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Amalia L. Factors Affecting the Delay of intravenous Thrombolysis in Hyperacute Ischemic Stroke Patients: A Single Centre Study. Int J Gen Med 2023; 16:2157-2163. [PMID: 37284035 PMCID: PMC10239640 DOI: 10.2147/ijgm.s412262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/24/2023] [Indexed: 06/08/2023] Open
Abstract
Introduction Intravenous thrombolysis with r-tPA is the gold standard procedure in managing acute ischemic stroke recommended by the World Stroke Association, which is performed by injecting the drug r-tPA (Alteplase) intravenously. Generally, the preparation time to achieve thrombolysis is divided into pre-hospital and in-hospital. If this time can be shortened, the efficacy of thrombolysis can be increased. This study aims to determine the factors that can affect the delay in thrombolysis. Methods This is an analytic observational study with a retrospective cohort design in ischemic stroke confirmed by a neurologist at the neurology emergency unit of Hasan Sadikin Hospital (RSHS) from January 2021 to December 2021 and divided into two groups, delay and non-delay thrombolysis. A logistic regression test was performed to determine the independent predictor of delayed thrombolysis. Results There were 141 patients with an ischemic stroke diagnosis confirmed by a neurologist at the neurological emergency unit at Hasan Sadikin Hospital (RSHS) from January 2021 to December 2021. A total of 118 (83.69%) patients were included in the "delay" category, while 23 (16.31%) patients were included in the "non-delay" category. Patients included in the "delay" category had an average age of 58.29+11.19 years with a male-to-female sex ratio of 57%, while patients included in the "non-delay" category had an average age of 55.57+15.55 years with a male-to-female sex ratio of 66%. The NIHSS admission score was a significant risk factor for delayed thrombolysis. Through multiple logistic regression, it was found that age, onset, female gender, NIHSS admission score, and NIHSS discharge score were independent predictors of delayed thrombolysis. However, all of them were not statistically significant. Conclusion Gender, risk factors for dyslipidemia, and arrival onset are independent predictors of delayed thrombolysis. Prehospital factors contribute relatively more to the delay in thrombolytic action.
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Affiliation(s)
- Lisda Amalia
- Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
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A new protocol reduces median door-to-needle time to the benchmark of 30 minutes in acute stroke treatment. NEUROLOGÍA (ENGLISH EDITION) 2021; 36:487-494. [PMID: 34537162 DOI: 10.1016/j.nrleng.2018.03.009] [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: 01/23/2018] [Accepted: 04/15/2018] [Indexed: 12/11/2022] Open
Abstract
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.
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Iglesias Mohedano A, García Pastor A, Díaz Otero F, Vázquez Alen P, Martín Gómez M, Simón Campo P, Salgado Cámara P, Esteban de Antonio E, Lázaro García E, Funes Molina C, del Valle Diéguez M, Saura Lorente J, Fernández Bullido Y, Gil Nuñez A. Un nuevo protocolo intrahospitalario reduce el tiempo puerta-aguja en el ictus agudo tratado con trombolisis intravenosa a menos de 30 minutos. Neurologia 2021. [DOI: 10.1016/j.nrl.2018.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Dessens FM, Groot AE, van der Veen B, Treurniet KM, Majoie CB, Driessen-Waaijer A, Weinstein HC, Roos YB, Van den Berg-Vos RM, Coutinho JM, van Schaik SM. The association between computed tomography angiography timing and workflow times in patients with acute ischemic stroke. Int J Stroke 2020; 16:534-541. [PMID: 32996877 DOI: 10.1177/1747493020962236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND In most hospitals, computed tomography angiography (CTA) is nowadays routinely performed in patients with acute ischemic stroke. However, it is unclear whether CTA is best performed before or after start of intravenous thrombolysis (IVT), since acquisition of CTA before IVT may prolong door-to-needle times, while acquisition after IVT may prolong door-to-groin times in patients undergoing endovascular treatment. METHODS We performed a before-versus-after study (CTA following IVT, period I and CTA prior to IVT, period II), consisting of two periods of one year each. This study is based on a prospective registry of consecutive patients treated with IVT in two collaborating high-volume stroke centers; one primary stroke center and one comprehensive stroke center. The primary outcome was door-to-needle times. Secondary outcomes included door-to-groin times. Quantile regression analyses were performed to evaluate the association between timing of CTA and workflow times, adjusted for prognostic factors. RESULTS A total of 519 patients received IVT during the study period (246 in period I, 273 in period II). In the adjusted analysis, we found a nonsignificant 1.13 min median difference in door-to-needle times (95% confidence interval: 1.03-3.29). Door-to-groin times was significantly shorter in period II in both unadjusted and adjusted analysis with the latter showing a 19.16 min median difference (95% confidence interval: 3.08-35.24). CONCLUSIONS CTA acquisition prior to start of IVT did not adversely affect door-to-needle times. However, a significantly shorter door-to-groin times was observed in endovascular treatment eligible patients. Performing CTA prior to start of IVT seems the preferred strategy.
