Introduction

Stroke is among the leading causes of severe long-term disability and death in t
he United States, ranking fourth as a cause for mortality behind heart disease,
cancer, and chronic lower respiratory disease (1). An estimated 795,000 people s
uffer from a new or recurrent stroke each year; stroke mortality was approximate
ly 134,000 in 2008 (1). In Massachusetts, stroke continues to be the third leadi
ng cause of death and disability, contributing to over 17,000 hospitalizations a
nd 2,500 deaths annually (2).
Emergency medical services (EMS) are the first point of contact for approximatel
y half of all patients with acute stroke symptoms in Massachusetts (3). Patients
transported by EMS have faster prehospital transport, in-hospital evaluation, a
nd treatment times (4 6). Patients arriving with suspected stroke also comprise most
cases presenting in the 3-hour window for intravenous tissue plasminogen activa
tor (IV t-PA), the only Food and Drug Administration approved treatment of acute isc
hemic stroke (3,7).
Guidelines that focus on the importance of stroke recognition, rapid triage and
transport, and hospital prenotification exist for EMS assessment and management
of patients with suspected stroke (8,9); however, there are no nationally recogn
ized prehospital stroke performance measures for gauging guideline adherence. Re
search suggests that prehospital stroke care is inconsistent (10,11), and gaps i
n stroke care significantly affect timely treatment on arrival at a hospital (12
). However, EMS agencies often have few resources available to identify and addr
ess gaps in performance.
Quality improvement collaboratives (QICs) are a popular method in use in health
care to address the gaps between evidence-based practice and clinical patient ca
re. QICs bring together providers from different organizations to work in a stru
ctured way to improve the quality of their patient care. Through a series of mee
tings, participants learn about evidence-based best practices and quality improv
ement (QI) methods while sharing their own experiences and making changes in the
ir organizations. The Massachusetts EMS Stroke QIC was based on the Institute fo
r Healthcare Improvement s (IHI) Breakthrough Series approach, which is designed to
help organizations make breakthrough improvements by creating a forum in which partic
pants can simultaneously learn improvement strategies from each other and from e
xperts (13). Hospitals, clinics, primary care practices, and nursing homes frequ
ently use this process. Evidence of the impact of QICs in these settings is posi
tive but limited (14). Little is known about the use of this approach in EMS.
In 2008, the Massachusetts Department of Public Health s (MDPH s) Heart Disease and Str
ke Prevention and Control Program began a stroke QIC pilot, modeled after their
Paul Coverdell National Acute Stroke Registry QIC, the Stroke Collaborative Reac
hing for Excellence (SCORE) (15). Its purpose was to understand how the collabor
ative model could be used to address gaps in prehospital stroke care. The goal o
f this pilot was 2-fold: to determine the feasibility of an EMS collaborative an
d to assist EMS providers with implementing changes that would lead to consisten
t delivery of high-quality stroke care. This article describes the formation and
characteristics of the QIC, the development and use of stroke performance measu
res, and best practices and challenges in using the collaborative method for EMS
clinical QI.