• B C Tilley, P D Lyden, T G Brott, M Lu, S R Levine, and K M Welch.
• Division of Biostatistics and Research Epidemiology, Henry Ford Health Sciences Center, Case Western Reserve University, Detroit, Mich., USA. btilley1@biostat.hfh.edu
• Arch Neurol Chicago. 1997 Dec 1;54(12):1466-74.

ObjectiveTo develop an approach for reducing time between emergency department (ED) admission and treatment in patients with acute ischemic stroke to meet the challenge of providing tissue plasminogen activator treatment within 180 minutes.DesignAn observational study.SettingForty trial-affiliated hospitals, including 30 community hospitals.ParticipantsA total of 17,324 consecutive patients admitted to trial-affiliated hospital EDs within 24 hours of possible stroke, from January 1991 through October 1994.InterventionAppraisal of the process of triage, evaluation, diagnosis, and treatment by means of total quality improvement techniques in each hospital. Staff participating in the process identified sources of variation and modifications by flow charting the process.Main Outcome MeasureTime between ED admission and treatment with study medication.ResultsTotal quality improvement methods identified hospital-specific process improvements. Many improvements were administrative, requiring no additional resources. More than 50% of screened patients arrived too late to be treated. Only 1268 patients were admitted between 0 and 125 minutes from stroke onset with no other trial exclusion criteria; 48% were treated. Of 243 patients admitted between 126 and 170 minutes from stroke onset with no exclusion criteria, 4% were treated. Mean time from ED admission to treatment was similar in teaching and community hospitals.ConclusionsTotal quality improvement methods identified ED-specific sources of process variability and reduced time between ED admission and treatment. Therefore, these methods should be considered in developing and monitoring emergent stroke treatment protocols.

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