Introduction: A significant burden of acute ischemic stroke (AIS) can be decreased by timely administration of tissue plasminogen activator (tPA). Door-to-needle (DTN) time is a nationally reported quality measure for patients with AIS. In a majority of primary and comprehensive stroke centers, acute stroke care is provided by teams comprising of trainees (residents/fellows). Adaptive learning is a well-studied paradigm to improve the quality of medical education. Conceptually, this model consists of four parts starting with planning, and subsequently involving learning, assessing and adjusting. It is a learner driven process.
Hypothesis: Utilizing the adaptive learning model will reduce DTN time in AIS patients who present to the emergency department of a rural, tertiary care medical center staffed by neurology residents.
Methods: Successive patients who received IV tPA for AIS in the emergency department of our academic medical center between January 1, 2014 and December 31, 2016 were included in the study. During months 1-18 (pre-intervention) DTN times were not shared with residents. During months 19-36 of study (post-intervention), we utilized our monthly stroke meeting to share DTN times anonymously. Discussions were held and emphasis was placed on the processes which led to shorter DTN times. Residents assessed responses, planned changes, and made adjustments in real time. Descriptive statistics were used to analyze the data.
Results: A total of 313 patients received IV tPA during the study period (150 pre-intervention, 171 post intervention period). After the implementation of the quality improvement initiative, mean and median DTN time significantly reduced from 54.7 minutes to 43.0 minutes (p<0.0001) and 52 minutes to 39 minutes (p<0.0001) respectively.
Conclusions: Our study exemplifies the success of the adaptive learning model in the care of patients with acute ischemic stroke. Our quality intervention led to significantly reduced DTN times. Furthermore, this educational initiative provided residents with objective feedback about their performance - one of the requirements of the accredited council of graduate medical education (ACGME).