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Inicio Neurología (English Edition) A set of care quality indicators for stroke management
Journal Information
Vol. 34. Issue 8.
Pages 497-502 (October 2019)
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106
Vol. 34. Issue 8.
Pages 497-502 (October 2019)
Original article
DOI: 10.1016/j.nrleng.2017.04.003
Open Access
A set of care quality indicators for stroke management
Conjunto de indicadores de calidad asistencial en el abordaje del ictus
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106
I.M. Navarro Solera,
Corresponding author
inavarro@umh.es

Corresponding author.
, E. Ignacio Garcíab, J. Masjuan Vallejoc, J. Gállego Culleréd, J.J. Mira Solvesa,e,f
a Calité Investigación, Universidad Miguel Hernández, Elche, Alicante, Spain
b Escuela Universitaria de Enfermería y Fisioterapia, Universidad de Cádiz, Cádiz, Spain
c Servicio de Neurología, Hospital Universitario Ramón y Cajal, Madrid, Spain
d Servicio de Neurología, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
e Departamento de Salud Alicante-Sant Joan, Alicante, Spain
f REDISEC, Red de Servicios de Salud Orientados a Enfermedades Crónicas, Madrid, Spain
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Article information
Abstract
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Tables (3)
Table 1. Control indicators.
Table 2. Process indicators.
Table 3. List of outcome indicators.
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Abstract
Objective

This study proposes a set of quality indicators for care outcomes in patients with acute cerebral infarction. These indicators are understandable and relevant from a clinical viewpoint, as well as being acceptable and feasible in terms of time required, ease of data capture, and interpretability.

Method

The method consisted of reaching consensus among doctors after having reviewed the literature on quality indicators in stroke. We then designed and conducted a field study to assess the understandability and feasibility of the set of indicators.

Results

Consensus yielded 8 structural indicators, 5 process indicators, and 12 result indicators. Additionally, standards of reference were established for each indicator.

Conclusion

This set of indicators can be used to monitor the quality care for stroke patients, identify strengths, and potentially to identify areas needing improvement.

Keywords:
Patient-centred care
Emergencies
Care quality
Consensus
Stroke
Quality indicators
Resumen
Objetivo

Mediante este estudio se propone un conjunto de indicadores de calidad del resultado en la atención con infarto cerebral agudo. El conjunto de indicadores se caracteriza por ser comprensible, relevante desde el punto de vista clínico-asistencial, aceptable y factible en términos de tiempos de dedicación, facilidad de captura del dato y sencillez de su interpretación.

Método

Tras la revisión de la literatura sobre indicadores de calidad en ictus, se llevó a cabo una metodología de consenso entre profesionales. Posteriormente, se diseñó y ejecutó un estudio de campo para valorar su comprensión y factibilidad.

Resultados

Se han consensuado 8 indicadores de estructura, 5 de proceso y 12 de resultado. Además, se han establecido estándares de referencia para cada uno.

Conclusión

Este conjunto de indicadores permite monitorizar el nivel de calidad de la atención sanitaria, identifican fortalezas y posibilita la identificación de áreas de mejora en la atención a los pacientes con ictus.

Palabras clave:
Atención centrada en el paciente
Atención urgente
Calidad asistencial
Consenso
Ictus
Indicadores de calidad
Full Text
Introduction

The Spanish National Health System's stroke care strategy and the national stroke care plan of the Spanish Society of Neurology's Stroke Study Group have established an organisational model for emergency stroke care.

The effectiveness of reperfusion treatments1–3 is influenced by the narrow risk/benefit margin ( < 4.5h for intravenous fibrinolysis and < 6h for endovascular treatment), requiring reorganisation of healthcare resources and circuits in order to provide care as soon as possible. Code stroke activation has been demonstrated to increase the number of patients benefiting from these specific treatments, since it reduces latency times for in-hospital and pre-hospital care.