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Affiliation(s)
| | - Adrien E Groot
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bas van der Veen
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Kilian M Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Charles Blm Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | | | - Yvo Bwem Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Renske M Van den Berg-Vos
- Department of Neurology, OLVG, Amsterdam, the Netherlands.,Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Chai E, Li C, Jiang L. Factors affecting in-hospital delay of intravenous thrombolysis for acute ischemic stroke: A retrospective cohort study. Medicine (Baltimore) 2019; 98:e15422. [PMID: 31083171 PMCID: PMC6531201 DOI: 10.1097/md.0000000000015422] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/26/2019] [Accepted: 04/04/2019] [Indexed: 12/17/2022] Open
Abstract
This study was designed to investigate the factors affecting the in-hospital delay of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS).Two hundred and forty-eight consecutive AIS patients treated with intravenous administration of alteplase in Gansu Provincial Hospital from December 2014 to August 2018 were enrolled retrospectively in this study. According to door-to-needle (DTN) time, the patients were divided into either a delay group (DTN time > 60 minutes; n = 184) or a non-delay group (DTN time ≤60 minutes; n = 64). The baseline data, laboratory tests, onset-to-door (OTD) time, door-to-accepting time (DTA), door-to-imaging time (DTI), and decision-making time in both groups were recorded. Multivariate logistic analysis was performed to analyze the data.There were significant differences in previous history of cerebral ischemic attack, emergency system admission, education degree of decision makers, annual income, admission National Institutes of Health Stroke Scale (NIHSS), OTD time, DTA time, decision-making time between the 2 groups (all P < .05). Other baseline data and clinical features showed no significant difference between 2 groups (P > .05). Multivariate logistic regression analysis revealed that the risk of in-hospital delay was lower for the higher NIHSS score (OR = 0.775, 95% CI: 0.644-0.933, P = .007), the longer OTD time (OR = 0.963, 95% CI: 0.937-0.991, P = .010), the shorter decision-making time (OR = 1.224, 95% CI: 1.004-1.492, P = .045).This study suggested that NIHSS score, OTD time and decision-making time are the independent factors affecting the in-hospital delay of IVT for AIS.
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Affiliation(s)
| | | | - Lei Jiang
- Department of Gynaecology and Obstetrics, Gansu Provincial Hospital, Lanzhou, No. 204 Donggang West Road, Lanzhou, China
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El-Tawil S, Wardlaw J, Ford I, Mair G, Robinson T, Kalra L, Muir KW. Penumbra and re-canalization acute computed tomography in ischemic stroke evaluation: PRACTISE study protocol. Int J Stroke 2017; 12:671-678. [PMID: 28730951 DOI: 10.1177/1747493017696099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rationale Multimodal imaging, including computed tomography angiography and computed tomography perfusion imaging, yields additional information on intracranial vessels and brain perfusion and can differentiate between ischemic core and penumbra which may affect patient selection for intravenous thrombolysis. Hypothesis The use of multimodal imaging will increase the number of patients receiving intravenous thrombolysis and lead to better treatment outcomes. Sample size 400 patients. Methods and design PRACTISE is a prospective, multicenter, randomized, controlled trial in which patients presenting within 4.5 h of symptom onset are randomized to either the current evidence-based imaging (NCCT alone) or additional multimodal computed tomography imaging (NCCT + computed tomography angiography + computed tomography perfusion). Clinical decisions on intravenous recombinant tissue plasminogen activator are documented. Total imaging time in both arms and time to initiation of treatment delivery in those treated with intravenous recombinant tissue plasminogen activator, is recorded. Follow-up will include brain imaging at 24 h to document infarct size, the presence of edema and the presence of intra-cerebral hemorrhage. Clinical evaluations include NIHSS score at baseline, 24 h and day 7 ± 2, and mRS at day 90 to define functional outcomes. Study outcomes The primary outcome is the proportion of patients receiving intravenous recombinant tissue plasminogen activator. Secondary end-points evaluate times to decision-making, comparison of different image processing software and clinical outcomes at three months. Discussion Multimodal computed tomography is a widely available tool for patient selection for revascularization therapy, but it is currently unknown whether the use of additional imaging in all stroke patients is beneficial. The study opened for recruitment in March 2015 and will provide data on the value of multimodal imaging in treatment decisions for acute stroke.
