TOTAL QUALITY IMPROVEMENT METHOD FOR REDUCTION OF DELAYS BETWEEN EMERGENCY DEPARTMENT ADMISSION AND TREATMENT OF ACUTE ISCHEMIC STROKE

Objective: To develop an approach for reducing time between emergency department (ED) admission and treatment in patients with acute ischemi c stroke to meet the challenge of providing tissue plasminogen activat or treatment within 180 minutes. Design: An observational study. Setti ng: Forty trial-affiliated hospitals, including 30 community hospitals . Participants: A total of 17324 consecutive patients admitted to tria l-affiliated hospital EDs within 24 hours Of possible stroke, from Jan uary 1991 through October 1993. Intervention: Appraisal of the process of triage, evaluation, diagnosis, and treatment by means of total qua lity improvement techniques in each hospital. Staff participating in t he process identified sources of variation and modifications by flow c harting the process. Main Outcome Measure: Time between ED admission a nd treatment with study medication. Results: Total quality-improvement methods identified hospital-specific process improvements. Many impro vements were administrative, requiring no additional resources. More t han 50% of screened patients arrived too late to be treated. Only 1268 patients were admitted between 0 and 125 minutes from stroke onset wi th no other trial exclusion criteria; 48% were treated. Of 243 patient s admitted between 126 and 170 minutes from stroke onset with no exclu sion criteria, 4% were treated. Mean time from ED admission to treatme nt was similar in teaching and community hospitals. Conclusions:: Tota l quality improvement methods identified ED-specific sources of proces s variability and reduced time between ED admission and treatment. The refore, these methods should be considered in developing and monitorin g emergent stroke treatment protocols.