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McDonough R, Ospel J, Kashani N, Kappelhof M, Liu J, Yang P, Majoie C, Roos Y, Goyal M. Influence of recent direct-to-EVT trials on practical decision-making for the treatment of acute ischemic stroke patients. Interv Neuroradiol 2021; 28:668-674. [PMID: 34787489 DOI: 10.1177/15910199211057984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Current guidelines recommend that eligible acute ischemic stroke (AIS) patients receive intravenous alteplase (IVT) prior to endovascular treatment (EVT). Six randomized controlled trials recently sought to determine the risks of administering IVT prior to EVT, five of which have been published/presented. It is unclear whether and how the results of these trials will change guidelines. With the DEBATE survey, we assessed the influence of the recent trials on physicians' IVT treatment strategies in the setting of EVT for large vessel occlusion (LVO) stroke. METHODS Participants were provided with 15 direct-to-mothership case-scenarios of LVO stroke patients and asked whether they would treat with IVT + EVT or EVT alone, a) before publication/presentation of the direct-to-EVT trials, and b) now (knowing the trial results). Logistic regression clustered by respondent was performed to assess factors influencing the decision to adopt an EVT-alone paradigm after publication/presentation of the trial results. RESULTS 289 participants from 37 countries provided 4335 responses, of which 13.5% (584/4335) changed from an IVT + EVT strategy to EVT alone after knowing the trial results. Very few switched from EVT alone to IVT + EVT (8/4335, 0.18%). Scenarios involving a long thrombus (RR 1.88, 95%CI:1.56-2.26), cerebral micro-hemorrhages (RR 1.78, 95%CI:1.43-2.23), and an expected short time to recanalization (RR 1.46 95%CI:1.19-1.78) had the highest chance of participants switching to an EVT-only strategy. CONCLUSION In light of the recent direct-to-EVT trials, a sizeable proportion of stroke physicians appears to be rethinking IVT treatment strategies of EVT-eligible mothership patients with AIS due to LVO in specific situations.
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Affiliation(s)
- Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, 37734University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Diagnostic Imaging, Foothills Medical Center, 2129University of Calgary, Calgary, AB, Canada
| | - Johanna Ospel
- Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, 30262University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nima Kashani
- Department of Diagnostic Imaging, Foothills Medical Center, 2129University of Calgary, Calgary, AB, Canada
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, 12521Naval Medical University, Shanghai, China
| | - Pengfei Yang
- Department of Neurosurgery, Changhai Hospital, 12521Naval Medical University, Shanghai, China
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo Roos
- Department of Neurology, University of Amsterdam, Amsterdam, The Netherlands
| | - Mayank Goyal
- Department of Diagnostic Imaging, Foothills Medical Center, 2129University of Calgary, Calgary, AB, Canada
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Ospel JM, McDonough R, Kunz WG, Goyal M. Is concurrent intravenous alteplase in patients undergoing endovascular treatment for large vessel occlusion stroke cost-effective even if the cost of alteplase is only US$1? J Neurointerv Surg 2021; 14:568-572. [PMID: 34187871 DOI: 10.1136/neurintsurg-2021-017817] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 06/08/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND The added value of intravenous (IV) alteplase in large vessel occlusion (LVO) stroke over and beyond endovascular treatment (EVT) is controversial. We compared the long-term costs and cost-effectiveness of a direct-to-EVT paradigm in LVO stroke patients presenting directly to the mothership hospital to concurrent EVT and IV alteplase. METHODS We used a decision model consisting of a short-run model to analyze costs and functional outcomes within 90 days after the index stroke and a long-run Markov state transition model (cycle length of 12 months) to estimate expected lifetime costs and outcomes. Outcome data were from the DIRECT-MT trial (NCT03469206). Incremental cost-effectiveness ratios and net monetary benefits were calculated and probabilistic sensitivity analysis was performed. Analysis was performed from a healthcare perspective and a societal perspective using both a minimal assumed alteplase cost of US$1 and true alteplase cost. RESULTS When assuming a minimal cost of alteplase of $1, EVT with concurrent IV alteplase resulted in incremental lifetime cost of $5664 (healthcare perspective)/$4804 (societal perspective) and a decrement of 0.25 quality-adjusted life years (QALYs) compared with EVT only, indicating dominance of the EVT only approach. Net monetary benefits were consistently higher for EVT only compared with EVT with concurrent alteplase. Probabilistic sensitivity analysis showed increased costs without an increase in QALYs for EVT and concurrent IV alteplase compared with EVT only. Results were even more in favor of EVT when the true cost of alteplase was used for analysis. CONCLUSION EVT without concurrent alteplase is the preferred strategy from a health economic standpoint.