In Spain, the QUICK project4 assessed whether response times (from symptom onset to the therapeutic decision in hospitals with a stroke unit) corresponded with those recommended in clinical practice guidelines. The PRACTIC study5 analysed the impact of the specialised neurological care provided by stroke teams or units in reducing mortality rates, in-hospital complications, and the percentage of patients with disability.

Hospitals in the different regional healthcare services vary greatly in the capacity to respond to new stroke cases; place of residence, more than distance to a healthcare centre, conditions access to adequate specialised treatment. For this reason, most care quality indicators for stroke management have focused on process.6–8 In this study, we propose a set of care quality indicators for acute stroke management, which are intended to be understandable and relevant from clinical and healthcare perspectives and acceptable and viable in terms of dedication time; our proposal includes a simple procedure for data collection and interpretation.

Methods

This study establishes a series of care quality indicators based on the consensus of neurology and healthcare quality specialists. The study was performed from May 2015 to July 2016.

In our study, stroke units are defined as non-intensive acute care units, with a limited number of beds on the neurology ward or pertaining to the neurology department, attending patients with acute stroke exclusively. This management should follow a protocol with pre-established criteria for admission and a specific system for diagnosis and treatment.

Process and outcome indicators were identified in a review of articles published in Spanish and English in the previous 5 years. We used the open-access search engine on the MEDLINE database, with the search terms indicator, stroke, quality assurance, and quality assessment, and combinations thereof. Researchers IN, JJM, and JM selected the articles relevant to the study, and from this selection we drafted an exhaustive list of indicators used in previous studies. From this list, consensus panel members eliminated duplicate articles and ruled out or proposed quality indicators to establish a control panel for these stroke units. In a final session, we agreed a draft set of control, process, and outcome indicators.

Seven neurologists from 6 hospitals subsequently analysed the feasibility (in terms of viability of data recording from current information systems) and the clinical significance of these indicators. Lastly, we conducted a field study to verify the reliability of data in clinical practice, based on the definitions and formulae established for each indicator. For each indicator, we specified: definition, the formula for calculating its value, type of indicator, and acceptable target level (standard).

This study was approved by the research ethics committee of the Universidad Miguel Hernández de Elche (report reference DPF.JJM.03.15).

Results

We identified indicators by analysing the titles and abstracts of 48 articles considered potentially relevant. We selected 15 articles, which were the basis for the draft set of indicators to establish a control panel for the monitoring of stroke care quality.

After a debate between working group members, we proposed a series of 8 indicators for control, 5 for process, and 12 for outcome.

Field work enabled us to verify understanding of the definitions and the feasibility of codifying data for the calculation of indicators. This also enabled us to establish reference standards. Tables 1–3 detail the working definition, formula, and reference standard for each process and outcome indicator included in the control panel.

Table 1.

Control indicators.

Definition  Neurologist availability 
Calculation  On-site or on-call neurologist (night and weekend) to take responsibility for the patient after the admission (yes/no) 
Reference standard  100% 
Definition  Nurse ratio 
Calculation  Total number of nurses at the ward where the patient is admitted (neurology or internal medicine), including all shifts/total number of beds in the ward 
Reference standard  0.2 
Definition  Stroke care protocol 
Calculation  Existence of a stroke care protocol, approved by the centre and updated in the 3 previous years (yes/no) 
Reference standard  100% 
Definition  First stroke event 
Calculation  Total number of patients admitted due to a first stroke event/total number of stroke patients admitted to the centre in the same period×100 
Reference standard  79%-83% 
Definition  ICU admission 
Calculation  Total number of stroke patients admitted to the ICU/total number of stroke patients admitted to the same centre×100 
Reference standard  1%-3% 
Definition  Adequate admission according to treatment 
Calculation  Total number of stroke patients meeting criteria for admission to the stroke unit/total number of stroke patients admitted to the same centre in the same period×100The following criteria are specified:− Age: older than 18− Symptom onset to hospital door: < 3 h; < 4.5h; < 6h− Baseline situation: modified Rankin Scale score ≤ 2− Focal neurological signs at the time of diagnosis: presence of any of the following symptoms suggestive of stroke:1. Numbness, weakness, or sudden paralysis of the face, arm, or leg on one side of the body2. Sudden confusion3. Difficulty speaking or understanding4. Sudden loss of vision in one or both eyes5. Intense, sudden-onset headache with no apparent cause, accompanied by nausea and vomiting (not attributable to other causes)6. Difficulty speaking, loss of balance or coordination 
Reference standard  93%-100% 
Definition  Cardiac monitoring 
Calculation  Total number of stroke patients with cardiac monitoring during admission/total number of stroke patients admitted to the same centre during the same period×100 
Reference standard  97% 
Definition  Type of treatment at discharge 
Calculation  Total number of patients admitted due to cardioembolic stroke who are following treatment with direct anticoagulant drugs or vitamin K antagonists at discharge 
Reference standard  22%-28% 
Table 2.

