Table 1
Elements of the multifaceted resource integration project.
| RESOURCE INTEGRATION STRATEGY | INITIAL RECOGNITION AND EMERGENCY TRANSPORTATION STAGE | FAST TRIAGE AND PRELIMINARY DIAGNOSIS STAGE | RAPID IMAGING AND THROMBOLYSIS ADMINISTRATION STAGE | |
|---|---|---|---|---|
| Operand resource integration | Sharing stroke ambulance with emergency center | Setting up neuro emergency | Thrombotic drugs stored in the CT room | |
| Operant resource integration | ||||
| Information-collection | Community education EMS staff training | Training stroke emergency nurses Training emergency triage nurses Using stroke screening tools Using a electronic wristband | Rapid acquisition of brain imaging | |
| Information-sharing | Pre-notification by EMS | Single-call activation Stroke code activation | Structured information sharing by multimedia instant messenger group | |
| Decision-making | \ | Rapid triage protocol Transport of patients by EMS directly to the scanner | Rapid interpretation of brain imaging Thrombolysis administering in the scanner/imaging area | |
[i] CT indicates computerized tomography and EMS, emergency medical services.
Figure 1
Conceptual framework of the project. This framework includes two dimensions composed of resource integration strategies (including operant resource integration and operand resource integration) and intravenous thrombolysis treatment processes (including recognition and emergency transportation stage, triage and preliminary diagnosis, imaging and thrombolysis administration).
Figure 2
Flowchart of the new treatment process. The new treatment process is designed in parallel. Tasks in different stages are clearly assigned to each of the members of the acute stroke treatment team.
Table 2
Characteristics of Patients in Pre-intervention and Post-intervention.
| PRE-INTERVENTION (N = 121) | POST-INTERVENTION (N = 398) | P VALUE | |
|---|---|---|---|
| Age (y), (mean ± SD) | 67.6 ± 11.4 | 66.2 ± 11.9 | 0.240 |
| Female (%) | 46 (38.0) | 143 (35.9) | 0.676 |
| Transferred by EMS (%) | 35 (28.9) | 131 (32.9) | 0.410 |
| Baseline NIHSS, median (IQR) | 4 (3–11) | 4 (2-10) | 0.080 |
| Prior Stroke/TIA (%) | 21 (17.4) | 82 (20.6) | 0.433 |
| Hypertension (%) | 72 (59.5) | 211 (53.0) | 0.209 |
| Diabetes mellitus (%) | 26 (21.5) | 110 (27.6) | 0.178 |
| Atrial fibrillation (%) | 17 (14.0) | 55 (13.8) | 0.949 |
| Coronary heart disease (%) | 20 (16.5) | 49 (12.3) | 0.231 |
| Current Smoker (%) | 63 (52.1) | 192 (48.2) | 0.461 |
[i] P values are from t test or a Kruskal–Wallis nonparametric test for continuous variables and χ2 test for categorical variables. IQR, interquartile range; NIHSS, National Institutes of Health Stroke Scale; and TIA, transient ischemic attack.
Figure 3
Statistical Process Control chart of monthly average door-to-needle times. Blue double arrow line shows the timing of the intervention. Black arrows show the timing of interventions: a. Ambulance sharing, neuro emergency establishing, stroke emergency and emergency triage nurse training, screening tool using, single-call activation, stroke code activation, rapid acquisition of brain imaging, thrombotic drugs storing in the CT room, transport of patients by EMS directly to the scanner, thrombolysis administering in the imaging area were implemented in July; b. Pre-notification by EMS, electronic wristband, rapid triage protocol, rapid interpretation of brain imaging were implemented in September; c. Community education, EMS staff training, structured information sharing by multimedia instant messenger group were implemented in November. DNT, door-to-needle times; CL, center line; LCL, lower control limit; UCL, upper control limit.
Table 3
Time Between ED Arrival and Thrombolysis Administration (Categorical Door-to-Needle Time in Minutes).
| PREINTERVENTION (N = 121) | POSTINTERVENTION (N = 398) | UNADJUSTED ODDS RATIO | P VALUE | ADJUSTED ODDS RATIO | P VALUE | |
|---|---|---|---|---|---|---|
| <60 min (%) | 54 (44.6) | 337 (84.7) | 6.85 (4.37–10.75) | <0.001 | 7.31 (4.59–11.63) | <0.001 |
| <45 min (%) | 21 (17.4) | 276 (69.4) | 10.77 (6.43–18.05) | <0.001 | 11.93 (7.04–20.20) | <0.001 |
| <30 min (%) | 3 (2.5) | 109 (27.4) | 14.84 (4.62–47.65) | <0.001 | 14.84 (4.62–47.65) | <0.001 |
[i] Multivariable models include adjustment for age, sex, medical insurance, baseline NIHSS score, history of hypertension, diabetes mellitus, atrial fibrillation, coronary heart disease, prior stroke and current smoker.
Table 4
Patient outcome (mRs at 90 days).
| PREINTERVENTION (N = 106) | POSTINTERVENTION (N = 311) | UNADJUSTED ODDS RATIO | P VALUE | ADJUSTED ODDS RATIO | P VALUE | |
|---|---|---|---|---|---|---|
| mRs 0–1 (%) | 57 (53.8) | 183 (58.8) | 1.12 (0.59-1.85) | 0.326 | 1.27 (0.78–2.31) | 0.471 |
| mRs 2–3 (%) | 17 (16.0) | 68 (21.9) | 1.44 (0.83-2.06) | 0.074 | 1.35 (0.92–1.71) | 0.183 |
| mRs 4–5 (%) | 27 (25.5) | 49 (15.8) | 1.83 (1.22-5.47) | 0.029 | 1.62 (1.36–7.64) | 0.037 |
| Mortality (%) | 5 (4.7) | 11 (3.5) | 1.13 (0.57-2.10) | 0.629 | 0.94 (0.58–2.82) | 0.562 |
[i] Multivariable models include adjustment for age, sex, medical insurance, baseline NIHSS score, history of hypertension, diabetes mellitus, atrial fibrillation, coronary heart disease, prior stroke and current smoker.