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Mark J. Alberts, MD Northwestern UniversityJean Range, MS The Joint CommissionAnn Watt, MBA The Joint CommissionVicki Cantwell, MBA The Joint CommissionJoe Troy, MS The Joint Commission
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Introduction
TJC has been certifying Primary Stroke Centers since 2003
The use of IV TPA to treat eligible patients with acute ischemic strokes is one important aspect of care at a PSC, but certainly not the main reason to become a PSC
IV TPA remains one of the few FDA-approved treatments for acute ischemic stroke
IV TPA is included in all acute stroke care guidelines
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MethodsData obtained through TJC files (site visits and
disease performance measures)2008 data
Data also obtained from AHA Helthcare Quick-Disc 2008 edition
TPA administration defined as patient presentation within 120 minutes of time last known wellIV TPA administered within 180 minutesPatients met inclusion/exclusion criteria used by
hospital/guidelinesCorrelated TPA use with cycles of certification and
type of facility
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Results
Data available from 418 PSCs251 teaching and 154 non-teaching200 certified within past 2 years (1st
cycle)197 in their second certification cycle21 are in their third certification cycle
1902 of 2469 total eligible patients received TPA 77% utilization rate
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Overall Rates of TPA Utilization and Cycle
Cycle Number TPA Use
1 72.7%
2 78.6%
3 94.4%
P = 0.03 for one to three cycle comparison
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Rates of TPA UtilizationTeaching vs Non-Teaching Hospitals
TJC classifies hospitals into 3 categoriesMajor teachingMinor teachingNon-teaching
Most certified PSCs (71%) are either non-teaching or minor teaching hospitals
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Rates of TPA UtilizationTeaching vs Non-Teaching Hospitals
70% use of TPA in non-teaching hospitals
81% rate of TPA use in major or minor teaching hospitals
11% absolute difference in rate of TPA utilization
This is only among eligible patients
P < 0.05
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Number of Hospitals per Cycle
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Number of Treated Patients per Cycle
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Number of Patients Treated per Hospital
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Rates of TPA Use, Hospital Type, and Cycles
Cycle 1 Cycle 2 Cycle 3
Teaching 78% 80% 94%
Non-Teach 67% 74% 100%
Difference - 11% - 6% + 6%
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Trends Over Time in Percent Eligible Treated
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Discussion Points
Higher rates of TPA use in teaching hospitals could be due to a number of factors:Availability of stroke teams 24/7Familiarity with TPA protocolImproved guidance from fellows and attendingBetter patient acceptance
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Discussion Points
Increase in TPA use with increased recertification cycles:More experience and comfort among medical
staffMore efficient care leading to fewer treatment
delaysImproved marketing of stroke center and its
programs May increase the number of overall eligible patients
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Discussion Points
What accounts for the narrowing of treatment rates between teaching and non-teaching facilities?Was due largely to gains at the non-teaching
hospitals But both groups showed improvements
Demonstrates that experience matters!!Perhaps diversion of acute patients to specific
facilities leads to improved care efficiency, comfort levels, and program development
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Limitations
Much of the data obtained from databasesMuch of the data generated by self-reporting
Few audited resultsWe did not analyze nor control for many
confounding factors:Risk stratificationSESReasons for exclusion from treatmentAscertainment biases
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Conclusions
TPA utilization at certified PSCs is associated with the duration of time a hospital has been a Stroke Center
While TPA utilization is higher initially at teaching hospitals, over time the non-teaching hospitals are able to achieve high levels of TPA use
Experienced teaching hospitals have the highest rate of TPA utilization
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Conclusions
These data further support the importance of PSCs and how time and experience improve some aspects of acute stroke care
The vast majority of patients at a PSC do not receive TPA, but still benefit from other aspects of organized care at these facilities