Multidisciplinary Approach to Decrease In-Hospital Delay for Stroke Thrombolysis

Abstract

Background and Purpose Decreasing the time delay for thrombolysis, including intravenous thrombolysis (IVT) with tissue plasminogen activator and intra-arterial thrombectomy (IAT), is critical for decreasing the morbidity and mortality of patients experiencing acute stroke. We aimed to decrease the in-hospital delay for both IVT and IAT through a multidisciplinary approach that is feasible 24 h/day. Methods We implemented the Stroke Alert Team (SAT) on May 2, 2016, which introduced hospital-initiated ambulance prenotification and reorganized in-hospital processes. We compared the patient characteristics, time for each step of the evaluation and thrombolysis, thrombolysis rate, and post-thrombolysis intracranial hemorrhage from January 2014 to August 2016. Results A total of 245 patients received thrombolysis (198 before SAT; 47 after SAT). The median door-to-CT, door-to-MRI, and door-to-laboratory times decreased to 13 min, 37.5 min, and 8 min, respectively, after SAT implementation (P<0.001). The median door-to-IVT time decreased from 46 min (interquartile range [IQR] 36–57 min) to 20.5 min (IQR 15.8–32.5 min; P<0.001). The median door-to-IAT time decreased from 156 min (IQR 124.5–212.5 min) to 86.5 min (IQR 67.5–102.3 min; P<0.001). The thrombolysis rate increased from 9.8% (198/2,012) to 15.8% (47/297; P=0.002), and the post-thrombolysis radiological intracranial hemorrhage rate decreased from 12.6% (25/198) to 2.1% (1/47; P=0.035). Conclusions SAT significantly decreased the in-hospital delay for thrombolysis, increased thrombolysis rate, and decreased post-thrombolysis intracranial hemorrhage. Time benefits of SAT were observed for both IVT and IAT and during office hours and after-hours.

Improving the Clinical Outcome in Stroke Patients Receiving Thrombolytic or Endovascular Treatment in Korea: from the SECRET Study

“…Earlier treatment would also reduce the risk of symptomatic intracranial hemorrhage. [26,27] In Korea, there have been continuing efforts on reducing the time delay for patients with stroke using the stroke code system based on the computerized physician order entry system [9,27]. Actually, our data showed that mean time from door to initiation of treatment was continuously decreasing (up to 41.1 min for IV t-PA or 113 min for groin puncture).…”

Delayed Intravenous Thrombolysis in Patients with Minor Stroke

“…The hospitals in the present study did not use a protocol for hospital prenotification by emergency medical services. Additionally, the behavior and actions of the ED staff with patients with minor stroke may differ in hospitals with such prenotification systems [4,21,22]. Therefore, possible differences in the hospitals' care systems should be considered when interpreting our results.…”

“…Other clinical studies also have shown that the shortening of treatment time for tPA was not often accompanied by improvements in clinical outcomes [3,4,20]. However, previous meta-analyses with larger sample sizes have demonstrated the benefit of rapid treatment even in patients with minor stroke [1,21]. Although no obvious difference in functional outcomes was found in this study, we think that every effort should be made to reduce the time delay even in patients with minor stroke, as is recommended in guidelines [22].…”

“…Next, we determined whether the intervals within the door-to-needle time were different between the groups to establish which step may contribute to the delayed door-to-needle time. We found that the door-to-notification time ( [11][12][13][14][15][16][17][18][19][20][21], p < 0.001) were significantly longer in the minor stroke group than they were in the non-minor stroke group. However, the notification-to-imaging time and imaging-to-needle time were not different between the 2 groups, nor was the onset-to-door time (Table 2).…”

Assessment of nursing care-associated predictors of in-hospital mortality in the patients with acute ischemic stroke

“…It is well known that complications are associated with worse outcome in those patients 23 . Further, in Korea, the nurses are included in the Stroke Alerts Teams (SAT) organized with the aim to accelerate time to thrombolysis in the patients with AIS 24 . In London, where 8 hyper-acute stroke units were established in 2010, the nursing staff is involved in thrombolysis treatment in terms of the patients' fulfillment of criteria for receiving this therapy, providing accommodation and adequate care 25 .…”