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Affiliation(s)
- Johanna Maria Ospel
- Radiology, Universitatsspital Basel, Basel, Switzerland.,Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Rosalie McDonough
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Diagnostic and Interventional Neuroradiology, Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | | | - Mayank Goyal
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada .,Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
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3
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Park PSW, Frost T, Tan S, Wong J, Pope A, Dewey HM, Choi PMC. The Quest to Reduce Stroke Treatment Delays at A Melbourne Metropolitan Primary Stroke Centre over the Last Two Decades. Intern Med J 2021; 52:1978-1985. [PMID: 34142750 DOI: 10.1111/imj.15429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/12/2021] [Accepted: 06/14/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Reducing door-to-needle time (DNT) for intravenous thrombolysis in acute ischaemic stroke can lead to improved patient outcomes. Long-term reports on DNT trends in Australia are lacking in the setting of extension of the thrombolysis time window, addition of mechanical thrombectomy and increasing presentations. AIMS To examine 17-year trends of DNT and identify factors associated with improved DNT at a high-volume, metropolitan primary stroke centre. METHOD Retrospective study between 2003 and 2019 of all thrombolysis cases using departmental stroke database. Since most strategies were implemented from 2012 onwards, intervention period has been defined as period 2012-2019. Factors associated with DNT reduction were examined by regression modelling. RESULTS 15 strategies were identified including alterations to 'Code Stroke' processes. 1250 patients were thrombolysed, with 737 (58.8%) treated during the intervention period. The proportion of DNT ≤60- minutes rose from average of 22.5% during 2003-2012 to 63% during 2015-2018 and 71% in 2019. However, median DNT has only marginally improved from 58 to 51 minutes between 2015 and 2019. Faster DNT was independently associated with two modifiable workflow factors, 'Direct-to-CT' protocol (P < 0.001) and acute stroke nurse presence (P < 0.005). Over time, treated patients were older and less independent (P < 0.001), and the number of annual stroke admissions and 'Code Stroke' activations have risen by 4- and 10-fold to 748 and 1298 by 2019, respectively. CONCLUSIONS Targeted quality improvement initiatives are key to reducing thrombolysis treatment delays in the Australian metropolitan setting. Relative stagnation in DNT improvement is concerning and needs further investigation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Peter S W Park
- Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Tanya Frost
- Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia
| | - Shuangyue Tan
- Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia
| | - Joseph Wong
- Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia
| | - Alun Pope
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Helen M Dewey
- Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Philip M C Choi
- Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
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Hung SH, Ebaid D, Kramer S, Werden E, Baxter H, Campbell BC, Brodtmann A. Pre-stroke physical activity and admission stroke severity: A systematic review. Int J Stroke 2021; 16:1009-1018. [PMID: 33527883 DOI: 10.1177/1747493021995271] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Admission stroke severity is an important clinical predictor of stroke outcomes. Pre-stroke physical activity contributes to stroke prevention and may also be associated with reduced stroke severity. Summarizing the evidence to date will inform strategies to reduce burden after stroke. AIMS To summarize the published evidence for the relationship between pre-stroke physical activity and admission stroke severity and to provide recommendations for future research. SUMMARY OF REVIEW MEDLINE, Embase, Emcare, CENTRAL, and gray literature databases were searched on 14 February 2020 using search terms related to stroke and pre-stroke physical activity in adult stroke survivors. We screened 8,152 references and assessed 172 full-text references for eligibility. We included seven studies (n = 41,800 stroke survivors). All studies were observational, assessed pre-stroke physical activity using self-reported questionnaires, and assessed admission stroke severity using the National Institute of Health Stroke Scale. Analyses were categorized as the presence of pre-stroke physical activity (four studies) or dose-response (five studies). In three studies, presence of pre-stroke physical activity was associated with milder stroke severity, and no association in one study. Greater pre-stroke physical activity duration and intensity (two studies) or amount (three studies) were associated with milder stroke severity. Studies ranged between moderate to critical risk of bias, primarily due to confounding factors. Pre-stroke physical activity may be associated with reduced risk factors for severe stroke, distal occlusion, smaller infarcts, and shorter time-to-treatment delivery. CONCLUSION Pre-stroke physical activity may be associated with reduced admission stroke severity. Lack of randomized controlled trials limited causality conclusions. Future research recommendations were provided.
