Stroke is the third leading cause of death in the United. Improving Stroke Care Through Development of a Stroke Intervention Team: A Case Study

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1 STROKE PROGRAM Improving Stroke Care Through Development of a Stroke Intervention Team: A Case Study Kevin Thorpe, Marilyn Rymer, MD, Sherry Marshall, RN, and Eugene Fibuch, MD Abstract Objective: To describe a program intended to achieve superior clinical outcomes in stroke care through appropriate use of interventional stroke reversal therapy. Methods: A team charter was developed along with defined project objectives and associated outcomes. Timelines, team members, operating budgets, key stakeholders, and key patient and physician requirements were also defined. The team developed actions that included the production of an information packet for referring facilities, onsite visits with referring physicians/hospitals, modification of patient transfer protocol, collaborating with emergency department and nursing personnel, developing a marketing program for the public, increasing the clinical research effort, and establishing patient care protocols. Results: The efforts have produced significant results, including improved NIHSS scores. Patient referrals have increased from the regional network of participating hospitals, resulting in a 31% increase in patient volume. The percentage of patients receiving stroke reversal therapy rose from 18% (2000) to 31% (2004). Profitability increased 85%. Conclusion: A complex community health care need can be met successfully through the development of a new service program that involves multiple specialties and referral hospitals. Stroke is the third leading cause of death in the United States and is the leading cause of disability in adults [1,2]. Every year there are 750,000 new or recurrent strokes [1]. National treatment guidelines call for the administration of intravenous tissue plasminogen activator (IV tpa) for acute ischemic stroke of less than 3 hours duration in patients without contraindications [3]. However, the reported national rate of IV tpa use is only 2% to 3% [4,5]. In this paper, we describe our approach to improving stroke care at our medical center, including increasing appropriate use of thrombolytic therapy. Setting Saint Luke s Hospital of Kansas City (SLH) is a voluntary not-for-profit comprehensive teaching and referral health care organization. It is Kansas City s largest hospital, with 582 beds, 3214 employees, and a staff of 500 physicians. It is also the tertiary care referral center of Saint Luke s Health System. The Mid America Brain and Stroke Institute (MABSI) of SLH was formed in 2001 to advance the practice of neuroscience and to further the work of SLH s nationally recognized stroke program established in The committee is a cross-functional team of interdependent clinicians and support staff. Its mission is to achieve common goals and superior clinical outcomes, especially in improving SLH s stroke intervention rate and utilizing advanced stroke reversal therapies. Selecting the Opportunity MABSI s first step was to utilize an internally produced community environmental assessment that identified stroke as a key health care issue for the Kansas City region. Early investigation also revealed that no other hospitals in the Kansas City market had chosen to develop clinical expertise in the diagnosis and treatment of ischemic stroke. These facts made forming a stroke team a sensible response to a well-defined community need. The team was formed in recognition of high morbidity and mortality following stroke and the desire to improve care. In the first quarter of 2002, the MABSI committee reviewed a variety of neurovascular performance data. An analysis of demographic data for January 2000 through June 2002 revealed that over 70% of stroke patients who received acute intervention therapy were transferred to SLH from hospital emergency departments within a 100-mile radius. Over this 30-month period, 18% of all ischemic stroke patients presenting to SLH received IV tpa, intra-arterial (IA) tpa, or a combination of these. Although SLH s intervention rate exceeded the national average by 15% to 16%, From the Mid America Brain and Stroke Institute and the Quality Resource Department, Saint Luke s Hospital, Kansas City, MO. 632 JCOM October 2004 Vol. 11, No. 10

2 REPORTS FROM THE FIELD PERFORMANCE IMPROVEMENT the team felt that it could do better and that the stroke program could set the national performance standard. Performance Improvement Project SLH ascribes to a formal 5-phase service design and performance improvement model (Plan, Design, Measure, Assess, and Improve). Plan After reviewing the data, the MABSI committee updated the stroke program s purpose statement (team charter) to reflect its new primary goals, which were to develop a clinical program and associated clinical practices that achieve stroke intervention rates higher than anywhere else in the world, to assure low rates for mortality and hemorrhage, and to improve neurologic function in stroke victims as measured by the National Institutes of Health Stroke Scale (NIHSS). In recognition of its new purpose, the stroke team was renamed the Extreme Neuro team. The Extreme Neuro team s goals were closely aligned with the hospital