Mo. stroke center surpasses benchmarks with systems approach

Saint Luke’s Neuroscience Institute (SLNI) bested national benchmarks in stroke care, including CT imaging and tissue plasminogen activator (tPA) use, after employing a systems approach to all aspects of stroke treatment, according to an article published online Nov. 13 in Stroke.

Despite the availability of tPA to treat acute ischemic stroke since 1996, its use remains low, and hovered between 3.4 percent to 5.2 percent in 2009. Since developing a dedicated stroke center in 1993, SLNI in Kansas City, Mo., has employed a comprehensive systems approach to stroke treatment.  

Marilyn M. Rymer, MD, neurologist at SLNI, and colleagues sought to compare access and outcomes at SLNI with three national databases. The researchers focused on 1,576 ischemic stroke patients treated at SLNI in 2005, 2007 and 2010; 423,809 stroke patients in the Get With the Guidelines (GWTG) Database; 91,598 stroke patients in the Premier database of community hospitals and 966 patients in the Merci Registry who were ineligible for or did not have success with tPA.

Rymer and colleagues observed differential access to CT imaging and stroke intervention between SLNI and the comparison databases. A total of 99.4 percent of SLNI patients underwent a CT scan of the head. The corresponding rate for Premier patients was 58.6 percent. CT is “critical" to an accurate diagnosis of ischemic stroke, according to the researchers, who hypothesized that lower rates at other hospitals may be related to late presentation, incorrect early diagnosis and lack of technology or personnel.

The use of tPA within 4.5 hours of stroke onset at SLNI increased from 13.6 percent in 2005 to 28.5 percent in 2010. For GTWG patients, the rate increased from 4 percent in 2005 to 6.8 percent in 2010.

“This study illustrates that incremental changes within an existing system can produce meaningful improvements in access and outcomes for cases of acute ischemic stroke, the leading cause of adult disability,” wrote Rymer et al. The researchers credited the improved outcomes to multiple factors, including:

  • 24/7 availability of neurologists, neurointerventionalists and neuro-critical care nursing;
  • Timely CT scanning and lab reports;
  • 30-minute catheterization lab staff response time;
  • Biplane technology;
  • Focused education and communication for referring emergency department staffs;
  • A streamlined transfer process with one telephone number and immediate access to stroke staff; and
  • Standardized order sets and care paths based on American Stroke Association guidelines.

The researchers noted that the SLNI model is replicable and could result in substantial improvement in stroke treatment in the U.S., which would, in turn, translate into substantial economic impacts.