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Affiliation(s)
- Stanley H Hung
- 56369The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Deena Ebaid
- 56369The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Sharon Kramer
- 56369The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia.,NHMRC Centre of Excellence in Stroke Rehabilitation and Recovery, Melbourne, Australia.,School of Nursing and Midwifery, Faculty of Health, Deakin University, Geelong, Australia
| | - Emilio Werden
- 56369The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia.,Melbourne Dementia Research Centre, Melbourne, Australia
| | - Helen Baxter
- 3805Austin Health Sciences Library, Heidelberg, Australia
| | - Bruce Cv Campbell
- 56369The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia.,Department of Medicine and Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Amy Brodtmann
- 56369The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia.,Melbourne Dementia Research Centre, Melbourne, Australia
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5
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Kuhrij L, van Zwet E, van den Berg-Vos R, Nederkoorn P, Marang-van de Mheen PJ. Enhancing feedback on performance measures: the difference in outlier detection using a binary versus continuous outcome funnel plot and implications for quality improvement. BMJ Qual Saf 2020; 30:38-45. [PMID: 32034014 PMCID: PMC7788228 DOI: 10.1136/bmjqs-2019-009929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 01/06/2020] [Accepted: 01/30/2020] [Indexed: 01/01/2023]
Abstract
Background Hospitals and providers receive feedback information on how their performance compares with others, often using funnel plots to detect outliers. These funnel plots typically use binary outcomes, and continuous variables are dichotomised to fit this format. However, information is lost using a binary measure, which is only sensitive to detect differences in higher values (the tail) rather than the entire distribution. This study therefore aims to investigate whether different outlier hospitals are identified when using a funnel plot for a binary vs a continuous outcome. This is relevant for hospitals with suboptimal performance to decide whether performance can be improved by targeting processes for all patients or a subgroup with higher values. Methods We examined the door-to-needle time (DNT) of all (6080) patients with acute ischaemic stroke treated with intravenous thrombolysis in 65 hospitals in 2017, registered in the Dutch Acute Stroke Audit. We compared outlier hospitals in two funnel plots: the median DNT versus the proportion of patients with substantially delayed DNT (above the 90th percentile (P90)), whether these were the same or different hospitals. Two sensitivity analyses were performed using the proportion above the median and a continuous P90 funnel plot. Results The median DNT was 24 min and P90 was 50 min. In the binary funnel plot for the proportion of patients above P90, 58 hospitals had average performance, whereas in the funnel plot around the median 14 of these hospitals had significantly higher median DNT (24%). These hospitals can likely improve their DNT by focusing on care processes for all patients, not shown by the binary outcome funnel plot. Similar results were shown in sensitivity analyses. Conclusion Using funnel plots for continuous versus binary outcomes identify different outlier hospitals, which may enhance hospital feedback to direct more targeted improvement initiatives.
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Affiliation(s)
- Laurien Kuhrij
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Erik van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Renske van den Berg-Vos
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands.,Department of Neurology, OLVG, Amsterdam, Noord-Holland, The Netherlands
| | - Paul Nederkoorn
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
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6
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Ospel JM, Kashani N, Fischer U, Menon BK, Almekhlafi M, Wilson AT, Foss MM, Saposnik G, Goyal M, Hill MD. How Do Physicians Approach Intravenous Alteplase Treatment in Patients with Acute Ischemic Stroke Who Are Eligible for Intravenous Alteplase and Endovascular Therapy? Insights from UNMASK-EVT. AJNR Am J Neuroradiol 2020; 41:262-267. [PMID: 31974081 DOI: 10.3174/ajnr.a6396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/11/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE With increasing use of endovascular therapy, physicians' attitudes toward intravenous alteplase in endovascular therapy-eligible patients may be changing. We explored current intravenous alteplase treatment practices of physicians in endovascular therapy- and alteplase-eligible patients with acute stroke using prespecified case scenarios and compared how their current local treatment practices differ compared with an assumed ideal environment. MATERIALS AND METHODS In an international multidisciplinary survey, 607 physicians involved in acute stroke care were randomly assigned 10 of 22 case scenarios, among them 14 with guideline-based alteplase recommendations (9 with level 1A and 5 with level 2B recommendation) and were asked how they would treat the patient: A) under their current local resources, and B) under assumed ideal conditions. Answer options were the following: 1) anticoagulation/antiplatelet therapy, 2) endovascular therapy, 3) endovascular therapy plus intravenous alteplase, and 4) intravenous alteplase. Decision rates were calculated, and multivariable regression analysis was performed to determine variables associated with the decision to abandon intravenous alteplase. RESULTS In cases with guideline recommendations for alteplase, physicians favored alteplase in 82.0% under current local resources and in 79.3% under assumed ideal conditions (P < .001). Under assumed ideal conditions, interventional neuroradiologists would refrain from intravenous alteplase most often (6.28%, OR = 2.40; 95% CI, 1.01-5.71). When physicians' current and ideal decisions differed, most would like to add endovascular therapy to intravenous alteplase in an ideal setting (196/3861 responses, 5.1%). CONCLUSIONS In patients eligible for endovascular therapy and intravenous alteplase, we observed a slightly lower decision rate in favor of intravenous alteplase under assumed ideal conditions compared with the decision rate under current local resources.
