Strategies Used by Hospitals to Improve Speed of Tissue-Type Plasminogen Activator Treatment in Acute Ischemic Stroke

Background and Purpose— The benefits of intravenous tissue-type plasminogen activator in acute ischemic stroke are time dependent, and several strategies have been reported to be associated with more rapid door-to-needle (DTN) times. However, the extent to which hospitals are using these strategies and their association with DTN times have not been well studied. Methods— We surveyed 304 Get With The Guidelines-Stroke hospitals joining Target: Stroke regarding their baseline use of strategies to reduce DTN times in the January 2008 to December 2009 time frame before the initiation of Target: Stroke and determined the association between hospital strategies and DTN times. Results— Among 5460 patients receiving tissue-type plasminogen activator within 3 hours of symptom onset in surveyed hospitals, the median DTN time was 72 minutes (interquartile range, 55–94). Reported use of the different strategies varied considerably. Of 11 hospital strategies analyzed individually by multivariable analysis, 3 strategies were independently associated with shorter DTN times. These included rapid triage/stroke team notification (209/304 [69%] hospitals, 8.1-minute reduction in DTN time), single-call activation system (190/304 [63%] hospitals, 4.3 minutes), and tissue-type plasminogen activator stored in the emergency department (189/304 [62%] hospitals, 3.5 minutes). When analyzed incrementally, hospitals that used a greater number of strategies had shorter DTN times with 1.3 minutes (adjusted mean difference) saved for each strategy implemented (14 minutes if all strategies were used). Conclusions— Although the majority of participating hospitals reported using some strategy to reduce delays in tissue-type plasminogen activator administration for acute ischemic stroke, the strategies applied vary considerably and those most strongly associated with shorter DTN times were applied relatively less frequently.

[1]  Eric E. Smith,et al.  Door-to-needle times in acute ischemic stroke , 2012, Neurology.

[2]  L. Schwamm,et al.  Hospital treatment of patients with ischemic stroke or transient ischemic attack using the "Get With The Guidelines" program. , 2008, Archives of internal medicine.

[3]  Peter Moyer,et al.  Recommendations for the Establishment of Stroke Systems of Care: Recommendations From the American Stroke Association’s Task Force on the Development of Stroke Systems , 2005, Circulation.

[4]  K. Anstrom,et al.  Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction. , 2007, JAMA.

[5]  J. Saver.  Time Is Brain—Quantified , 2006, Stroke.

[6]  M. Malkoff,et al.  Code stroke. An attempt to shorten inhospital therapeutic delays. , 1994, Stroke.

[7]  Gregory W Albers,et al.  Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials , 2010, The Lancet.

[8]  M. Schulzer,et al.  Reduction in IV t-PA Door to Needle Times Using an Acute Stroke Triage Pathway , 2006, Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques.

[9]  Eric E. Smith,et al.  Data quality in the American Heart Association Get With The Guidelines-Stroke (GWTG-Stroke): results from a national data validation audit. , 2012, American heart journal.

[10]  E. Peterson,et al.  Patterns of Emergency Medical Services Use and Its Association With Timely Stroke Treatment: Findings From Get With the Guidelines-Stroke , 2013, Circulation. Cardiovascular quality and outcomes.

[11]  Eric E. Smith,et al.  Characteristics, Performance Measures, and In-Hospital Outcomes of the First One Million Stroke and Transient Ischemic Attack Admissions in Get With The Guidelines-Stroke , 2010, Circulation. Cardiovascular quality and outcomes.

[12]  H. Krumholz,et al.  A campaign to improve the timeliness of primary percutaneous coronary intervention: Door-to-Balloon: An Alliance for Quality. , 2008, JACC. Cardiovascular interventions.

[13]  Maarten Schrooten,et al.  Treatment Time-Specific Number Needed to Treat Estimates for Tissue Plasminogen Activator Therapy in Acute Stroke Based on Shifts Over the Entire Range of the Modified Rankin Scale , 2009, Stroke.

