Stroke-related education to emergency department staff: An acute stroke care quality improvement initiative
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.253636
Source of Support: None, Conflict of Interest: None
Keywords: Acute stroke, quality improvement, stroke education, thrombolysis
Reperfusion therapy in the form of intravenous thrombolysis with or without endovascular mechanical thrombectomy is the standard of care for acute ischemic stroke. Acute ischemic stroke therapy is highly underutilized due to its time sensitive nature. Pre-hospital  and in-hospital delays , are major hurdles for the generalized applicability of reperfusion therapy. In developing countries like India where pre-hospital delays have not improved significantly due to various factors , including population burden, no/inefficient emergency medical services, illiteracy, poverty, remote villages and limited resources, it may be more feasible to reduce in-hospital delays. Stroke-related education to ED staff is one among various interventions ,,,,, designed to improve the efficiency of delivering reperfusion therapy, stroke care, and outcomes. We hypothesized that stroke education improves the quality of acute stroke care by timely management of stroke patients.
After approval from the institutional ethics committee, a prospective observational cohort (before and after design) study was conducted at the All India Institute of Medical Sciences, New Delhi, India from September 2014 to August 2015. Our institute is a large public, academic, teaching, and referral hospital with a catchment area of around 300 km radius, serving both rural and urban population. It is an approximately 2800-bed hospital with a large number of doctors (graduate, post-graduate, and super-specialist doctors) and paramedical staff.
In India, there is no pre-notification system and most of the patients tend to arrive either on their own or by an ambulance system, which may be public or private. In our hospital, once a stroke patient arrives in the emergency, he/she is evaluated by the ED staff, including junior resident and physician. Our institute has a stroke alarm system based on mobile phones. The neurology resident is alerted through a mobile call, who then alerts the stroke neurology faculty, neuro-radiology resident and faculty. The computed tomography (CT) scan facility is available 24 hours round the clock and is located near the emergency. The angiography laboratory is located adjacent to the CT scan room. The 3-T magnetic resonance imaging (MRI) room is located just a few meters away from the CT facility.
All consecutive stroke patients presenting within 12 hours of stroke onset were enrolled. The study period of 1 year was divided into three phases of four months each. Phase-I or pre-education phase, phase-II or immediate post-education phase, and phase-III or delayed post-education phase. Members of the stroke team educated the ED staff including 80 junior residents, 14 physicians, and 30 paramedical staffs in the month of January 2015 by an audiovisual lecture based format twice per week in a 2-hour session each. All junior residents were graduate with 1-year post internship, with some of them doing postgraduate training in internal/emergency medicine with variable experience in months-year(s) in handling all medical emergencies. Physicians were postgraduates in internal medicine or emergency medicine with variable years of experience in handling all types of medical emergencies. Paramedical staff included diploma holders/graduates in nursing with adequate experience in managing emergencies.
After patients' informed consent, data including demographic details and risk factors including history of hypertension, diabetes mellitus, coronary artery disease, valvular and nonvalvular atrial fibrillation, rheumatic heat disease, history of prior stroke, etc., were recorded. Stroke care quality matrices were recorded including (1) stroke onset time (defined as time of first observed symptom and either last seen normal or time to go to bed for wake-up stroke, (2) Door time/arrival time defined as the time of arrival in the emergency room, (3) onset to arrival time (OAT), (4) door to imaging time (DTI) defined as time interval between arrival to completion and interpretation of neuroimaging by treating stroke team member,(5) door to needle time (DTN) defined as time interval between arrival to start of reperfusion therapy, were recorded. The patient's outcomes were assessed using modified Rankin scale score (mRS) at 3 months either during scheduled outpatient department (OPD) visits or by a telephonic call. The primary efficacy outcome was a change in acute stroke care quality matrices. Secondary outcome was mRS score at 3 months. A mRS ≤2 was defined as a good outcome. Statistical analysis was done using STATA 12.0 (StataCorp LP, USA).
A total of 936 stroke patients were admitted in the 12 months of study period in our hospital. Out of these, 264 consecutive acute stroke patients (onset to arrival time <12 hours) were enrolled during the study period of 1 year. These included 179 (66%) ischemic stroke and 85 (34%) hemorrhagic stroke patients with a total of 56,101 and 107 patients enrolled in the three study phases, respectively. The baseline characteristics of patients were similar in all phases [Table 1] including age, gender, risk factors, and baseline stroke severity (NIHSS) except the pre-hospital median time which was significantly different between phase-I [217.5 (90–420) minutes] and phase-III [300 (135–570) minutes].
The primary efficacy outcome, as judged by the acute stroke care quality matrices, improved significantly (P ≤ 0.01). Median DTI reduced from 114 (74–168) minutes in phase-I to 35 (21–46) minutes in phase-II and 47 (26–64) minutes in phase-III [Table 2]. Proportions of patients imaged within 25 minutes increased by 35% in the immediate post-education phase [Table 2].
Analysis of patients with an ischemic stroke presenting within 6 hours of onset showed that there was a 20% increase in the proportion of patients who were imaged within the window period of intravenous reperfusion therapy (4.5 hours); 48% (12/25) in phase-I and 68% (28/41) in phase-II [Figure 1].
Among 41 patients treated with reperfusion therapy, the mean DTN time reduced from 142 ± 49.7 minutes in phase I to 63.7 ± 25.1 minutes in phase-II and 83.9 ± 38.1 minutes in phase-III. Proportions of patients receiving reperfusion therapy within 60 minutes were increased by 63% in phase-II [Table 3].
