The American Stroke Association endorses an evidence-base protocol for treating patients with a stroke. Each step is vital, and together they help achieve the best possible outcome for the patient. The metric "defect-free care" describes whether patients received all of the eligible quality-of-care measures that are established by the Get with the Guidelines recommendations. These include:

• IV tPA within 3 hours of symptom onset
• Deep Venous Thrombosis (DVT) prophylaxis
• Discharge antithrombotics
• Anticoagulation for atrial fibrillation
• Lipid lowering agent if LDL>100mg/dL
• Smoking cessation intervention¹. 

Compliance to these guidelines helps to improve the outcomes of stroke patients1. However, national defect-free care for stroke patients remains relatively low. In 2017 only 21.9% of patients presenting non-primary stroke centers received care that met all of the necessary guidelines nationally. This number was as high as 52% in certified stroke center hospitals². 

The American Heart Association/Arkansas Stroke Associtaion has set a benchmark that 75% of acute stroke patientes recieve defect-free care. In 2018 the Arkansas defect-free care percentage was 66.5% which has been trending upward since 2012 when it was 54.9%. This trend is promising, and the benchmark could be met in the coming years with continued proper care of Arkansans. 

Source: ¹Ormseth, C. H., Sheth, K. N., Saver, J. L., Fonarow, G. C., & Schwamm, L. H. (2017). The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke and vascular neurology, 2(2), 94–105. doi:10.1136/svn-2017-000092

Source : ²Mozaffarian D, Benjamin EJ, Go AS, et al. on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2015 update: a report from the American Heart

• Acute Stroke Care Task Force
• American College of Cardiology 
• Arkansas Department of Health Tobacco Cessation and Prevention Branch 
• Arkansas Department of Health Trauma Branch – Stroke and STEMI Section 
• Arkansas Department of Health Chronic Disease Branch 
• Heart Disease and Stroke Prevention Coalition 
• Mercy Telestroke System 
• UAMS Center for Distance Health - AR SAVES (Arkansas Stroke Assistance through Virtual Emergency Support)

Each of the performance guidelines that constitute defect free care are important individually and as a whole. The importance of timely rt-tPA has been discussed elsewhere in this scorecard, and the evidence clearly shows its relationship with improved post-stroke recovery¹. DVT prophylaxis is important in patients with stroke because they are at an increased risk of forming a blood clot due to immobility and increased clotting activity². Antithrombotics are also recommended to decrease the risk of future clots, and strokes. Anticoagulation must be initiated at discharge if the patient is diagnosed with atrial fibrillation. Atrial fibrillation increases the risk of future stroke if left untreated³. Additionally, statins hve been shown to decrease the risk of future stroke⁴. Of course smoking cessation is also encouraged. One study demonstrated that the 5-year risk for stroke decreased from 22 to 15.7% in people who quit smoking⁵.

All of this evidence supports the need to ensure that Arkansas meets the American Health Association benchmark for defect free care. Action is necessary in order to ensure that this is accomplished.

Source: ¹Saver JL, Fonarow GC, Smith EE, et al. Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke. JAMA. 2013;309(23):2480–2488. doi:10.1001/jama.2013.6959

Source: ²Kappelle LJ. Preventing deep vein thrombosis after stroke: strategies and recommendations. Curr Treat Options Neurol. 2011;13(6):629–635. doi:10.1007/s11940-011-0147-4

Source: ³McGrath ER, Kapral MK, Fang J, et al. ; Investigators of the Ontario Stroke Registry . Antithrombotic therapy after acute ischemic stroke in patients with atrial fibrillation. Stroke. 2014;45(12):3637-3642. 

Source: ⁴Flint AC, Conell C, Ren X, Kamel H, Chan SL, Rao VA, et al. Statin adherence is associated with reduced recurrent stroke risk in patients with or without atrial fibrillation. Stroke. 2017;48:1788–1794. doi: 10.1161/STROKEAHA.117.017343. 

Source: ⁵Boehme, Amelia. Smoking cessation and secondary stroke prevention. Neurology Oct 2017, 89 (16) 1656-1657; DOI:10.1212/WNL.0000000000004530

The CDC/COV Defect Free Care is a “high bar” to reach. It is a reflection of “perfect care” with relationship to the measures “IV-tPA: Arrive by 2 hours, treat by 3 hours”; “Early anti-thrombotics”; “VTE prophylaxis”; “LDL 100 or ND”; “Antithrombotics”; “Anticoagulation for A-fib/Aflutter”; “Smoking Cessation”; “Dysphagia Screen”; “Stroke Education”; “Rehabilitation Considered”. The denominator is the number of PATIENTS and the numerator is the number of PATIENTS that received all 10 of the consensus measures (if appropriate). It is an “all or nothing” measure. By improving adherence to the 10 stroke consensus measures, defect –free care will improve. The Arkansas Department of Health State Stroke Coordinator works with Arkansas Hospitals’ stroke teams and EMS agencies to implement quality improvement projects that consist of up-to-date, evidence-based initiatives that uses an interdisciplinary team to improve stroke care, increase low adherence rates for state and nationally recognized stroke measure performance scores, improved timely stroke documentation needed to show compliance with stroke performance measures and community stroke education and awareness. Optimal reduction in delays is not achievable by any single intervention, but rather results from thecontinuous analysis and improvement of the system as a whole which includes Arkansas Stroke Partners and Leaders, Hospitals’ Stroke Teams and EMS Agencies. 

Hospitals’ Internal Stroke Teams are asked to meet monthly or bi-monthly to review registry data and make recommendations for stroke care quality improvement initiatives that are reasonable and feasible for hospitals to implement and closely communicate and collaborate with EMS Stroke Leaders to continuously monitor adherence rates to stroke measures and proposed quality improvement initiatives accordingly. The continuous use the Plan-Do-Study-Act (PDSA) model for quality improvement projects has assisted the Arkansas Department of Health State Stroke Nurse Coordinator to aim at making best available changes within Arkansas hospitals programs and EMS agencies, especially for timely stroke care improvements.