Hospitals also have KPIs? Improve the quality of intravenous thrombolysis for stroke, and do the same!

Comprehensively assess and improve the quality of AIS intravenous thrombolytic care and improve the functional prognosis
of patients.

Stroke is one of the main diseases leading to human disability and death, with the aging of the population, stroke has now jumped to the first cause of death and adult disability in China, of which ischemic stroke (AIS) accounts for more than 80% of all strokes ^[1].

The key to AIS treatment is to start reperfusion therapy as early as possible to save the ischemic semi-dark zone
.

In order to strengthen the public's understanding of stroke and mobilize the forces of all walks of life to prevent and treat stroke, the World Stroke Organization established World Stroke Day, October 29 this year is the 17th World Stroke Day, but China's AIS intravenous thrombolytic treatment rate is still far behind other developed countries in the world, so it is urgent to carry out further medical quality improvement work, in order to achieve a more scientific, more standardized, more reasonable and effective intravenous thrombolytic treatment goal
.

What are the data of AIS intravenous thrombolysis in the real world?

The National Institute of Neurological Disorders and Stroke (NINDS) research and the European Acute Stroke Collaborative Study (ECASS) III have been published successively, laying an evidence-based evidence base
for intravenous thrombolytic therapy.
Domestic and foreign guidelines for the acute treatment of stroke recommend intravenous thrombolytic therapy to patients with AIS within 4.
5 hours of onset if there is no contraindication ^[1].

In 1994, Switzerland established Riksstroke, the world's first national stroke registry, followed by similar projects
in Europe, Australia and Canada 。 In 2003, the American Heart Association/American Stroke Society (AHA/ASA) launched a disease management project called "Follow the Guidelines - Stroke (GWTG-Stroke)", in which "Target: Stroke" is a sub-project of GWTG-Stroke with the main purpose of improving the quality of AIS reperfusion therapy; In addition, the "Bridging the Gap - Stroke (CTGS)" project conducted by the National Center for Cardiovascular and Cerebrovascular Diseases in Japan counted the diagnosis and treatment data of AIS patients receiving reperfusion therapy in Japan from 2013 to 2017 ^[2-4].

Since 2002, China has carried out prospective case registration studies
for stroke in Chengdu, Nanjing and other regions.
In 2007, the Chinese Stroke Registry Study (CNSR), a national prospective registry study for hospitalized patients with acute cerebrovascular events, was launched, and data from three phases: CNSR-I.
, CNSR-II, and CNSR-III.
have been released ^[1,5,6].

At present, data from AIS Thrombolytic Application and Monitoring (TIMS-China) and China Stroke Center Alliance (CSCA) have also been released
.
These registry studies provide valuable data support
for the clinical practice and scientific research of AIS.

Table 1: Summary of key medical quality evaluation indicators of AIS intravenous thrombolysis at home and abroad

Table note: QI: quality evaluation index; IVT: the table refers to the rate of intravenous thrombolytic therapy in AIS patients with indications for intravenous thrombolysis; DNT: arrival to time of administration; sICH: incidence of symptomatic intracranial hemorrhage after intravenous thrombolysis; mRS: Modified Rankin scale, mRS 0~1 score or 0~2 points are mostly used in studies as the evaluation criteria for good prognosis of intravenous thrombolysis, and this percentage is the proportion of this type of patient population

Comparing domestic and foreign data, it can be found that there is still a big gap between China and foreign developed countries in evaluating the key indicators of AIS intravenous thrombolytic medical services, such as intravenous thrombolytic treatment rate, DNT time, DNT less than 60min and 45min patient ratio
.
To this end, experts from China's National Medical Quality Control Center for Neurological Diseases and the Chinese Stroke Society recommended the target value of intravenous thrombolytic therapy for AIS in the future ^[1].

Looking at the current recommended AIS intravenous thrombolytic therapy target value in China, has your KPI been completed this year?

• The basic target value of intravenous thrombolysis rate is not less than 50%, and the advanced target value is not less than 70%.
  
  

• The proportion of the basic target value of DNT <60min exceeds 50%, and the proportion of advanced target value DNT<45min exceeds 50%.
  <b10>

• The target incidence of symptomatic intracranial hemorrhage (ECASS-II criteria) after intravenous thrombolysis in AIS is less than 5%.
  
  

• The target value of the prognosis of 90-day good neurological function (mRS 0~1 points) in patients treated with intravenous thrombolysis is not less than 50%.
  
