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Using simple forms can improve stroke care


Using standardized forms at the time stroke patients are admitted to and discharged from the hospital can improve care, according to a study published in the August 9, 2005 issue of Neurology, the scientific journal of the American Academy of Neurology.

Studies have shown that several treatments for stroke patients reduce the amount of disability, complications and the risk of having another stroke. The treatments are for people with ischemic stroke, which is the most common type, caused by blocked or reduced blood flow to the brain. The treatments are also recommended in guidelines from the American Academy of Neurology and other organizations. Despite this evidence and recommendations, these treatments are not used as often as they could be due to oversight or lack of awareness.

"Care of stroke patients is complicated, and the evidence is growing rapidly," explained S. Claiborne Johnston, MD, PhD, principal investigator for the study and a neurologist and director of the Stroke Service at University of California, San Francisco. "It’s difficult for busy clinicians to keep up with proven best practices, and things can fall through the cracks."

In an effort to increase the use of these treatments, six California hospitals in the study developed standardized forms for use when stroke patients were admitted to and discharged from the hospital. The forms included the recommended treatments. The treatments are: using a clot-busting treatment within three hours of the start of the stroke; preventive treatment for blood clots in the leg veins; drugs that prevent blood clots from forming within 48 hours of arrival at the hospital and at discharge; cholesterol-lowering drugs at discharge; and smoking cessation counseling.

If the treatment was not used, the forms included boxes to check for acceptable reasons for not using the treatment, such as not using a clot-busting drug for a patient who arrived at the hospital more than three hours after the first symptoms or not using cholesterol-lowering drugs for a patient who already had low cholesterol.

The treatment stroke patients received in the year after the new forms were implemented was compared to the treatment they received in the year before the forms were implemented. During that time, 413 patients were treated in the six hospitals.

Overall, patients were more likely to receive optimal treatment after the forms were implemented than before. Optimal treatment was defined as receiving all of the recommended treatments unless there was an appropriate reason not to receive a treatment.

After the forms were implemented, 63 percent of patients received optimal treatment. In the year before the forms were implemented, 44 percent of patients received optimal treatment.

One additional hospital started the study, but did not implement the forms due to an administrative delay. In that hospital, there was no change in the percentage of patients who received optimal treatment from the first year to the second year.

The rate of optimal treatment improved for these treatments: preventive treatment for blood clots in the leg veins; drugs that prevent blood clots from forming within 48 hours of arrival at the hospital and at discharge; and cholesterol-lowering drugs at discharge.

Increasing the use of clot-busting drugs is difficult, according to Dr. Johnston, because most patients do not come to the hospital soon enough. "People need to know that stroke is an emergency," he said. "It’s a brain attack. If you or someone you know has signs of stroke, call 911 immediately. We can only use one of the most effective treatments if it can be given within three hours after the first symptom starts."

Johnston said the study shows that it is feasible to significantly improve stroke treatment. However, he noted that the researchers cannot be certain that use of the forms led to the improvement. "All hospitals were aware that these measures were being monitored, and there were many discussions about the treatments," he said. "It’s not possible to know whether simply measuring outcomes and providing feedback would have produced similar improvements in care."

Johnston also noted that increased advertising for cholesterol-lowering drugs could have led to increased use that was unrelated to the stroke forms.

"Additional studies are needed to confirm these results," Johnston said. "Regardless, the study shows that we need to do better but that we can make it happen fairly painlessly."

Robin Stinnett | EurekAlert!
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