Process indicators.

Definition  Onset-to-door 
Calculation  Time (in minutes) from onset of the first symptoms to arrival at hospital 
Reference standard  104min 
Definition  Door-to-needle 
Calculation  Time (in minutes) from the patient's arrival at hospital to the start of intravenous thrombolytic treatment 
Reference standard  60min 
Definition  Onset-to-needle 
Calculation  Time (in minutes) from symptom onset to the start of intravenous thrombolytic treatment 
Reference standard  157min 
Definition  Door-to–CT scan 
Calculation  Time (in minutes) from the patient's arrival at hospital to the first diagnostic imaging assessment 
Reference standard  20min 
Definition  CT scan–/MRI-to-needle 
Calculation  Time (in minutes) from the first diagnostic imaging study (CT or MRI scan) to the start of intravenous thrombolytic treatment 
Reference standard  30min 
Table 3.

List of outcome indicators.

Definition  Patients treated with intravenous thrombolysis 
Calculation  Total number of stroke patients treated with intravenous thrombolysis/total number of stroke patients admitted to the same centre during the same period×100 
Reference standard  15% 
Definition  Patients treated with mechanical thrombectomy 
Calculation  Total number of stroke patients treated with mechanical thrombectomy/total number of stroke patients admitted to the same centre during the same period×100 
Reference standard  8%-10% 
Definition  Mortality 
Calculation  Total number of patient deaths due to any cause during admission/total number of stroke patients admitted to the same centre during the same period×100 
Reference standard  7% 
Definition  Complications during treatment 
Calculation  Total number of stroke patients treated with rtPA developing symptomatic complications after thrombolysis/total number of stroke patients treated with rtPA and admitted to the same centre during the same period×100 
Reference standard  4% 
Definition  Adverse events during treatment 
Calculation  Total number of stroke patients presenting symptomatic haemorrhagic transformation during intravenous thrombolysis/total number of stroke patients treated in the same centre during the same period×100 
Reference standard  3% 
Definition  Adverse effects due to nosocomial infection 
Calculation  Total number of stroke patients requiring treatment due to infection of any cause during admission/total number of stroke patients treated in the same centre during the same period×100 
Reference standard  18% 
Definition  Adverse events during treatment 
Calculation  Total number of stroke patients presenting pulmonary embolism/total number of stroke patients treated in the same centre during the same period×100 
Reference standard  <1% 
Definition  Rehabilitation 
Calculation  Total number of stroke patients who were assessed for rehabilitation treatment during the first 48h after admission/total number of stroke patients treated in the same centre during the same period×100 
Reference standard  80% 
Definition  Health education 
Calculation  Total number of stroke patients admitted for least one day who were informed verbally and in writing about self-care and treatment precautions before discharge/total number of stroke patients treated in the same centre during the same period×100 
Reference standard  95% 
Definition  Disability 
Calculation  Total number of stroke patients with mRS>2 at discharge/total number of stroke patients treated in the same centre during the same period×100 
Reference standard  ≤ 40% 
Definition  Use of resources 
Calculation  Mean stay of stroke patients. “Stay” is defined as a patient spending at least one night or 24h at hospital as an inpatient 
Reference standard  7-8 days 
Definition  Satisfaction 
Calculation  Total number of stroke patients with a mean score ≥5 on a satisfaction scale/total number of stroke patients treated in the same centre during the same period×100 
Reference standard  > 8 
Discussion

The set of control, process, and outcome indicators used in this study enable specialists to monitor the functioning of stroke units. Interpreted in their entirety, these indicators identify strengths and areas for improvement in stroke management.