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Affiliation(s)
- J M Ospel
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Division of Neuroradiology (J.M.O.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - N Kashani
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - U Fischer
- University Hospital Bern (U.F.), Inselspital, University of Bern, Bern, Switzerland
| | - B K Menon
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - M Almekhlafi
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - A T Wilson
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
| | - M M Foss
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
| | - G Saposnik
- Division of Neurology (G.S.), Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - M Goyal
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - M D Hill
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
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Choi PM, Tsoi AH, Pope AL, Leung S, Frost T, Loh PS, Chandra RV, Ma H, Parsons M, Mitchell P, Dewey HM. Door-in-Door-Out Time of 60 Minutes for Stroke With Emergent Large Vessel Occlusion at a Primary Stroke Center. Stroke 2019; 50:2829-2834. [DOI: 10.1161/strokeaha.119.025838] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Rapid reperfusion with mechanical thrombectomy in ischemic strokes with emergent large vessel occlusions leads to significant reduction in morbidity and mortality. The door-in-door-out (DIDO) time is an important metric for stroke centers without an on-site mechanical thrombectomy service. We report the outcome of a continuous quality improvement program to improve the DIDO time since 2015.
Methods—
Retrospective analysis of consecutive patients transferred out from a metropolitan primary stroke center for consideration of mechanical thrombectomy between January 1, 2015, and October 31, 2018. Clinical records were interrogated for eligible patients with DIDO times and reasons for treatment delays extracted.
Results—
One hundred thirty-three patients were transferred over the 46-month period. Median DIDO time reduced by 14% per year, from 111 minutes interquartile range (IQR, 98– 142) in 2015 to 67 minutes (IQR, 55–94) in 2018. A median DIDO time of 59 minutes (IQR, 51–80) was achieved in 2018 during working hours (0800–1700 hours). Overall, 65 patients had no documented delays (49%) with a median DIDO time of 75 minutes (IQR, 54–93) and 103 minutes (IQR, 75–143) in those with at least one delay factor documented.
Conclusions—
A median DIDO time of <60 minutes can be achieved in a primary stroke center.
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Affiliation(s)
- Philip M.C. Choi
- From the Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia (P.M.C.C., A.H.T., S.L., T.F., P.-S.L., H.M.D.)
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences (P.M.C.C., A.L.P., H.M.D.), Monash University, Victoria, Australia
| | - Andrew H. Tsoi
- From the Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia (P.M.C.C., A.H.T., S.L., T.F., P.-S.L., H.M.D.)
| | - Alun L. Pope
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences (P.M.C.C., A.L.P., H.M.D.), Monash University, Victoria, Australia
| | - Shelton Leung
- From the Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia (P.M.C.C., A.H.T., S.L., T.F., P.-S.L., H.M.D.)
| | - Tanya Frost
- From the Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia (P.M.C.C., A.H.T., S.L., T.F., P.-S.L., H.M.D.)
| | - Poh-Sien Loh
- From the Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia (P.M.C.C., A.H.T., S.L., T.F., P.-S.L., H.M.D.)
| | - Ronil V. Chandra
- NeuroInterventional Radiology (R.V.C), Monash University, Victoria, Australia
| | - Henry Ma
- Department of Neurology (H.M.) Monash Medical Centre, Monash University, Victoria, Australia
- School of Clinical Sciences, Department of Medicine (H.M.), Monash University, Victoria, Australia
| | - Mark Parsons
- Department of Neurology, Melbourne Brain Centre (M.P.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Peter Mitchell
- Department of Radiology (P.M.) Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Helen M. Dewey
- From the Department of Neurosciences, Box Hill Hospital, Eastern Health, Victoria, Australia (P.M.C.C., A.H.T., S.L., T.F., P.-S.L., H.M.D.)
