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

Abstract

For each subgroup, we analyzed frequency of thrombolytic treatments, time intervals, and outcomes (3-month modified Rankin Scale score 0-2 as good functional outcome, mortality, symptomatic intracerebral hemorrhage). Results-We included 21 513 patients. Considering the mean expected number of patients treated per hour (0.4) and per day of the week (9.8), if no temporal variations were present, patients were significantly treated more during day hours and weekdays (P<0.0001). Median door-to-needle and onset-to-treatment times were longer for patients treated during night hours and on weekends (P<0.01). After adjustment for confounding variables, treatment during day hours was an independent predictor of good functional outcome (odds ratio, 1.12; 95% confidence interval, 1.04-1.21; P=0.004), and patients treated during weekdays were at risk of higher mortality (odds ratio, 1.15; 95% confidence interval, 1.04-1.28; P=0.008). Conclusions-Frequency of thrombolytic treatment seems to follow the same circadian pattern of stroke incidence, whereas its correspondence to a weekly pattern is less clear. Time of treatment is an independent predictor of outcome. (Stroke. 2014;45:176-184.)

Pre-hospital notification is associated with improved stroke thrombolysis timing

“…It continues to prove challenging to achieve the Quality Improvement Scotland standard for 80% of thrombolysed stroke patients having door to needle times ≥60 minutes, 11 and a minority of patients tend to be treated within 60 minutes of hospital arrival in international studies. 13,[17][18][19][20] In contrast, both in England and from the SITS registry, the majority of patients treated in higher volume centres (defined as thrombolysis of >50 or >100 stroke patients/year, respectively) have door to needle times within 60 minutes. 19,20 Earlier door to CT time is also noted in higher volume centres 18 and when prehospital notification is used.…”

“…12 Analysis of the SITS database found that median door to needle times were several minutes longer for patients treated during a weeknight or at the weekend compared to treatment on a weekday. 13 The reason for the lack of difference in out of hours treated patients in our centre is unclear, although locally we have been working collaboratively with our ambulance service, radiological and emergency department colleagues to improve thrombolysis times over several years. Other reasons may include less competing clinical work out of hours, and fewer routine scans potentially delaying emergency scans.…”

Effect of an Enhanced Paramedic Acute Stroke Treatment Assessment on Thrombolysis Delivery During Emergency Stroke Care

“…1 In the UK, national audit reports continue to show large differences in performance between services and diurnal fluctuations attributable to variations in local assessment processes and stroke specialist availability. [2][3][4] Improvements in delivery have resulted from hospital-based reorganization of services, [4][5][6] but many sites still report suboptimal rates and slow treatment times. 2,3 The prehospital phase of emergency stroke care has been targeted with interventions to facilitate thrombolysis treatment, including multiprofessional workforce training, 6 raising the service priority level for suspected stroke, 7 hospital prenotification, 8 and personalized feedback to paramedics about care quality.…”

“…[2][3][4] Improvements in delivery have resulted from hospital-based reorganization of services, [4][5][6] but many sites still report suboptimal rates and slow treatment times. 2,3 The prehospital phase of emergency stroke care has been targeted with interventions to facilitate thrombolysis treatment, including multiprofessional workforce training, 6 raising the service priority level for suspected stroke, 7 hospital prenotification, 8 and personalized feedback to paramedics about care quality. 9 Reports have described short-term improvements, but studies were setting specific and/or observational.…”

Effects of Golden Hour Thrombolysis

“…In the Safe Implementation of Thrombolysis-Stroke Monitoring Study (SITS-MOST) registry, 7 10.6% of 6483 patients were treated within 90 minutes and only 1.4% within 60 minutes. The median OTT in the SITS-International Stroke Thrombolysis Register 8 was 145 (interquartile range [IQR], 115-170) minutes. Structured approaches have been successful in increasing thrombolysis rates and shortening door-to-needle times.…”