Provincial Door-to-Needle Improvement Initiative Results in Improved Patient Outcomes Across an Entire Population
Authors: Kamal Noreen , Jeerakathil Thomas , Stang Jillian , Liu Mingfu , Rogers Edwin , Smith Eric E. , Demchuk Andrew M. , Siddiqui Muzaffar , Mann Balraj , Bestard Jennifer , Lang Eddy , Shand Elaine , Benard Magali , Collins Lisa , Martin Kevin , Hartley Corinna , Reiber Marnie , Valaire Shelley , Mrklas Kelly J. , Hill Michael D. , Allen Dana , Anderson Bill , Angelstand Joanne , Anokye Emmanuel , Antymniuk Cherylyn , Arsenault Natalie , Ashman Brenda , Baker Kathy , Bakker Jackie , Balenga Darla , Berg Melissa , Berry Lori-Ann , Betzner Michael , Black Lauren , Blain Denise , Boutilier Tracy , Brady Joanne , Lynn Brewster Stacey , Brown Patricia , Buchynski Ken , Bugbee Erin , Bullard Michael , Burke Doug , Burnett Chloe , Butcher Kenneth , Cackett Paula , Canham Hal , Chiovetti Ann , Chivers Lana , Cobb Caitlin , Cote M.C. , Coutts Shelagh , Currie Deb , Eric Daniels James , Desouza Natasha , Diebert Mona , Dixon Tanya , Dotchin Jennifer , Duckett Sandy , Dustow Verlyne , Dwyer Robyn , Dymond Margaret , Edmond Cathy , Eesa Muneer , Elias Nicole , Elliott Tara , Empson Simone , Falls Liz , Forder Mark , Foreman Rhonda , Forsythe Darrel , Fortier Twyla , Fowler Laura , Franklin Shelly , Garland Jim , Garon Catherine , Gerl Darrin , Ghauri Imran , Gough Sherry , Mark Kevin Govender , Mary-Lou Halabi Gripp , Halldorson Sandy , Harsch Jean , Hatcher Caroline , Hebner Kathryn , Hemsley Richard , Holloway Dawn , Holman Denise , Holsworth Scott , Holton Stephanie , Hull Gavin , Hyciek Barb , Ibach Richard , Imoukhuede Oje , Jeal Barbara , Jill Denman , Johnson Marie , Jones Ozi , Kabaroff Alison , Kalashyan Hayrapet , Kay Frddy , Kaytor Pam , Keppy Tim , King Philo , Kiszszak Sharon , Klick Ryan , Koshurba Evelyn , Kruhlak Rob , Lacasse Julie , Lane Mike , Laughs Tamara , Laut-Barss Leslie , Lavalee Pam , Leclair Tania , Linden Paul , Linderman Troy , Livingstone Jason , Lodder Marilyn , Lundgard Karen , Lyle Elaine , Mackenzie Kathleen , Malarczuk Ashleigh , Malfair Dave , Malone Jamie , Manosalva Alzate Herbert , McCann Kerry , McCarthy Shannon , McKenzie Melissa , McRobert Leta , Meroniuk Dana , Millar Ryan , Miller Rob , Mir Bilan , Montpetit John , Morissette Jackie , Morrison Laurel , Murray-Galbraith Fiona , Mydeen Firdaus , Namagiri Lakshmi , Neidig Nicole , Neil Gordon , Newcommon Nancy , Newell Craig , Nichol Chris , Norris Colleen , Norton Dana , Noseworthy Sara , O’Hara Linda , O’Neail Shannon , Orr Wes , Panes Elysia , Panes Tita , Paradis Joyce , Parry Teresa , Peacock Darlene , Peebles Thomas , Petersen Steen , Phelps Ian , Pooley Roy , Potvin Nicholas , Pryor Rosanne , Ramsahoye Max , Rashead Mohammad , Reedyk Kevin , Reynolds Darla , Rideout Steven , Rimmer Kara , Salih Emad , San Agustin Patrick , Sandbeck Darren , Sattar Salim , Sauter Natalie , Schmidt Kim , Seib Elizabeth , Selzler Jason , Sevcik Bill , Sharman Donna , Shuaib Ashfaq , Smith Dawn , Snider Brent , Snider Jonathan , Stander Joe , Stephenson Caroline , Stewart Candice , Stoyberg Carol , Suranyi Yvonne , Tablin Myles , Taralson Colleen , Throndson Janice , Traverse Kristen , van der Nest Dalique , Van Mulligan Tyler , Van Vuuren Cornelius , Vanderlinde Erich , Vilneff Renee , Volk Glenda , Wall Krystal , Wang De Juan (Thur) , Warharft Dave , Watson Jaylene , Weir Lorraine , Weiss Dale , Welch Dave , Winder Toni , Winsor Winona , Woudstra Douglas , Youn Dana , Young Leane , Zerna Charlotte 
Published: July 2020

Background and Purpose:
Improving door-to-needle times (DNTs) for thrombolysis of acute ischemic stroke patients improves outcomes, but participation in DNT improvement initiatives has been mostly limited to larger, academic medical centers with an existing interest in stroke quality improvement. It is not known whether quality improvement initiatives can improve DNT at a population level, including smaller community hospitals. This study aims to determine the effect of a provincial improvement collaborative intervention on improvement of DNT and patient outcomes.

Methods:
A pre post cohort study was conducted over 10 years in the Canadian province of Alberta with 17 designated stroke centers. All ischemic stroke patients who received thrombolysis in the Canadian province of Alberta were included in the study. The quality improvement intervention was an improvement collaborative that involved creation of interdisciplinary teams from each stroke center, participation in 3 workshops and closing celebration, site visits, webinars, and data audit and feedback.

Results:

Two thousand four hundred eighty-eight ischemic stroke patients received thrombolysis in the pre- and postintervention periods (630 in the post period). The mean age was 71 years (SD, 14.6 years), and 46% were women. DNTs were reduced from a median of 70.0 minutes (interquartile range, 51–93) to 39.0 minutes (interquartile range, 27–58) for patients treated per guideline (
P
<0.0001). The percentage of patients discharged home from acute care increased from 45.6% to 59.5% (
P
<0.0001); the median 90-day home time increased from 43.3 days (interquartile range, 27.3–55.8) to 53.6 days (interquartile range, 36.8–64.6) (
P
=0.0015); and the in-hospital mortality decreased from 14.5% to 10.5% (
P
=0.0990).

Conclusions:
The improvement collaborative was likely the key contributing factor in reducing DNTs and improving outcomes for ischemic stroke patients across Alberta.