[14]  K. Welch,et al.  Total quality improvement method for reduction of delays between emergency department admission and treatment of acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. , 1997, Archives of neurology.

[15]  Harlan M Krumholz,et al.  Strategies for reducing the door-to-balloon time in acute myocardial infarction. , 2006, The New England journal of medicine.

[16]  Eric E. Smith,et al.  Improving Door-to-Needle Times in Acute Ischemic Stroke: The Design and Rationale for the American Heart Association/American Stroke Association's Target Stroke Initiative , 2011, Stroke.

[17]  S. Y. Kim,et al.  Pre‐hospital notification reduced the door‐to‐needle time for iv t‐PA in acute ischaemic stroke , 2009, European journal of neurology.

[18]  E. Antman,et al.  Development of Systems of Care for ST-Elevation Myocardial Infarction Patients , 2007 .

[19]  M. Kaste,et al.  Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. , 2008, The New England journal of medicine.

[20]  Eric E. Smith,et al.  Emergency Medical Service Hospital Prenotification Is Associated With Improved Evaluation and Treatment of Acute Ischemic Stroke , 2012, Circulation. Cardiovascular quality and outcomes.

[21]  Adnan I. Qureshi,et al.  Guidelines for the Early Management of Adults With Ischemic Stroke , 2007 .

[22]  L. Thomassen,et al.  Intravenous thrombolysis for ischaemic stroke: short delays and high community-based treatment rates after organisational changes in a previously inexperienced centre , 2009, Emergency Medicine Journal.

[23]  Eric E. Smith,et al.  Temporal Trends in Patient Characteristics and Treatment With Intravenous Thrombolysis Among Acute Ischemic Stroke Patients at Get With the Guidelines–Stroke Hospitals , 2013, Circulation. Cardiovascular quality and outcomes.

[24]  M. Wintermark,et al.  Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association , 2013, Stroke.

[25]  Xin Zhao,et al.  The “Golden Hour” and Acute Brain Ischemia: Presenting Features and Lytic Therapy in >30 000 Patients Arriving Within 60 Minutes of Stroke Onset , 2010, Stroke.

[26]  Adrian F Hernandez,et al.  Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. , 2013, JAMA.

[27]  Peter Moyer,et al.  Recommendations for the Establishment of Stroke Systems of Care: Recommendations From the American Stroke Association’s Task Force on the Development of Stroke Systems , 2005, Circulation.

[28]  Atte Meretoja,et al.  Reducing in-hospital delay to 20 minutes in stroke thrombolysis , 2012, Neurology.

[29]  K. Labresh,et al.  Get with the guidelines. , 2013, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[30]  R E Latchaw,et al.  Recommendations for the establishment of primary stroke centers , 2000 .

[31]  A systems approach to immediate evaluation and management of hyperacute stroke. Experience at eight centers and implications for community practice and patient care. The National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Study Group. , 1997, Stroke.

[32]  Li Liang,et al.  Get With the Guidelines–Stroke Is Associated With Sustained Improvement in Care for Patients Hospitalized With Acute Stroke or Transient Ischemic Attack , 2009, Circulation.

[33]  Jeffrey L Saver,et al.  Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. , 2009, Stroke.

[34]  M. Kaste,et al.  Door to thrombolysis: ER reorganization and reduced delays to acute stroke treatment , 2006, Neurology.

[35]  W. Heiss,et al.  The Cologne Stroke Experience: Safety and Outcome in 450 Patients Treated with Intravenous Thrombolysis , 2007, Cerebrovascular Diseases.

[36]  Joseph P. Broderick,et al.  Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. , 1995 .

[37]  J. Grotta,et al.  Early stroke treatment associated with better outcome: the ninds rt-pa stroke study , 2000, Neurology.

[38]  Adrian F Hernandez,et al.  Timeliness of Tissue-Type Plasminogen Activator Therapy in Acute Ischemic Stroke: Patient Characteristics, Hospital Factors, and Outcomes Associated With Door-to-Needle Times Within 60 Minutes , 2011, Circulation.