s vision statement The best place to get care; the best place to give care. The objectives devised to meet the goals and outcomes were defined as follows: Make MABSI the best place to get stroke care. Increase the intervention rate by 4% per year through 2005 for patients arriving within 5 hours of the onset of stroke symptoms; improve NIHSS scores from admission to discharge by 2% per year; in 2004, reduce the triage to treatment time from 1.5 hours to the benchmark level of 1 hour. Advance the expertise of participating physicians and nurses to the level of best national practices. The number of nurses in the stroke program attaining American Association of Neurological Nursing (AANN) certification will increase by 3 per year through Increase the number of clinical and pharmaceutical drug/device trials with the aim of evaluating all new technology that can help expand the intervention window from 3 to 8 hours (eg, mechanical thrombolysis). Seek external peer review of performance results through presentations and peer-reviewed scientific journal publications. Improve SLH s customer preference ranking (neurology services as measured by National Research Corporation annual market survey) by 2% per year and improve customer satisfaction results (Press-Ganey inpatient satisfaction scores for the stroke unit) to top 15 (national) benchmark performance level. Improve financial performance (contribution margin) by 3% to 5% per year through The team established that the target for completing its objectives would be December It also recognized that capital and operating expenses would need to be considered during the hospital s 2003/2004 budget planning cycles. Patients with life-threatening, disabling acute strokes and their families were identified as primary customers (stakeholders external to SLH). Referring physicians were also considered customers. Key internal stakeholders were other physicians and nurses practicing at SLH whose patients suffer ischemic strokes while in the hospital, as well as ancillary department team members providing clinical services. Key patient care requirements were determined by the SLH business research and analysis department using customer satisfaction surveys and were defined as timely access to service; competent, safe, and compassionate care; and good clinical outcomes. Referring physicians had similar key requirements but stressed timely communication. Establishing and Developing the Team Based on the MABSI committee s assessment, the program s medical director in consultation with hospital administration recommended the formal chartering of the Extreme Neuro team. Team members were asked to participate based on their skills, knowledge, and expertise in clinical care, data management, or general operations. The team s charter and membership were reviewed and approved by the MABSI committee and the SLH performance improvement steering committee. Table 1 lists the Extreme Neuro team members. The core team was given the task of carrying out the objectives identified by the MABSI committee. The core team was supported by key individuals who were critical in supporting the team s effort. The Extreme Neuro team members shared a common vision, value set, sense of purpose, and goals, which were derived from a series of brainstorming sessions. Daily team member interactions facilitated individual patient case review and care coordination discussions. The MABSI committee and the department of neurosciences each met monthly to formally review the Extreme Neuro team s progress, to discuss program development, and to review aggregated data. The team s dynamics closely match the development model described in complexity theory literature [6]. Selforganization suggests that if people in an organization are given the freedom and information they need, they will be able to adapt to changing conditions better than if their behavior is closely managed and directed. The Extreme Neuro program could be described as a self-organizing, Vol. 11, No. 10 October 2004 JCOM 633

3 STROKE PROGRAM Table 1. The Extreme Neuro Team Role Core team Chair and medical director Advance practice nurse Patient care director Stroke data manager Clinical research nurse Administrative assistant Vice president Support team Chair, MABSI committee of the board Neurologist Interventional neuroradiologist East-1 and MICU stroke nurses Emergency department physicians and nurses Radiology nurses and technicians Responsibility Stroke program development, clinical practice guideline development, outcomes oversight Meeting oversight Represent medical staff interests Communication to medical staff Clinical expertise Stakeholder for clinical pathway development and maintenance, patient and community education Development of process for communicating to referring physician Stakeholder for assuring patient access to competent, compassionate nursing staff Stakeholder for data collection, aggregation, preliminary analysis Stakeholder for coordination of device and pharmaceutical clinical trials The glue that holds the team together Agenda and meeting minutes preparation Support the team Provide operational expertise Resource planning Community oversight of business strategies, stroke program objectives, and performance results Provide medical management of patient to include