Improving Access and Efficiency of Acute Ischemic Stroke Treatment Across Four Canadian Provinces: A Stepped-Wedge Trial

Abstract

Background: An evidence-to-practice gap exists in acute ischemic stroke treatment, and improvements in access and efficiency of treatment with iv thrombolysis and endovascular thrombectomy (EVT) is needed. The objective of this study was to improve access and efficiency of ischemic stroke treatment across four Atlantic Canadian Provinces. Methods: A stepped-wedge cluster trial was conducted over 30 months with 3 clusters covering 34 sites. The trial was conducted across all 4 Atlantic Canadian provinces: Nova Scotia (NS), New Brunswick (NB), Prince Edward Island (PE), and Newfoundland and Labrador (NL). The design was quasi-randomized, with each cluster associated with one or more provinces: cluster 1 — NS; cluster 2 — NB and PE; and cluster 3 — NL. The patient population was all ischemic stroke patients across all 4 provinces. The intervention was a 6-month modified Quality Improvement Collaborative (mQIC), which was modified from the Breakthrough Series Collaborative to be half of the 1-year period and conducted virtually. The intervention consisted of assembling an interdisciplinary improvement team, 2 full-day workshops, webinars, and virtual site visits. Suggested changes included 6 process improvement strategies. Results: The proportion of patients that received treatment did not increase significantly with the intervention [0.4% increase for patients that received thrombolysis and/or EVT (p=0.68)]. Median door-to-needle time was reduced by 9.2 minutes with the intervention (p=0.01). Cluster 3 saw the greatest improvements in both access and efficiency. Conclusions: A mQIC intervention resulted in improvement of process measures like door-to-needle time. Quality improvement initiatives may need to be longer to see improvements in proportion of patients treated. Tailored interventions for each health system can ensure that each system sees improvement. In-person activities might be critical to ensure fidelity of the intervention.