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences (P.M.C.C., A.L.P., H.M.D.), Monash University, Victoria, Australia
- Florey Institute of Neurosciences and Mental Health, Heidelberg, Victoria, Australia (H.M.D.)
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Kamal N, Smith EE, Jeerakathil T, Hill MD. Thrombolysis: Improving door-to-needle times for ischemic stroke treatment - A narrative review. Int J Stroke 2017; 13:268-276. [PMID: 29140185 DOI: 10.1177/1747493017743060] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The effectiveness of thrombolysis is highly time dependent. For this reason, short target times have been set to reduce time to treatment from hospital arrival, which is called door-to-needle time. Summary of review There has been considerable work done at single centers and across multiple hospitals to improve door-to-needle time. There have been reductions of 8 to 47 min when applying one or more improvement strategies at single centers, and there have been many multi-hospital initiatives. The delays to treatment have been attributed to both patient and hospital factors, and strategies to address these delays have been proven to reduce door-to-needle time. The most effective strategies include pre-notification of arrival by Emergency Medical Services (EMS), single-call activation of stroke team, rapid registration process, moving the patient to computed tomography on EMS stretcher, and administration of alteplase in the scanner. There are many exciting areas of future direction including reduction of door-to-needle time in developing countries, improving pre-hospital response times, and improving the efficiency of endovascular treatment. Conclusions There is now a broad understanding of the causes of delays to fast treatment and the strategies that can be employed to improve door-to-needle time such that most centers could achieve median door-to-needle time of 30 min.
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Affiliation(s)
- Noreen Kamal
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Eric E Smith
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,2 Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | | | - Michael D Hill
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,2 Department of Community Health Sciences, University of Calgary, Calgary, Canada.,4 Department of Medicine, University of Calgary, Calgary, Canada.,5 Department of Radiology, University of Calgary, Calgary, Canada
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Kamal N, Holodinsky JK, Stephenson C, Kashayp D, Demchuk AM, Hill MD, Vilneff RL, Bugbee E, Zerna C, Newcommon N, Lang E, Knox D, Smith EE. Improving Door-to-Needle Times for Acute Ischemic Stroke: Effect of Rapid Patient Registration, Moving Directly to Computed Tomography, and Giving Alteplase at the Computed Tomography Scanner. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.003242. [PMID: 28096208 DOI: 10.1161/circoutcomes.116.003242] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 10/26/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The effectiveness of specific systems changes to reduce DTN (door-to-needle) time has not been fully evaluated. We analyzed the impact of 4 specific DTN time reduction strategies implemented prospectively in a staggered fashion. METHODS AND RESULTS The HASTE (Hurry Acute Stroke Treatment and Evaluation) project was implemented in 3 phases at a single academic medical center. In HASTE I (June 6, 2012 to June 5, 2013), baseline performance was analyzed. In HASTE II (June 6, 2013 to January 24, 2015), 3 changes were implemented: (1) a STAT stroke protocol to prenotify the stroke team about incoming stroke patients; (2) administering alteplase at the computed tomography (CT) scanner; and (3) registering the patient as unknown to allow immediate order entry. In HASTE III (January 25, 2015 to June 29, 2015), we implemented a process to bring the patient directly to CT on the emergency medical services stretcher. Log-transformed DTN time was modeled. Data from 350 consecutive alteplase-treated patients were analyzed. Multivariable regression showed the following factors to be significant: giving alteplase in the CT (32% decrease in DTN time, 95% confidence interval [CI] 38%-55%), stretcher to CT (30% decrease in DTN time, 95% CI 16%-42%), patient registered as unknown (12% decrease in DTN time, 95% CI 3%-20%), STAT stroke protocol (11% decrease in DTN time, 95% CI 1%-20%), and stroke severity (National Institutes of Health Stroke Scale score 6-8: 19% decrease in DTN time, 95% CI 6%-31%; National Institutes of Health Stroke Scale score >8: 27% decrease in DTN time, 95% CI 17%-37%). CONCLUSIONS Taking the patient to CT on the emergency medical services stretcher, registering the patient as unknown, STAT stroke protocol, and administering alteplase in CT are associated with lower DTN time.
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Affiliation(s)
- Noreen Kamal
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Jessalyn K Holodinsky
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Caroline Stephenson
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Devika Kashayp
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Andrew M Demchuk
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Michael D Hill
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Renee L Vilneff
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Erin Bugbee
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Charlotte Zerna
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Nancy Newcommon
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Darren Knox
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Eric E Smith
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada.
