Impact of Hospital Admission During Nonworking Hours on Patient Outcomes After Thrombolysis for Stroke

Abstract

Background and Purpose-Whether the time of hospital admission is relevant for short-term outcome after stroke is under debate and may depend on care facilities. Methods-We retrospectively analyzed medical records from patients who received thrombolytic therapy within 4.5 hours of stroke onset in a stroke unit of the Charité-University Hospital Berlin (Charité; nϭ291) or within the stroke telemedicine (TEMPiS) network, comprising 12 community hospitals with telestroke units in Bavaria (nϭ616). Results-Thrombolytic therapy was administered during nonworking hours in 59.5% (Charité) and 55.0% (TEMPiS) of patients. A trend toward a lower rate of symptomatic intracranial hemorrhage (3.4% versus 9.2%; Pϭ0.053), clinical worsening (11.9% versus 19.7%; Pϭ0.079), and 7-day mortality (3.4% versus 8.7%; Pϭ0.073) after admission during working hours was seen at Charité. However, multivariable analysis did not show a significant impact of the time of admission on clinical worsening, symptomatic intracranial hemorrhage, or 7-day mortality in both cohorts. Thrombolysis based on brain computed tomography instead of magnetic resonance imaging (odds ratioϭ4.98, 95% CI, 1.09 to 22.7) and more severe National Institutes of Health Stroke Scale score on admission (odds ratioϭ1.15 per point; 95% CI, 1.07 to 1.24) were associated with 7-day mortality at Charité. National Institutes of Health Stroke Scale score on admission (odds ratioϭ1.13 per point; 95% CI, 1.06 to 1.19) and older age (odds ratioϭ1.05 per year; 95% CI, 1.004 to 1.09) were correlated with 7-day mortality in TEMPiS. National Institutes of Health Stroke Scale on admission was the only independent predictor of symptomatic intracranial hemorrhage or clinical worsening in both cohorts. Conclusions-The majority of stroke patients received thrombolysis during nonworking hours. The time of hospital admission did not significantly influence the short-term outcome after thrombolysis. (Stroke. 2011;42:2521-2525.)

Within-Day and Weekly Variations of Thrombolysis in Acute Ischemic Stroke

“…Patients' characteristics were mostly homogeneous across all the subgroups, particularly, as previously reported, 23,28 with regard to the median baseline stroke severity. There is the exception for some, more statistically than clinically, significant differences, probably related to the large sample size that allows the detection of even small imbalances.…”

“…We did not find statistical differences in the door-to-imaging time between the paired subgroups, suggesting that there were no disparities at least in the availability of diagnostic procedures, similar to what was reported in recent studies. 23,28 The longer door-to-needle time and onset-to-treatment time in the range of a few minutes during night hours and on weekends may suggest a tendency to a delay, although little, in certain procedures for the management of patients with stroke during these time periods.…”

“…41 Finally, other studies, some of which specifically focused on patients treated with thrombolysis, did not observe a night or weekend effect. [25][26][27][28][29] All those studies were conducted in single or few centers in a single country and hence were at risk for center effects, and their results could not be generalized.…”

“…Hence, it is urgent to understand whether the access to thrombolytic treatment is always guaranteed, and with the same safety and efficacy, irrespective of time and day of treatment. Few recent studies on this issue found controversial results, 16,[23][24][25][26][27][28][29] one reporting higher case fatality rates in patients treated during working hours, 23 whereas another reporting that diurnal IV tissue-type plasminogen activator (t-PA) administration was independently associated with early recanalization and better 90-day functional outcome. 24 Other studies showed that the majority of patients with stroke received thrombolysis during nonworking hours and that time of hospital admission was not an independent predictor of outcome.…”

“…24 Other studies showed that the majority of patients with stroke received thrombolysis during nonworking hours and that time of hospital admission was not an independent predictor of outcome. 16,[25][26][27][28][29] In a large cohort of patients treated with IV thrombolysis in several centers from European and non-European countries and entered into the Safe Implementation of Treatments in StrokeInternational Stroke Thrombolysis Register (SITS-ISTR), we aimed to evaluate whether thrombolytic treatment for acute ischemic stroke has a within-day variation corresponding to the circadian pattern of stroke onset and a weekly variability, and whether these have an impact on clinical outcome.…”