diagnosis, treatment, follow-up care Provide 24/7/365 stroke intervention therapy in rapid response mode Provide diagnostic imaging and therapeutic 24/7/365 rapid response mode for radiologic intervention Provide bedside nursing care Expedited implementation of stroke ready protocols Rapid communication to stroke neurologists Immediate assistance with diagnostic and therapeutic radiologic procedures 24/7/365 MABSI = Mid America Brain and Stroke Institute; MICU = medical intensive care unit. complex, adaptive system shaped by team member interactions and areas of expertise. Leadership is distributed and task dependent. This approach created a sense of ownership among the team members and set the stage for a positive and energetic workplace. Team members were given the freedom and information they needed to adapt to changing conditions, which facilitated rapid-cycle learning and problem solving. The additional brainstorming sessions, which were held to identify improvement opportunities, were good examples of this process in action. Through these sessions, the team developed a flowchart to describe the Extreme Neuro process from onset of symptoms through intervention and created an adjunct emergency department nursing clinical pathway. Key factors for the team s success were a basic ground rule that extreme ideas are always encouraged and success is recognized and celebrated. Team member s contributions are recognized in their annual performance reviews. Team member birthdays are celebrated with a lunch outing. Program participants are rewarded for success with attendance at national conferences, celebration lunches, acknowledgment at hospital and board meetings, as well as with national and local news media exposure. Analyzing the Current Situation (Design) The Extreme Neuro team reviewed current literature to look for best practices and discovered that the existing stroke program already exceeded published results. A number of data elements were reviewed, including patient volume; intervention rate with IV tpa, IA tpa, or combined IV/IA tpa; mortality rate; discharge disposition; NIHSS score; customer satisfaction results; and profit/loss statements for ischemic stroke patients. The stroke database was originally developed (1994) in MIDAS (Medical Information Data Analysis System), utilizing data elements developed by the American Stroke Association. These were later exported from MIDAS to a new MS Access database that incorporated and expanded the data elements to create a comprehensive clinical intervention data set. To better stratify the patient population and compare the data, the team adapted a utilization strategy used by the University of Cincinnati Stroke Center, which delineated 5 patient groups according to their ICD-9 principal diagnosis codes at discharge: ischemic stroke, hemorrhagic stroke, unruptured aneurysm, transient ischemic attack, and carotid stenosis without infarct. Data were abstracted from the patient medical records concurrently and retrospectively and entered into the MS Access Neuro database. Financial data were captured in SLH s decision support system and provided to the program monthly to support financial performance analyses during budget deliberations. Patient satisfaction scores, reported weekly, reflected the percentage of patients that rated their overall experience as a 4 or 5 on a 5-point Likert scale. Aggregated data were reported quarterly in both table and run chart formats and reviewed by key stakeholder groups. Data drilldown was conducted as needed when unexpected 634 JCOM October 2004 Vol. 11, No. 10

4 REPORTS FROM THE FIELD PERFORMANCE IMPROVEMENT results were encountered. Also, because it is important for program growth to establish SLH as a preferred market leader, each year SLH contracts with the National Research Corporation to conduct a random telephone survey that asks consumers which area provider is the most preferred for neurology services. The results of these surveys were analyzed and considered in planning. The team reviewed all information during regularly held team meetings, looking for trends and reviewing and discussing new information published in the scientific literature and any new clinical trials under consideration or in progress. The team analyzed aggregated annual data and, with the assistance of a biostatistician, evaluated its statistical significance. When a negative data trend was observed, a detailed investigation, including drilldown and analysis, was undertaken. Selecting Alternatives and Solutions The following 5 activities were deemed to have the greatest potential impact on the clinical outcomes of stroke patients: 1. Develop and use the emergency department stroke intervention protocols to encourage early treatment in referring facilities through ongoing education and communication. 2. Facilitate rapid access to stroke expertise and rapid patient transport for transfer through the Doctor s One Call Transfer program. The program was developed to help physicians and community hospitals efficiently transfer patients to Saint Luke s Health System s programs and services. The program is staffed 24 hours a day with registered nurses who are available to take calls. 3. Educate the public on the importance of seeking medical help immediately at the onset of stroke symptoms. 