Secondary efficacy outcome, as judged by mRS at 3 months [Table 4], was analyzed among ischemic and hemorrhagic stroke patients separately. There was a significant improvement in the 3-month mRS among ischemic stroke patients (P = 0.04) but no significant change in the outcome of hemorrhagic stroke patients was observed (P = 0.72).
In this study, we measured the effectiveness of stroke education to ED staff in terms of acute stroke care quality matrices as well as change in outcomes. We also observed wearing-off of the effect with time as a surrogate evidence of presence of the effect, and the requirement of repetition for sustained effectiveness. During this study, we tested our hypothesis that stroke-related education not only improves knowledge  but also changes attitude and practice, which may lead to improvement in acute stroke care and outcome among stroke patients. Our results suggest that there was a faster and better recognition of stroke patients after education which leads to an increase in the number of stroke patients who were admitted and treated.
The major reasons for delay in the pre-education phase were delayed recognition of stroke patients, lack of constancy of preference of stroke patients over other emergency patients, and less aggressive approach towards stroke treatment among patients who came after 6 hours of stroke onset, leading to delayed or improper reporting of stroke onset and arrival time.
To overcome these hurdles, we educated the ED staff regarding the importance of time in stroke management, available treatment options as well as benefits of early admission of stroke patients to stroke units. We also instructed the staff to give preference to stroke patients over other emergency patients if there is a long queue in the emergency triage. We also educated the personnel on the multiple ways to understand the onset times and avoid improper reporting. The triage screening room staff was optimally educated to directly alert the neurology resident and directly send the patient to the CT room where the patient could be rapidly evaluated and treated promptly. We educated and instructed the security personnel at the emergency entry to allow immediate entry of any suspected stroke patients. We instructed the CT room technicians to perform the CT scan of stroke patients on a priority basis.
In post-education phases, not only rapid recognition but rapid triage for imaging as well as therapy by early information to stroke team was observed with a significant improvement in all acute stroke care quality matrices.
Various interventions have been tried either singly or simultaneously to reduce pre-hospital as well as in-hospital treatment delays with a variable effectiveness in the literature.,,,,, Behrens et al., also observed that there was significant reduction (P ≤ 0.01) of around 79 minutes in the in-hospital delay after stroke education to ED staff including medical professionals. Data published from the SITS-EAST registry  observed that the proportion of patients treated with DNT ≤60 minutes ranged from 18% to 84% which is comparable to our centre where 63% patients were treated within 60 minutes during immediate post-education phase and 33% during delayed post-education phase.
There was a significant delay during phase III compared to phase 2 (P ≤ 0.01) in acute stroke quality matrices (although it was still significantly better than phase I (P ≤ 0.01), suggesting a wearing-off effect of education with time. It could also be explained partially by the changes in postings of resident doctors who may not have enough understanding regarding the time critical nature of stroke therapy. A persistent and ongoing educational initiative is probably a solution for this observation.
The main aim of education was to sensitize the ED staff for all stroke patients even if patients presented late after onset of the index event. Upon comparison of patients who came within six hours to those who came after 6hours of stroke onset, a significant difference was observed between phase II and III for patients who came after 6hours but no significant difference was observed for patients who came within 6hours [Table 2], suggesting that the effect of education wears off first for patients who came late.
In the post-education phase, almost double the numbers of patients were admitted to the neurology wards within 12 hours of stroke onset. The possible reasons for this increase in the numbers of stroke patients are better recognition of stroke patients, timely information to the stroke team, as well as better reporting of onset time, and onset to arrival time. Therefore, this apparent increase is reflected by more proportions of patients being admitted in >6 hours of onset to arrival time in the post-education phases [16/56 (29%),35/101 (35%),47/107 (44%), respectively], explaining the increase in onset to arrival time from 217 minutes in Phase-1 to 300 minutes in Phase-3.A total of 41 patients (10, 16, and 15 patients in each study phase, respectively) were thrombolyzed. There was a significant increase in the proportion of patients who were thrombolyzed within 60 minutes. Although there was no significant increase in the number of patients who were thrombolyzed, patients during the post-education phases were imaged and treated more rapidly [Figure 1].
There was a significant improvement in the 3-months mRS score in ischemic stroke patients in the post-education phase, reiterating the point that rapid recognition and treatment of acute stroke increases the number of patients who are independent at 3 months (mRS, 0–2).,,,,,, No significant change in the outcomes of hemorrhagic stroke patients is probably explained by the fact that intracerebral hematoma is a more serious illness with the mainstay of therapy being supportive and that the outcomes in patients with a hemorrhagic stroke are dependent on other important variables such as hematoma volume, intraventricular extension, and hematoma expansion rather than just time dependent treatment alone.
Our study has limitations. It is a single-centre study, has a small sample size, and analysis of needle time was done only for those patients who got reperfusion therapy. Moreover, organized emergency services may be variable and may not be optimally organized in all hospitals and many developing countries will have limited formal emergency training systems. However, this study will interest other institutes or hospitals to adopt practices and improve stroke systems of care and to provide basic knowledge and training for such important time sensitive emergencies to the emergency doctors and personnel to atleast recognize a stroke victim and call the specialist immediately or refer them to the a nearest advanced centre. The significance of the present study is that stroke education intervention is effective in improving patient care, is easy to apply, and can be repeated with time.
Stroke education to ED staff is an effective method to improve acute stroke care quality and outcomes among ischemic stroke patients. Effect of education is likely to wear off with time. Repeated education is, therefore, required for a sustained effect to be maintained.
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Conflicts of interest
There are no conflicts of interest.
[Table 1], [Table 2], [Table 3], [Table 4]