Efficacy of New Measures Saving Time in Acute Stroke Management: A Quantified Analysis

Delays in receiving Alteplase and related factors in patients with stroke referred to Shahid Beheshti Hospital in Kashan-Iran in 2020-2021

BACKGROUND

The benefits of using Alteplase are time-dependent. This study aimed to evaluate delays between the onset of symptoms and the administration of Alteplase and related factors in patients with acute ischemic stroke (AIS).

MATERIALS AND METHODS

In this cross-sectional study, 60 AIS patients receiving Alteplase were selected by census sampling from July 2020 to July 2021 from the eligible patients referred to Shahid Beheshti Hospital in Kashan, Iran. The data collection tool was a researcher-made questionnaire containing demographic information, time periods from the onset of symptoms to the injection of Alteplase, and associated factors. The required information was collected from the patients, their relatives, their health records, and Kashan Emergency Medical Service (EMS) information system. Data were analyzed in SPSS-16.

RESULTS

Eighty-five percent of the 60 patients participating in the study were transferred to the hospital by EMS ambulances. The mean time intervals between different phases were as follows: Onset-To-Door (OTD) time 81.35 ± 33.76 minutes; Door-To-CT (DTC) scan time 16.12 ± 17.46 minutes; Door-To-Needle (DNT) time 51.30 ± 26.14 minutes; and the overall Onset-To-Needle (ONT) time 133.75 ± 39.17 minutes. Also, the mean ONT in people transferred by EMS was about 129 minutes, and the longest prehospital delay in these patients was related to the time between the arrival of the EMS ambulance to the hospital. Marital status and geographical location where the stroke had occurred showed a significant relationship with prehospital delay and pre-hospital notification (PHN) by EMS But there was no relationship between underlying diseases or economic status and prehospital delays; also, the patient's diastolic blood pressure at the time of receiving Alteplase showed a significant relationship with in-hospital delay.

CONCLUSION

The findings of the study showed that the majority of people trust and use EMS ambulances to transfer to the hospital and the time spent in different stages, from the onset of symptoms to the injection of the thrombolytic drug, was in an acceptable range in the patients.

Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review

BACKGROUND

After onset of acute ischemic stroke (AIS), there is a limited time window for delivering acute reperfusion therapies (ART) aiming to restore normal brain circulation. Despite its unequivocal benefits, the proportion of AIS patients receiving both types of ART, thrombolysis and thrombectomy, remains very low. The organization of a stroke care pathway is one of the main factors that determine timely access to ART. The knowledge on organizational factors influencing access to ART is sparce. Hence, we sought to systematize the existing data on the type and frequency of pre-hospital and in-hospital organizational factors that determine timely access to ART in patients with AIS.

METHODOLOGY

Literature review on the frequency and type of organizational factors that determine access to ART after AIS. Pubmed and Scopus databases were the primary source of data. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale.

RESULTS

A total of 128 studies were included. The main pre-hospital factors associated with delay or access to ART were medical emergency activation practices, pre-notification routines, ambulance use and existence of local/regional-specific strategies to mitigate the impact of geographic distance between patient locations and Stroke Unit (SU). The most common intra-hospital factors studied were specific location of SU and brain imaging room within the hospital, and the existence and promotion of specific stroke treatment protocols. Most frequent factors associated with increased access ART were periodic public education, promotion of hospital pre-notification and specific pre- and intra-hospital stroke pathways. In specific urban areas, mobile stroke units were found to be valid options to increase timely access to ART.

CONCLUSIONS

Implementation of different organizational factors and strategies can reduce time delays and increase the number of AIS patients receiving ART, with most of them being replicable in any context, and some in only very specific contexts.

Reducing care time after implementing protocols for acute ischemic stroke: a systematic review

Background The treatment of acute ischemic stroke with cerebral reperfusion therapy requires rapid care and recognition of symptoms.

Objective To analyze the effectiveness of implementing protocols for acute ischemic stroke in reducing care time.

Methods Systematic review, which was performed with primary studies in Portuguese, English, and Spanish published between 2011 and 2020. Inclusion criteria: study population should comprise people with acute ischemic stroke and studies should present results on the effectiveness of using urgent care protocols in reducing care time. The bibliographic search was conducted in June 2020 in the LILACS, MEDLINE, Embase, Scopus, CINAHL, Academic Search Premier, and SocINDEX databases. The articles were selected, and data were extracted by two independent reviewers; the synthesis of the results was performed narratively. The methodological quality of articles was evaluated through specific instruments proposed by the Joanna Briggs Institute.

Results A total of 11,226 publications were found, of which 35 were included in the study. Only one study reported improvement in the symptoms-onset-to-door time after protocol implementation. The effectiveness of the therapeutic approach protocols for ischemic stroke was identified in improving door-to-image, image-to-needle, door-to-needle and symptoms-onset-to-needle times. The main limitation found in the articles concerned the lack of clarity in relation to the study population.

Conclusions Several advances have been identified in in-hospital care with protocol implementation; however, it is necessary to improve the recognition time of stroke symptoms among those who have the first contact with the person affected by the stroke and among the professionals involved with the prehospital care.

A new protocol reduces median door-to-needle time to the benchmark of 30 minutes in acute stroke treatment

INTRODUCTION

Recent analyses emphasise that The Benchmark Stroke Door-to-Needle Time (DNT) should be 30min. This study aimed to determine if a new in-hospital IVT protocol is effective in reducing door-to-needle time and correcting previously identified factors associated with delays.

MATERIAL AND METHODS

In 2014, we gradually introduced a series of measures aimed to reduce door-to-needle time for patients receiving IVT, and compared it before (2009-2012) and after (2014-2017) the new protocol was introduced.

RESULTS

The sample included 239 patients before and 222 after the introduction of the protocol. Median overall door-to-needle time was 27min after the protocol was fully implemented (a 48% reduction on previous door-to-needle time [52min], P<.001)]. Median door-to-needle time was lower when pre-hospital code stroke was activated (22min). We observed a 26-min reduction in the median time from onset to treatment (P<.001). After the protocol was implemented, the "3-hour-effect" did not affect door-to-needle time (P=.98). Computed tomography angiography studies performed before IVT were associated with increased door-to-needle time (P<.001); however, the test was performed after IVT was started in most cases.

CONCLUSIONS

Hospital reorganisation and multidisciplinary collaboration brought median door-to-needle time below 30min and corrected previously identified delay factors. Furthermore, overall time from onset to treatment was also reduced and more stroke patients were treated within 90min of symptom onset.