4. Expand the research agenda to incorporate additional stroke care methods that would expand the intervention window beyond 3 hours. 5. Increase SLH staff understanding and utilization of NIHSS to enhance assessment skills throughout the program. The MABSI committee concluded that these 5 activities would directly address 4 of the program s 6 objectives and indirectly address 2 (customer preference and financial growth) through overall results and effects. The committee consulted with key stakeholders regarding the planned activities, and the stakeholders approved them as supportive of the objectives. The committee then utilized brainstorming and negotiation techniques to develop a plan for implementing the activities. These efforts yielded lists from which individual team members were assigned to meet with contacts throughout Saint Luke s Health System and with other stakeholders to refine, enhance, and supplement the plan. Findings were brought back to the Extreme Neuro team to finalize the team s plan and the actions required. The recommended actions included: 1. Development of an information packet for referring facilities containing treatment protocols, laminated information cards, and standing order sets that could be delivered by the outreach department staff. 2. One-on-one visits to the top referring hospitals to identify communication improvement opportunities and to provide coincidental education. Team members met with referring physicians and SLH outreach department members to ascertain what education and communication would be most helpful to them. 3. Modification of the Doctor s One Call Transfer program protocol to facilitate connecting a stroke neurologist with the referring physician. 4. Collaboration with the emergency department and nursing department to identify strategies to minimize emergency department diversion of stroke patients. 5. Development in conjunction with the marketing department of a campaign to inform the public of the need to seek immediate treatment at the onset of symptoms. This included billboards and collateral advertising materials featuring patients and staff sharing their success stories. The campaign s message was simple Just Get Here! Advertising materials also further established MABSI as a key SLH business center of excellence. 6. The need for a dedicated research nurse was identified as a way to increase the clinical research trials. Subsequently, a job description was developed for the clinical research nurse role. Through this role, additional clinical research trials would be identified and completed with the resulting funding used to support this role on an ongoing basis. 7. Collaboration between the stroke unit and the team s advanced practice nurse member produced the content for weekly education sessions that used the NIHSS assessment to focus on all aspects Vol. 11, No. 10 October 2004 JCOM 635

5 STROKE PROGRAM of neurovascular diagnosis and treatment. The program also supported the objective of preparing nurses for the AANN certification examination. The team worked daily, sharing information and learning from stakeholders. Its meetings focused on reviewing patient specific situations and discussing potential solutions in the context of overall performance. Implementing Improvements To implement each selected action, the team met with key stakeholders to solicit input. It was in these meetings that the foundation for ongoing communication was set, timelines were established, and defined action steps were determined. Given the team s desire to maximize the efficiency and effectiveness of the selected actions, the logistics of the implementation process were considered very important. For example, in delivering the information packet to the referring hospitals, the team specified the best practices associated with early treatment of stroke and talked with referring physicians about how best to present the information for their use. Given the number of facilities that needed to be contacted within the desired geographic region, the team called upon SLH s outreach department. The outreach department had productive relationships with many of the referring facilities and had established and effective mechanisms of ongoing communication. The outreach department supported the team by distributing information packets and by tracking end-user comments. Implementation was staged to allow team members time to assess the effectiveness of the solution and to maximize existing resources. Timelines were created to guide team members and to provide communication to the MABSI committee. Workload and financial ramifications were factored into the action plans. For example, when implementing the education sessions for the stroke nurses, consideration was given to staffing schedules (the unit is staffed 24 hours per day, 7 days per week), which necessitated multiple education sessions, self-learning packets, and other unique strategies. This ongoing education was built through collaboration between the stroke team advanced practice nurse and the East-1 education committee; it matched current best practice information with nurse specific needs. The full team and the MABSI committee approved all action plans and accompanying timelines. The Design phase also included a plan to develop tools for appropriately and accurately measuring the effect