertensive
treatment.
QI3: Percentage of patients with 42.7% 43.0%
systolic BP >220 mm Hg or mean BP (36.3%, 49.2%) (35.2%, 51.1%)
>130 mm Hg who were treated for n = 239 n = 158
hypertension.
QI4: Percentage of all patients who 65.8% 80.1%
had an initial brain imaging study (62.7%, 68.7%) (76.9%, 83.0%)
(CT/MRI) [less than or equal to]2 n = 1,019 n = 684
hours after presentation.
QI5: Percentage of patients who 75.9% 78.9%
underwent cardiac monitoring in (73.1%, 78.5%) (75.7%, 81.9%)
the ED. n = 1,019 n = 684
QI6: Percentage of patients treated 68.0% 93.8%
for hypertension who did not (60.5%, 74.9%) (87.0%, 97.7%)
receive calcium channel blockers n = 172 n = 97
(sublingual or oral) in the ED.
Odds ratio (b)
Quality indicator (95% CI)
QI1: Percentage of presenting 2.28
patients with three or more BP (1.74, 2.98)
measurements P = 0.001 (d)
[less than or equal to]30 minutes
after presentation.
QI2: Percentage of treated patients 1.91
with three or more BP measurements (0.86, 4.24)
[less than or equal to]30 minutes P = 0.110
after first antihypertensive
treatment.
QI3: Percentage of patients with 0.96
systolic BP >220 mm Hg or mean BP (0.62, 1.49)
>130 mm Hg who were treated for P = 0.870
hypertension.
QI4: Percentage of all patients who 2.08
had an initial brain imaging study (1.66, 2.62)
(CT/MRI) [less than or equal to]2 P = 0.001
hours after presentation.
QI5: Percentage of patients who 1.26
underwent cardiac monitoring in (0.99, 1.61)
the ED. P = 0.060
QI6: Percentage of patients treated 8.62
for hypertension who did not (3.39, 22.22)
receive calcium channel blockers P = 0.001
(sublingual or oral) in the ED.
(a) QI, quality indicator
CI, confidence interval
BP, blood pressure
CT, computed tomography
MRI, magnetic resonance imaging
ED, emergency department.
(b) Mantel-Haenzel common odds ratio.
(c) Number of observations.
(d) P value.
Accepted April 9, 2002. References (1.) Bonita Bonita (Spanish and Portuguese for "beautiful") is the name of:
lan·cet n. 1992;339:342-344. (2.) Adams HP Jr, Brott TG, Crowell RM, et al. Guidelines for the management of patients with acute ischemic stroke: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Circulation 1994;90:1588-1601. (3.) Florida Agency for Health Care Administration. Universe of Florida Patients with Acute Ischemic Brain Attack. Tallahassee, State of Florida Agency for Health Care Administration, June 1997. (4.) Working Group on Emergency Brain Resuscitation resuscitation /re·sus·ci·ta·tion/ (-sus?i-ta´shun) restoration to life of one apparently dead. cardiopulmonary resuscitation . Emergency brain resuscitation: A Working Group on Emergency Brain Resuscitation. Ann Intern intern /in·tern/ (in´tern) a medical graduate serving in a hospital preparatory to being licensed to practice medicine. in·tern or in·terne n. Med 1995;122:622-627. (5.) Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Guidelines for cardiopulmonary resuscitation cardiopulmonary resuscitation (CPR), emergency procedure used to treat victims of cardiac and respiratory arrest. CPR can be done in a hospital with drugs and special equipment or as a first-aid technique. and emergency cardiac care: Part IV--Special resuscitation situations. JAMA JAMA abbr. Journal of the American Medical Association 1992;268:2242-2250. (6.) Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines clinical practice guidelines Clinical policies, practice guidelines, practice parameters, practice policies Medtalk Systematically developed statements to assist practitioner and Pt decisions about appropriate health care for specific clinical circumstances. See Psychology. ? A framework for improvement. JAMA 1999;282:1458-1465. (7.) Jencks SF, Wilensky GR. The health care quality improvement initiative: A new approach to quality assurance in Medicare. JAMA 1992;268:900-903. (8.) Halm EA, Atlas SJ, Borowsky LH, Benzer TI, Singer DE. Change in physician knowledge and attitudes after implementation of a pneumonia practice guideline. J Gen Intern Med 1999;14:688-694. (9.) Newell SD Jr, Englert J, Box-Taylor A, Davis KM, Koch KE. Clinical efficiency tools improve stroke management in a rural southern health system. Stroke 1998;29:1092-1098. (10.) Solberg LI, Brekke ML, Fazio CJ, et al. Lessons from experienced guideline implementers: Attend to many factors and use multiple strategies. Jt Comm See comms. J Qual Improv 2000;26:171-188. RELATED ARTICLE: Key Points * The Florida Medicare peer review organization collaborated with 32 acute care hospitals statewide to determine how closely current guidelines for emergent emergent /emer·gent/ (e-mer´jent) 1. coming out from a cavity or other part. 2. pertaining to an emergency. emergent 1. coming out from a cavity or other part. 2. coming on suddenly. treatment of stroke were being followed and to improve compliance with the guidelines. * Medical record reviews of stroke patients focused on six quality indicators based on American Heart Association guidelines and the Florida Agency for Health Care Administration guidelines for the management of patients with acute ischemic stroke. * Six months after hospitals received their results and implemented interventions, medical records of stroke patients were reviewed. From Florida Medical Quality Assurance, Inc., Tampa, FL. Supported by the Health Care Financing Administration, U.S. Department of Health and Human Services. Reprint reprint An individually bound copy of an article in a journal or science communication requests to Ferdinand Richards III, MD, Florida Medical Quality Assurance, Inc., 4350 W. Cypress Street, Suite 900, Tampa, FL 336074151. Email: frichards@SDPS SDPS Society for Design and Process Science SDPS Science Data Processing Segment (NASA) SDPS Standard Data Processing System SDPS Surface Deformation Prediction System (mining) .org Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9601-0023 |
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