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Barbara C. Tilley, PhD; Patrick D. Lyden, MD; Thomas G. Brott, MD; Mei Lu, PhD; Steven R. Levine, MD; K. M. A. Welch, MD; National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group

Arch Neurol. 1997;54(12):1466-1474.

Abstract
Objective
To develop an approach for reducing time between emergency department (ED) admission and treatment in patients with acute ischemic stroke to meet the challenge of providing tissue plasminogen activator treatment within 180 minutes.

Design
An observational study.

Setting
Forty trial-affiliated hospitals, including 30 community hospitals.

Participants
A total of 17324 consecutive patients admitted to trial-affiliated hospital EDs within 24 hours of possible stroke, from January 1991 through October 1994.

Intervention
Appraisal of the process of triage, evaluation, diagnosis, and treatment by means of total quality improvement techniques in each hospital. Staff participating in the process identified sources of variation and modifications by flow charting the process.

Main Outcome Measure
Time between ED admission and treatment with study medication.

Results
Total quality improvement methods identified hospital-specific process improvements. Many improvements were administrative, requiring no additional resources. More than 50% of screened patients arrived too late to be treated. Only 1268 patients were admitted between 0 and 125 minutes from stroke onset with no other trial exclusion criteria; 48% were treated. Of 243 patients admitted between 126 and 170 minutes from stroke onset with no exclusion criteria, 4% were treated. Mean time from ED admission to treatment was similar in teaching and community hospitals.

Conclusions
Total quality improvement methods identified ED-specific sources of process variability and reduced time between ED admission and treatment. Therefore, these methods should be considered in developing and monitoring emergent stroke treatment protocols.

Author Affiliations
From the Division of Biostatistics and Research Epidemiology, Henry Ford Health Sciences Center, Detroit Campus of Case Western Reserve University, Detroit, Mich (Drs Tilley and Lu); Department of Neurology, Henry Ford Hospital, Detroit (Drs Levine and Welch); Department of Neurosciences, University of California, San Diego (Dr Lyden); and Department of Neurology, University of Cincinnati, Cincinnati, Ohio (Dr Brott). Members of the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group are listed in the box on page 1473.

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