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Hospital Staff Often Overestimate Emergency Stroke Care Performance

DURHAM, NC – When it comes to speedy delivery of clotbusters to stroke patients, many emergency departments aren’t doing as well as they think.

That’s according to a new study, published recently in the Journal of the American Heart Association, which finds that hospitals frequently overestimate their efficiency in initiating tissue plasminogen activator (tPA).

The study team, led by current and former Duke University researchers, surveyed emergency medical staff in 141 hospitals treating 48,201 stroke patients in 2009 and 2010. Hospital staff survey responses were compared with actual data on patients, including the onset of their stroke symptoms; hospital arrival time; treatments, initiation of tPA; and complications from the drug.

Based on that, hospitals were categorized as high-, middle- or low-performing based on the percentage of time they appropriately administered tPA. Included in the assessment was "door-to-needle" time, which is how quickly the clotbusting drug is administered from the time the patient arrives at the hospital; guidelines recommend that occur within 60 minutes.

Study results indicate that only 29% of hospital staff accurately identified door-to-needle performance. In fact, 42% of middle-performing hospitals and 85% of low-performing hospitals overestimated their ability to quickly administer the drug. Furthermore, nearly 20% of low-performing hospitals believed their door-to-needle time was above the national average.

“Hospitals often overestimate their ability to deliver timely tPA to treated patients,” study authors point out. “Our findings indicate the need to routinely provide comparative provider performance rates as a key step to improving the quality of acute stroke care.”

The exaggeration was not without consequence: Hospitals that overestimated their performance tended to have lower volumes of tPA administration, smaller percentages of eligible patients receiving tPA and smaller percentages of door-to-needle time of 60 minutes or less minutes among treated patients.

The surveyed hospitals all participated in the American Heart Association's Get With the Guidelines-Stroke national quality improvement program designed to ensure consistency in timely stroke care. Stroke patient volume affected the disparity between hospital perception and performance, but hospital size or region did not appear to be a major factor.

"Institutions at any performance level could benefit from making protocol changes that would better align performance with perception," lead author Cheryl Lin, MD, a former researcher at Duke Clinical Research Institute in Durham, NC, advised in an AHA press release. "This would have a significant impact on the quality of stroke care delivered across the U.S."