Use of Strategies to Improve Door-to-Needle Times With Tissue-Type Plasminogen Activator in Acute Ischemic Stroke in Clinical Practice

Abstract

Background— The implementation of Target: Stroke Phase I, the first stage of the American Heart Association’s national quality improvement initiative to accelerate door-to-needle (DTN) times, was associated with an average 15-minute reduction in DTN times. Target: Stroke phase II was launched in April 2014 with a goal of promoting further reduction in treatment times for tissue-type plasminogen activator (tPA) administration. Methods and Results— We conducted a second survey of Get With The Guidelines-Stroke hospitals regarding strategies used to reduce delays after Target: Stroke and quantify their association with DTN times. A total of 16 901 ischemic stroke patients were treated with intravenous tPA within 4.5 hours of symptom onset from 888 surveyed hospitals between June 2014 and April 2015. The patient-level median DTN time was 56 minutes (interquartile range, 42–75), with 59.3% of patients receiving intravenous tPA within 60 minutes and 30.4% within 45 minutes after hospital arrival. Most hospitals reported routinely using a majority of Target: Stroke key practice strategies, although direct transport of patients to computed tomographic/magenetic resonance imaging scanner, premix of tPA ahead of time, initiation of tPA in brain imaging suite, and prompt data feedback to emergency medical services providers were used less frequently. Overall, we identified 16 strategies associated with significant reductions in DTN times. Combined, a total of 20 minutes (95% confidence intervals 15–25 minutes) could be saved if all strategies were implemented. Conclusions— Get With The Guidelines-Stroke hospitals have initiated a majority of Target: Stroke–recommended strategies to reduce DTN times in acute ischemic stroke. Nevertheless, certain strategies were infrequently practiced and represent a potential immediate target for further improvements.

Time to acute stroke treatment in‐hours was more than halved after the introduction of the Helsinki Model at Westmead Hospital

“…They determined that the median reduction in DNT by using all of their strategies was 20 min. 13,14 Wu et al 15 at Christchurch Hospital, New Zealand, report a similarly significant DNT reduction to our study. They implemented features of the Helsinki protocol over a 2-year period with a similarly resourced stroke team as in our study and achieved a reduction of their in-hours DNT from 87 to 34 min.…”

“…In the United States, the Target:Stroke initiative implemented similar processes as those reported in Helsinki. They determined that the median reduction in DNT by using all of their strategies was 20 min …”

“…Both groups recorded very rapid DCT of 3 min or less; in both groups, this occurred only in patients who were pre‐notified. This emphasises the importance placed on moving patients straight through the emergency department on the ambulance stretcher, which on its own has been shown to contribute to reducing DNT . Nevertheless, each patient underwent an initial assessment to ensure safe transfer to the radiology department.…”

“…This emphasises the importance placed on moving patients straight through the emergency department on the ambulance stretcher, which on its own has been shown to contribute to reducing DNT. 13 Nevertheless, each patient underwent an initial assessment to ensure safe transfer to the radiology department. This included recording of vital signs, an assessment by the stroke registrar regarding whether a patient carried a potential stroke diagnosis and any contraindications for proceeding to urgent CT.…”

Geospatial Visualization of Mobile Stroke Unit Dispatches: A Method to Optimize Service Performance

“…Prior to MSU program expansion in the USA, a survey of hospitals participating in the Get With The Guidelines-Stroke Target: Stroke Phase II initiative revealed that alteplase was given to only 59.3% of eligible stroke presenters within 60 min and to only 30.4% within 45 min [11]. Mobile stroke units have shown an ability to treat patients rapidly, with median alarmto-treatment times more than 20 to 30 min faster than standard hospital treatment [2][3][4].…”