Association between i.v. thrombolysis volume and door-to-needle times in acute ischemic stroke

Abstract

Centralization of intravenous thrombolysis (IVT) for acute ischemic stroke in high-volume centers is believed to improve the door-to-needle times (DNT), but limited data support this assumption. We examined the association between DNT and IVT volume in a large Dutch province. We identified consecutive patients treated with IVT between January 2009 and 2013. Based on annualized IVT volume, hospitals were categorized as low-volume (≤24), medium-volume (25–49) or high-volume (≥50). In logistic regression analysis, low-volume hospitals were used as reference category. Of 17,332 stroke patients from 11 participating hospitals, 1962 received IVT (11.3 %). We excluded 140 patients because of unknown DNT (n = 86) or in-hospital stroke (n = 54). There were two low-volume (total 101 patients), five medium-volume (747 patients) and four high-volume hospitals (974 patients). Median DNT was shorter in high-volume hospitals (30 min) than in medium-volume (42 min, p < 0.001) and low-volume hospitals (38 min, p < 0.001). Patients admitted to high-volume hospitals had a higher chance of DNT < 30 min (adjusted OR 3.13, 95 % CI 1.70–5.75), lower risk of symptomatic intracerebral hemorrhage (adjusted OR 0.39, 95 % CI 0.16–0.92), and a lower mortality risk (adjusted OR 0.45, 95 % CI 0.21–1.01), compared to low-volume centers. There was no difference in DNT between low- and medium-volume hospitals. Onset-to-needle times (ONT) did not differ between the groups. Hospitals in this Dutch province generally achieved short DNTs. Despite this overall good performance, higher IVT volumes were associated with shorter DNTs and lower complication risks. The ONT was not associated with IVT volume.

Disparities and Trends in Door-to-Needle Time

“…[18] DTNT≤60 was also more common in patients treated at larger hospitals. Hospitals with greater ischemic stroke admissions per year and greater volume of IV tPA treated patients per year [6, 8, 19] are more likely to treat within 60 minutes. Previous studies reported that hospitals that treat larger proportions of Black patients have better tPA administration rates for Blacks.…”

Thrombolysis related symptomatic intracranial hemorrhage in estimated versus measured body weight

“…Linear regression analysis was performed to assess the association between weight modality and DNT, presented as regression coefficient (B) and corresponding 95% CI. In secondary analysis, we adjusted for baseline characteristics associated with outcomes (P < 0.1) except for the analysis related to the outcome DNT where we adjusted for variables known to have an association with the DNT: availability of a CT in the emergency room (ER), blood pressure above the threshold for IVT (>185/110 mmHg), NIHSS score at baseline, 22,23 onset-to-door time (defined as the time between stroke onset and patient arrival at the hospital) and for annual IVT-volume divided as follows: lowvolume ( 24), medium-volume (25-49), or highvolume (!50) as described previously, with low-volume as reference category. 24 In subgroup analyses we investigated if differences in methods within the EBW or the MBW group could have affected the association between weight modality and the outcome measures.…”

“…Finally, in our study weight modality was not associated with DNT even after adjusting for factors such as IVT volume, CT availability on the ER, baseline NIHSS, and blood pressure above IVT threshold. 24,[29][30][31] Nevertheless, other unknown factors related to the DNT we could not adjust for could possibly explain this lack of an association.…”

Treatment with Intravenous Thrombolysis in Acute Ischemic Stroke Through the Perspective of a State Hospital

“…Bu durumu, merkezimizin bulunduğu Aydın ilinin nüfusunun diğer çalışmaların yapıldığı illere oranla daha az olması, dolayısıyla hasta yoğunluğunun servislerde daha az olması ve hastalara daha hızlı müdahale edilebilmesi ile açıklayabiliriz. Bizim çalışmamız da dahil olmak üzere ülkemizde yapılan çalışmalarda (19,21,33) bildirilen Kİ zamanı; yurt dışındaki çalışmalarda (20,22) Sonuç olarak NINDS rt-PA, ECASS, ECASS II, ATLANTIS çalışmalarının dâhil edildiği havuz analizinde erken zaman diliminde tedavi alanların, iyileşme yönünde daha yüksek şansa sahip olduğu anlaşılmaktadır (25). Çalışmamızda; Sİ zamanı ile NIHSS' da ki düzelme arasındaki ilişki incelendi ve orta derecede negatif bağıntı saptandı.…”

“…Tedavinin %10'u bolus olarak ve geri kalan kısmı bir saat içinde infüzyon olarak verildi. Ayrıca 3-4.5 saat aralığında olan iskemik inme hastaları için ek göreceli uygulamama kriterleri dikkate alındı (7 Tüm hastalar birlikte değerlendirildiğinde NIHSS ortalaması; başvuru esnasında 12±4 (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22), tedaviden sonra yirmi dördüncü saatte 8±7 (0-22) hesaplandı. Kaybedilen hastaları çıkardığımızda ise NIHSS ortalaması tedaviden önce 11±4 (3-18), tedaviden sonra yirmi dördüncü saatte 5±5 (0-18), taburculuk sırasında ise 3±5 (0-18) olarak belirlendi.…”