of each proposed action. To implement the selected measures, the team determined the data to be collected, the collection frequency, the data gathering mechanism, and the data analysis methods and then assigned related responsibilities to appropriate individuals or departments. For example, the team identified the need to collect specific measures related to each clinical trial as well as the number of clinical trials underway. The clinical research nurse collected these measures each month and reported them to the Extreme Neuro team. The team also relied on measures that were historically collected, such as volume statistics, to support comparison against historical performance. The stroke team reviewed all measures monthly and considered the impacts of results on team objectives. Agreement from the stakeholders was sought throughout the design and implementation of the actions. Stakeholder input was key to the evaluation and determination of the solution and implementation plan. This feedback allowed the team to further refine the solutions implemented. Additionally, the team established and followed a regular schedule of communication with key leadership groups, such as the MABSI committee, the performance improvement steering committee, and SLH s board of directors. These reports summarized key actions, current performance measures, and the program s effects on the defined objectives. Results Table 2 lists the measures and results for 2000 to The Extreme Neuro team achieved key milestones in 2002, 2003, and The stroke intervention rate increased from 18% in 2000 to 31% year-to-date July The overall volume of patients referred to the stroke program has increased dramatically (76%) since Triage time has remained close to the recommended time of 1 hour [3,12]. The mortality rate rose in as compared with 2000, but this reflects the increasing complexity and illness of patients referred to the stroke program as indicated by higher admission NIHSS scores. A regional network of 30 hospitals has been established and a marketing plan was fully developed in 2002 that has increased community awareness of stroke symptoms and the importance of prompt treatment. In addition, an educational grant was obtained for the development of a CD-ROM to communicate to physicians and the community about the Extreme Neuro team. MABSI s research agenda has grown during this time from 1 to 5 clinical trials, allowing the intervention window to be expanded from 3 hours (IV tpa) to 8 hours (mechanical clot retrieval). An analysis of the data collected on patients seen from January 2000 through June 2003 was done to compare outcomes in patients who were transferred to SLH versus the patients who primarily presented to SLH. Mortality rates and good outcomes (defined as a NIHSS score of 4 or lower at discharge) were similar in the 2 groups. The conclusion was that the protocols for transfer were safe and effective (Table 3). The program had other positive results as well, including 636 JCOM October 2004 Vol. 11, No. 10

6 REPORTS FROM THE FIELD PERFORMANCE IMPROVEMENT Table 2. Ischemic Stroke Outcome Summary Data Element * Comparative Data Patient volume, n NA TIA Ischemic Hemorrhagic Intervention Total Intervention rate, % [4,5] Stroke intervention, % NA IV tpa IA tpa IV/IA tpa Device alone NA NA Device + tpa NA NA Mortality rate, % Intervention case [7] Neurovascular (all) [7 9] Symptomatic hemorrhage [10] Triage to treatment time, hr 1:00 [11] Referring hospital 1:22 1:28 1:23 1:23 1:33 St. Luke s 2:09 1:28 1:21 1:22 1:12 Discharge disposition, % NA Home Rehab Nursing home Customer preference market NA NA NA ranking Customer satisfaction rating of NA 4 or 5, % Profit/loss, contribution * NA margin 1000 *2004 data annualized YTD, 2nd quarter Through 2nd quarter improved staff retention and enhanced recruitment. Four nurses in the stroke program renewed their AANN certification and the program s recognition resulted in the recruitment of 2 additional neurologists. In 2004, the stroke program was awarded Joint Commission on Accreditation of Healthcare Organizations disease-specific certification as a primary stroke center. The MABSI business line showed increased profitability (contribution margin) from $4.9 million in 2000 to $6.1 million in Discussion MABSI s stroke intervention rate is higher than that reported in the literature [4,5,10,13,14]. We believe this is partly due to the regional network of hospitals that partners with the Extreme Neuro team neurologists in managing and transferring patients. The network has self-organized, developing organically and informally in response to defined educational programs established by the Extreme Neuro team, to communication links between the attending neurologists, and to the referring physicians ease of transfers and access. Instituting standardized protocols and order sets within the referring institutions has systematized the care process. A primary reason for the program s success is the commitment of its neurologists and interventional neuroradiologists to respond 24 hours a day, 7 days a week for clinical and technical coverage. The availability of several tpa protocols also has increased the intervention rate. Finally, the 6-hour window for IA tpa allows many more patients to be treated. Based on its current experience and using the Improve step of SLH s performance improvement model, the Vol. 11, No. 10 October 2004 JCOM 637