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10
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Kamal N, Sheng S, Xian Y, Matsouaka R, Hill MD, Bhatt DL, Saver JL, Reeves MJ, Fonarow GC, Schwamm LH, Smith EE. Delays in Door-to-Needle Times and Their Impact on Treatment Time and Outcomes in Get With The Guidelines-Stroke. Stroke 2017; 48:946-954. [DOI: 10.1161/strokeaha.116.015712] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/22/2016] [Accepted: 01/13/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Despite quality improvement programs such as the American Heart Association/American Stroke Association Target Stroke initiative, a substantial portion of acute ischemic stroke patients are still treated with tissue-type plasminogen activator (alteplase) later than 60 minutes from arrival. This study aims to describe the documented reasons for delays and the associations between reasons for delays and patient outcomes.
Methods—
We analyzed the characteristics of 55 296 patients who received intravenous alteplase in 1422 hospitals participating in Get With The Guidelines-Stroke from October 2012 to April 2015, excluding transferred patients and inpatient strokes. We assessed eligibility, medical, and hospital reasons for delays in door-to-needle time.
Results—
There were 27 778 patients (50.2%) treated within 60 minutes, 10 086 patients (18.2%) treated >60 minutes without documented delays, and 17 432 patients (31.5%) treated >60 minutes with one or more documented reasons for delay. Delayed door-to-needle times were associated with delayed diagnosis (36 minutes longer than those without delay in diagnosis) and hypoglycemia or seizure (34 minutes longer than without those conditions). The presence of documented delays was associated with higher odds of in-hospital mortality (odds ratio, 1.2; 95% confidence interval, 1.1–1.3) and symptomatic intracranial hemorrhage (odds ratio, 1.2; 95% confidence interval, 1.1–1.3) and lower odds of independent ambulation at discharge (odds ratio, 0.92; 95% confidence interval, 0.9–1.0) after adjusting for patient and hospital characteristics.
Conclusions—
Hospital and eligibility delays such as delay diagnosis and inability to determine eligibility were associated with longer door-to-needle times. Improved stroke recognition and management of acute comorbidities may help to reduce door-to-needle times.
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Affiliation(s)
- Noreen Kamal
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Shubin Sheng
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Ying Xian
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Roland Matsouaka
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Michael D. Hill
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Deepak L. Bhatt
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Jeffrey L. Saver
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Mathew J. Reeves
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Gregg C. Fonarow
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Lee H. Schwamm
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
| | - Eric E. Smith
- From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S
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11
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Holodinsky JK, Kamal N, Wilson AT, Hill MD, Goyal M. Workflow in Acute Stroke: What Is the 90th Percentile? Stroke 2017; 48:808-812. [DOI: 10.1161/strokeaha.116.015951] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/30/2016] [Accepted: 01/09/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Jessalyn K. Holodinsky
- From the Department of Community Health Sciences (J.K.H., M.D.H.), Department of Clinical Neurosciences (N.K., A.T.W., M.D.H., M.G.), Department of Medicine (M.D.H.), Department of Radiology (M.D.H., M.G.), and Hotchkiss Brain Institute (J.K.H., A.T.W., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Noreen Kamal
- From the Department of Community Health Sciences (J.K.H., M.D.H.), Department of Clinical Neurosciences (N.K., A.T.W., M.D.H., M.G.), Department of Medicine (M.D.H.), Department of Radiology (M.D.H., M.G.), and Hotchkiss Brain Institute (J.K.H., A.T.W., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Alexis T. Wilson
- From the Department of Community Health Sciences (J.K.H., M.D.H.), Department of Clinical Neurosciences (N.K., A.T.W., M.D.H., M.G.), Department of Medicine (M.D.H.), Department of Radiology (M.D.H., M.G.), and Hotchkiss Brain Institute (J.K.H., A.T.W., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Michael D. Hill
- From the Department of Community Health Sciences (J.K.H., M.D.H.), Department of Clinical Neurosciences (N.K., A.T.W., M.D.H., M.G.), Department of Medicine (M.D.H.), Department of Radiology (M.D.H., M.G.), and Hotchkiss Brain Institute (J.K.H., A.T.W., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Mayank Goyal
- From the Department of Community Health Sciences (J.K.H., M.D.H.), Department of Clinical Neurosciences (N.K., A.T.W., M.D.H., M.G.), Department of Medicine (M.D.H.), Department of Radiology (M.D.H., M.G.), and Hotchkiss Brain Institute (J.K.H., A.T.W., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
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