The impact of standardized stroke orders on adherence to best practices

Background: Standardized order templates have been credited with improving care for several common medical conditions. The authors sought to determine whether use of standard orders would be associated with improvement in stroke care. Methods: All patients with a discharge diagnosis of ischemic stroke were identified from seven hospitals in California participating in a CDC-sponsored Coverdell Acute Stroke Pilot Registry. The authors tracked six points of care: thrombolysis, receipt of antithrombotic medications within 48 hours, prophylaxis for deep venous thrombosis (DVT), smoking cessation counseling, and prescription of lipid-lowering and antithrombotic medications at discharge. Scoring was based on optimal treatment, defined as receiving or having a valid contraindication to a given intervention. Baseline scores in year 1 were compared to those in year 2, after implementation of an intervention based upon standardized stroke orders. Results: Overall, rates of optimal treatment improved for patients treated in year 2 (n = 226) compared to year 1 (n = 187), with 63% of patients receiving a perfect score in year 2 compared to 44% in year 1 (p < 0.0001). Rates significantly improved in four of six hospitals, when the hospital was considered the unit of intervention, and for four of the six specific measures. A seventh hospital that participated in the registry but did not implement standardized orders showed no improvement in optimal treatment. Conclusions: Implementation of standardized stroke orders and registry monitoring was associated with improvements in utilization of a number of proven interventions. Although these data are observational, they demonstrate the potential impact of simple system-wide interventions in improving care of stroke.