7 STROKE PROGRAM Table 3. Comparison of Patients Receiving Stroke Reversal Therapy No Transfer (n = 62) All Transfer (n = 158) Variable Admission Discharge Admission Discharge NIHSS score > Mortality NIHSS = National Institutes of Health Stroke Scale. Extreme Neuro team has identified future actions that will further improve its performance. These actions are to: Increase the number of hospitals in the regional network and to help top referring hospitals gain designation as primary stroke centers Shorten triage to treatment time from 1.5 hours to 1 hour Further refine metrics to reflect the intervention rate of patients reaching SLH within the treatment window Continue to operate and update the community outreach Web site that was completed in summer 2004 Continue to increase the number of nurses attaining AANN certification Improve overall customer satisfaction scores The Extreme Neuro team has shared the lessons it has learned internally with the nursing quality committee, nursing practice council, medical grand rounds, and the hospital leadership group. The team presented at the SLH Quality Teamwork Day, sharing its best practices with other performance improvement teams. Within MABSI, it is anticipated that additional teams will be chartered to look at other MABSI patient populations using Extreme Neuro s approach as a method for identifying and implementing improvement strategies. The team has also shared its lessons learned beyond SLH. An article in the journal Stroke articulates lessons learned to external audiences [7]. The data presented there supports the premise that a comprehensive stroke center in a tertiary hospital can work with regional hospitals to increase the use of tpa in the treatment of acute stroke. Since 1999, SLH has shared its expertise with 24 hospitals that have visited to learn from its experience in stroke care. The innovative aspect of the development of the Extreme Neuro approach is the use of the hospital s service design and performance improvement model to create a patient care service that delivers life-saving care in a very short time frame by coordinating the activities of not only a large number of care givers across multiple specialty lines, but also the efforts of 30 institutions while simultaneously educating the public on the symptoms of stroke and the importance of seeking immediate help. Corresponding author: Marilyn Rymer, MD, 3rd Fl., Saint Luke s Hospital, 4401 Wornall Rd., Kansas City, MO The Extreme Neuro team members are Marilyn Rymer, MD, Debbie Summers, RN, Lauri Higgins, RN, Duane Thrutchley, RN, Barbara Grunenefelder, RN, Veronica Koontz, and Kevin Thorpe. The Extreme Neuro support team members are Marshall Dean, Steve Arkin, MD, Irene Bettinger, MD, Christine Boutwell, MD, Michael Schwartzman, MD, Charles Weinstein, MD, Naveed Akhtar, MD, Thomas Grobelny, MD, the East-1 and MICU stroke nurses, the emergency department physicians and nurses, and the radiology specials team. References 1. Goldstein LB, Adams R, Becker K, et al. Primary prevention of ischemic stroke: a statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke 2001;32: Brott T, Bogousslavsky J. Treatment of acute ischemic stroke. N Engl J Med 2000;343: Adams HP, Adams RJ, Brott T, et al. Guidelines for the early management of patients with ischemic stroke. A scientific statement from the Stroke Council of the American Heart Association. Stroke 2003;34: Alberts MJ, Hademenos G, Latchaw RE, et al. Recommendations for the establishment of primary stroke centers. Brain Attack Coalition. JAMA 2000;283: Katzan IL, Furlan AJ, Lloyd LE, et al. Use of tissue-type plasminogen activator for acute ischemic stroke: the Cleveland area experience. JAMA 2000;283: Gharajedaghi J. Systems thinking: managing chaos and complexity a platform for designing business architecture. Woburn (MA): Butterworth-Heinemann; Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-pa Stroke Study Group. N Engl J Med 1995;333: Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA 1999;282: del Zoppo GJ, Higashida RT, Furlan AJ, et al. PROACT: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. PROACT Investigators. Prolyse in Acute Cerebral Thromboembolism. 638 JCOM October 2004 Vol. 11, No. 10

8 REPORTS FROM THE FIELD PERFORMANCE IMPROVEMENT Stroke 1998;29: Wang DZ, Rose JA, Honings DS, et al. Treating acute stroke patients with intravenous tpa. The OSF stroke network experience. Stroke 2000;31: National Institute of Neurological Disorders and Stroke. Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke. Bethesda (MD): National Institutes of Health; NIH Publication No Rymer MM, Thurtchley D, Summers D. Expanded modes of tissue plasminogen activator delivery in a comprehensive stroke center increases regional acute stroke interventions. Stroke 2003;34:e Hill MD, Barber PA, Demchuk AM, et al. Building a brain attack team to administer thrombolytic therapy for acute ischemic stroke. CMAJ 2000;162: Grotta JC, Burgin WS, El-Mitwalli A, et al. Intravenous tissuetype plasminogen activator therapy for ischemic stroke: Houston experience 1996 to Arch Neurol 2001;58: Copyright 2004 by Turner White Communications Inc., Wayne, PA. All rights reserved. Vol. 11, No. 10 October 2004 JCOM 639