Standardized guidelines improve outcomes in stroke care

By Vanessa deGier

Cover of the 8-9-05 issue of Neurology -----

Patients suffering from a stroke are more likely to have improved outcomes and fewer complications when hospitals use standardized guidelines for stroke care during a patient’s admission and discharge from the hospital, according to a study led by researchers at UCSF Medical Center. The study results appear in the August 9 issue of Neurology. 

“There are several treatments for the most common form of stroke, which is ischemic stroke, and these have been proven to reduce disability and complications,” said lead author S. Claiborne Johnston, MD, PhD, director of the stroke service at UCSF Medical Center. “Yet in spite of these recommendations, the interventions are often under-utilized at hospitals.” 

In an effort to increase the use of these treatments, UCSF Medical Center and five other hospitals in California collaborated to create standardized stroke care guidelines. The guidelines include a list of recommended therapies at the time of hospital admission and discharge, as well as a hand-out with key follow-up information when the patient leaves the hospital. The hand-out is specific for each patient and is designed as a document for the patient to provide at the first doctor visit after discharge. It includes information on discharge diagnosis, discharge medications received (including dosage and frequency), life style changes to reduce risk factors for a second stroke, and directives for follow-up labs and appointments.

The researchers compared treatment before and after implementation of the standardized guidelines, tracking six specific interventions associated with quality stroke care.  The interventions are administration of the anticlotting drug tPA (tissue plasminogen activator) within three hours of the onset of stroke symptoms, receipt of additional anticlotting medications within 48 hours of arrival in the emergency department, documentation of preventive treatment for DVT (deep venous thrombosis, or blood clots in the leg) by the second hospital day, smoking cessation counseling prior to discharge, receipt of cholesterol-lowering medication at discharge, and receipt of anticlotting medications at discharge.

Results showed patients were more likely to receive optimal treatment after the standardized guidelines were implemented, with rates improved significantly in four of the six treatment areas: administration of preventive treatment for DVT, cholesterol-lowering medications at discharge, anticlotting medications within 48 hours of arrival in the emergency department, and anticlotting medications at discharge. Optimal treatment was defined as receiving all of the six therapies unless there was a reason to not give a particular treatment.

The study included a total of 413 patients with a discharge diagnosis of ischemic stroke, characterized by a blockage of blood flow to the brain. The researchers compared rates of treatment in year one, which served as the baseline, to those in year two, after implementation of the standardized stroke care guidelines. In year two, 63 percent of patients received an optimal score compared to 44 percent of patients in year one. 

A seventh hospital originally participated in the study but never implemented the standardized guidelines due to an administrative delay.  Data from this institution showed no change in the percentage of patients who received optimal treatment.

“Clearly, this study demonstrates that it is feasible to significantly improve stroke care,” added Johnston. “It is vital that we continue to work on creating a nexus in which quality improvement is discussed, encouraged and implemented.”

The study was supported by the Centers for Disease Control and Prevention. Patient data was obtained through the Coverdell Acute Stroke Pilot Registry in California. The prospective registry was designed to help identify priorities for quality improvement. Its data includes all patients diagnosed with a suspected stroke or TIA (mini stroke), at admission or discharge, who were admitted to one of seven medical institutions in California, including UCSF Medical Center.