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CLEVELAND ACUTE STROKE EXPERIENCE

This article examines the Cleveland Acute Stroke Experience and its impact on stroke care quality. It highlights the systematic data collection initiated in 1991, emphasizing the role of IV tPA in ischemic stroke treatment from 1996 onwards. The Cleveland Health Quality Choice program and Cuyahoga County's Operation Stroke initiatives illustrate the challenges and successes in improving stroke care, addressing barriers, protocol deviations, and training needs. Key data from various studies reveal trends in treatment utilization and outcomes, showcasing the benefits of quality improvement in stroke management across community hospitals.

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CLEVELAND ACUTE STROKE EXPERIENCE

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  1. CLEVELAND ACUTE STROKE EXPERIENCE • Cleveland Health Quality Choice • stroke data collected by trained abstractors since 1991 • IV tPA datapoints added 1996 • disbanded 1998 • Cuyahoga County Operation Stroke 1999 • data collection instrument designed by the Medical Committee and The Stroke Group (ETHOSR) • grants from Genentech/Astra Zeneca • Cleveland Clinic Health System Stroke QI Program • presented to JCAHO 4/01

  2. Cleveland Health Quality ChoiceIV tPA Utilization: Ischemic StrokesJuly 1997 - June 1998 n=70 tPA1.8% n=4275 No tPA 98.2% Katzan IL etal. JAMA 2000;283:1151

  3. Cleveland Health Quality Choice IV tPA Utilization by HospitalJuly 1997 - June 1998 N = 27 (N = 70) Katzan IL etal. JAMA 2000;283:1151

  4. Cleveland Health Quality ChoiceIV tPASymptomatic Intracranial Hemorrhage (ICH)July 1997 - June 1998 Symptomatic ICH 15.7%* n = 11 n = 59 * 95% CI 8.1% - 26.4% Katzan IL etal. JAMA 2000;283:1151

  5. Cleveland Health Quality Choice IV tPA: Identified Protocol DeviationsJuly 1997 - June 1998 Deviations in 50% High Blood Pressure12.5% Beyond Time Window 22.5% Antithrombotics < 24hr 65% Katzan IL etal. JAMA 2000;283:1151

  6. Intracranial Hemorrhage after IV tPA

  7. Connecticut IV tPA experience(Bravata DM etal. Arch Intern Med 2002;162:1994) • Retrospective cohort of 16 community based hospitals 5/96-12/98 • 67% (42/63) major protocol deviations • dosing errors • >3 hours • known increased bleeding risk (eg low platelets) • Serious extracranial hemorrhage 17% (NINDS 2%) • In-hospital mortality 31% (NINDS 13%)

  8. Cuyahoga County Operation StrokeDoor to Doctor (N=692) (N=65) (N=224) (N=253) (N=65) (N=101) (N=59) 1/00 - 3/01 Katzan IL etal. Stroke 2003 in press

  9. Cuyahoga County Operation StrokeTime to Initiation of CT (N=671) (N=56) (N=241) (N=262) (N=53) (N=78) (N=58) 1/00 - 3/01 Katzan IL etal. Stroke 2003 in press

  10. Cuyahoga County Operation Stroke Center line = median, box=25-75% quartiles, whiskers=1.5x interquartile range Katzan IL etal. Stroke 2003 in press

  11. Cleveland Clinic Health SystemStroke Quality Improvement ProgramSymptomatic Intracranial Hemorrhage Symptomatic ICH 13.8%* No symptomatic ICH 86.2% n=4 n=25 *95% CI = 5.5% - 30.6% 7/97-6/98 CHQC

  12. CLEVELAND ACUTE STROKE EXPERIENCE • Stroke QI requires data • quality of data varies (many hospitals = no data) • multiple barriers must be overcome (behavioral, political, resources) • team building through trust building • Performance varies widely across hospitals • physicians and hospitals may not like their data • outliers may not mean bad care • community effectiveness may differ from NINDS efficacy • Protocol deviations are very common • linked with bad outcomes • Data can change behavior and improve stroke care • community performance improves over time with systematic QI • Community hospitals can & should give IV tPA IF they are able to demonstrate they know how

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