  

After understanding the real-world treatment data of AIS intravenous thrombolysis and determining the relevant treatment target values, how to reasonably and effectively achieve the goals has become a problem
that clinicians, researchers and medical administrators need to consider.
Quality improvement studies can highlight current gaps in health care and provide strategies and feasible measures
to close these gaps.

The medical quality of intravenous thrombolytic therapy has improved, and there is still much to be done in the future

In recent years, a series of research
on improving the quality of medical services in the field of AIS has been carried out at home and abroad.
For example, in the Target: Stroke project in the United States, through organized stroke team building, the application of the core 10 "best clinical practice" interventions, and continuous data monitoring and feedback, the level of in-hospital treatment of AIS has been continuously improved, and finally the DNT has been significantly shortened, so that more AIS patients have received timely treatment and thus avoided death and disability ^[3].

In the Japanese CTGS project, the proportion of DNT < 60min in AIS patients was significantly increased by continuously optimizing the quality evaluation index <b13>[4].

Fig.
1 Stroke quality improvement steps [2].

IN 2014, THE "GOLDEN BRIDGE-AIS" STUDY IN CHINA USED A CLUSTER-RANDOMIZED CONTROLLED DESIGN TO EVALUATE THE IMPACT OF MEDICAL SERVICE QUALITY IMPROVEMENT ON PHYSICIANS' COMPLIANCE WITH GUIDELINES AND PATIENT PROGNOSIS, AND FOUND THAT THE RECURRENCE RATE AND DISABILITY RATE OF AIS PATIENTS CAN BE SIGNIFICANTLY REDUCED THROUGH MULTIPLE INTERVENTION METHODS AND THE APPLICATION OF CONTINUOUS MONITORING AND IMPROVEMENT OF INFORMATION PLATFORMS ^[7].

In 2016, a theory-based resource integration project was launched at the Advanced Stroke Center of Wuhan First Hospital, in which a total of 18 interventions for the healthcare environment were implemented in a one-year intravenous thrombolytic medical quality improvement project, which significantly reduced DNT time and patient hospital stay, and significantly increased intravenous thrombolysis rates within 30, 45, and 60 minutes ^[8].

Fig.
2 Conceptual framework of AIS intravenous thrombolysis quality improvement project [8].

Note: The framework includes two dimensions of resource integration strategies, including operational resource integration and object resource integration, and the intravenous thrombolytic therapy process (including identification and emergency transport phases, triage and initial diagnosis, imaging, and thrombolysis management).

After mastering the process and results of the research on medical service quality improvement at home and abroad, domestic experts summarized a number of core suggestions for improving the quality of intravenous thrombolytic therapy based on China's national conditions, most of which are the core standards for the construction of stroke centers and comprehensive stroke centers, and are also the key links in the quality improvement of
AIS intravenous thrombolytic therapy.

How to improve the quality of intravenous thrombolytic diagnosis and treatment in AIS? Here comes the practical advice ^[1]:

• Establish a good regional emergency coordination mechanism
  for the 120/999 pre-hospital emergency team to notify the hospital in advance.
  

• Develop and use a stroke first aid green channel workbook
  .
  

• Prompt triage and prompt notification to the reperfusion treatment emergency team
  .
  

• Establish a one-click start green channel call system
  .
  

• Set up the post
  of stroke green channel guide.
  

• Establish a priority system for stroke patients and quickly complete brain imaging and laboratory tests
  .
  

• Set up a nearby thrombolytic treatment room, quickly obtain the informed consent of patients or their families, and quickly administer intravenous thrombolytic drugs
  .
  

• Establish a complete time recording system
  .
  

• Establish a data registration system
  for periodic feedback.
  

• Establish a regular quality control meeting system
  for continuous improvement.
  

prospect

At present, there is a large gap between AIS intravenous thrombolytic therapy rates in China in different medical institutions and regions, and there is a certain gap compared with foreign developed countries, and there are relatively few studies on the improvement of medical quality of AIS intravenous thrombolytic therapy supported by evidence-based evidence in China, but the concept of medical quality management has been deeply rooted in the hearts of the people, and medical institutions have consciously and spontaneously promoted the continuous improvement
of AIS intravenous thrombolytic therapy medical quality in clinical practice 。 When the relevant clinical evidence is strong enough, it should be actively promoted to clinical practice under the framework of quality management, so as to achieve the quality and homogenization of the medical quality of AIS intravenous thrombolytic therapy, improve the prognosis of patients, and benefit more patients
.