This proposed control panel for characterising and assessing stroke care quality may help reorganise healthcare services and procedures as proposed by other studies.9,10

Funding

This study was funded within the framework of a collaboration agreement with Boehringer Ingelheim España, S.A.

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
M.M. Lahr, G.J. Luijckx, P.C. Vroomen, D.J. van der Zee, E. Buskens.
Proportion of patients treated with thrombolysis in a centralized versus a decentralized acute stroke care setting.
Stroke, 43 (2012), pp. 1336-1340
[2]
S. Prabhakaran, K. O’Neill, L. Stein-Spencer, J. Walter, M.J. Alberts.
Prehospital triage to primary stroke centers and rate of stroke thrombolysis.
JAMA Neurol, 70 (2013), pp. 1126-1132
[3]
A.M. Van Dishoeck, W.J. Dippel, M. Dirks, C.W. Looman, J.P. Mackenbach, E.W. Steyerberg.
Measuring quality improvement in acute ischemic stroke care: interrupted time series analysis of door-to-needle time.
Cerebrovasc Dis Extra, 4 (2014), pp. 149-155
[4]
J. Masjuán, J. Álvarez-Sabín, S. Arias-Rivas, M. Blanco, A. de Felipe, I. Escudero-Martínez, et al.
Atención urgente al ictus en hospitales con unidad de ictus Proyecto Quick.
Rev Neurol, 62 (2016), pp. 303-310
[5]
J. Álvarez-Sabín, M. Ribó, J. Masjuán, J.R. Tejada, M. Quintana, Investigadores del Estudio PRACTIC.
Importancia de una atención neurológica especializada en el manejo intrahospitalario de pacientes con ictus.
Neurología, 26 (2011), pp. 510-517
[6]
S. Abilleira, A. Ribera, E. Sánchez, J. Roquer, E. Duarte, R. Tresserras, et al.
La atención hospitalaria al paciente con ictus en Cataluña Resultados del Primer Audit Clínic de l’Ictus. Catalunya, 2005/2006.
Gac Sanit, 6 (2008), pp. 565-573
[7]
A. Ganesh, M. Camden, P. Lindsay, M.K. Kapral, R. Coté, J. Fang, et al.
The quality of treatment of hyperacute ischemic stroke in Canada: a retrospective chart audit.
CMAJ OPEN, 2 (2014), pp. E233-E239
[8]
S. Wiedmann, P.U. Heuschmann, S. Hillmann, O. Busse, H. Wiethölter, G.M. Walter, et al.
The quality of acute stroke care — an analysis of evidence-based indicators in 260 000 Patients.
Dtsch Arztebl Int, 111 (2014), pp. 759-765
[9]
J. Álvarez-Sabín, M. Ribó, J. Masjuán, J.R. Tejada, M. Quintana, Investigadores del Estudio PRACTIC.
Hospital care of stroke patients: importance of expert neurological care.
Neurologia, 26 (2011), pp. 510-517
[10]
M. Salvat-Plana, S. Abilleira, C. Jiménez, J. Marta, M. Gallofré.
Priorización de indicadores de calidad de la atención al paciente con ictus a partir de un método de consenso.
Rev Calid Asist, 26 (2011), pp. 174-183

Please cite this article as: Navarro Soler IM, Ignacio García E, Masjuan Vallejo J, Gállego Culleré J, Mira Solves JJ. Conjunto de indicadores de calidad asistencial en el abordaje del ictus. Neurología. 2019;34:497–502.

Part of this study was presented at the 34th Congress of the Spanish Society of Healthcare Quality.

Copyright © 2017. Sociedad Española de Neurología
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