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Affiliation(s)
- Salwa El-Tawil
- 1 Institute of Neuroscience & Psychology, Queen Elizabeth University Hospital, University of Glasgow, Glasgow, UK
| | - Joanna Wardlaw
- 2 Division of Neuroimaging Sciences, Western General Hospital, Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Ian Ford
- 3 Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Grant Mair
- 2 Division of Neuroimaging Sciences, Western General Hospital, Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Tom Robinson
- 4 Department of Cardiovascular Sciences, Ageing and Stroke Medicine Group, University of Leicester, Leicester, UK
| | - Lalit Kalra
- 5 Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neurosciences, King's College London, London, UK
| | - Keith W Muir
- 1 Institute of Neuroscience & Psychology, Queen Elizabeth University Hospital, University of Glasgow, Glasgow, UK
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Iglesias Mohedano AM, García Pastor A, Díaz Otero F, Vázquez Alen P, Vales Montero M, Luque Buzo E, Redondo Ráfales N, Chavarria Cano B, Fernández Bullido Y, Villanueva Osorio JA, Gil Núñez A. Efficacy of New Measures Saving Time in Acute Stroke Management: A Quantified Analysis. J Stroke Cerebrovasc Dis 2017; 26:1817-1823. [PMID: 28522232 DOI: 10.1016/j.jstrokecerebrovasdis.2017.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 04/10/2017] [Accepted: 04/12/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Time to treatment remains the most important factor in acute ischemic stroke prognosis. We quantified the effect of new interventions reducing in-hospital delays in acute stroke management and assessed its repercussion on door-to-imaging (DTI), imaging-to-needle (ITN), and door-to-needle (DTN) times. METHODS Prospective registry of consecutive stroke patients who were candidates for reperfusion therapy attended in a tertiary care hospital from February 1 to December 31, 2014. A series of measures aimed at reducing in-hospital delays were implemented. We compared DTI, ITN, and DTN times between patients who underwent the interventions and those who did not. RESULTS 231 patients. DTI time was lower when personal history was reviewed and tests were ordered before patient arrival (2.5 minutes saved, P = .016) and when electrocardiogram was not made (5.4 minutes saved, P < .001). Not performing a computed tomography angiography and not waiting for coagulation results from laboratory before intravenous thrombolysis (25.5%) reduced ITN time significantly (14 and 12 minutes saved, respectively, P < .001). These interventions remained as independent predictors of a shorter ITN and DTN time. Completing all steps resulted in the lowest DTI and ITN times (13 and 19 minutes, respectively). CONCLUSIONS Every measure is an important part of a chain focused on saving time in acute stroke: the lowest DTI and ITN times were obtained when all steps were completed. Measures shortening ITN time produced a greater impact on DTN time reduction; therefore, ITN interventions should be considered a critical part of new protocols and guidelines.
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Affiliation(s)
- Ana María Iglesias Mohedano
- Neurology Department-Vascular Neurology Section, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Andrés García Pastor
- Neurology Department-Vascular Neurology Section, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Fernando Díaz Otero
- Neurology Department-Vascular Neurology Section, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Pilar Vázquez Alen
- Neurology Department-Vascular Neurology Section, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marta Vales Montero
- Neurology Department-Vascular Neurology Section, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Elisa Luque Buzo
- Neurology Department-Vascular Neurology Section, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Nuria Redondo Ráfales
- Neurology Department-Vascular Neurology Section, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Beatriz Chavarria Cano
- Neurology Department-Vascular Neurology Section, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Yolanda Fernández Bullido
- Neurology Department-Vascular Neurology Section, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Antonio Gil Núñez
- Neurology Department-Vascular Neurology Section, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Palazón-Cabanes B, López-Picazo-Ferrer JJ, Morales-Ortiz A, Tomás-García N. [Why is reperfusion therapy delayed in stroke code patients? A qualitative analysis]. ACTA ACUST UNITED AC 2016; 31:347-355. [PMID: 27084299 DOI: 10.1016/j.cali.2016.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 01/14/2016] [Accepted: 01/27/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Efficacy and safety of reperfusion therapy in acute ischaemic stroke is time-dependent and has a limited therapeutic window, which is, in fact, the main exclusion criterion. Initiatives to evaluate the quality of care are essential to design future interventions and ensure the shortest management times and application of such treatments. OBJECTIVE The aim of the study is to identify and classify potential causes of delay in the administration of reperfusion therapy in a tertiary hospital, a reference for the comprehensive treatment of acute ischaemic stroke. MATERIAL AND METHODS The project was developed in Hospital Universitario Virgen de la Arrixaca, Murcia, Spain. A total of 337 patients with acute ischaemic stroke treated with reperfusion therapies were evaluated. For qualitative analysis, 2 working groups were formed: an advocacy group that designed and directed the entire project, and a multidisciplinary one, which served as a source of information and a mechanism for active involvement of all professionals in the stroke-care chain. Information was collected in 3 meetings and then, both the flowcharts and the cause-effect diagram were prepared. RESULTS Based on the above tools, potential causes of delay were identified and classified according to an operational criterion into unmodified structures, and modifiable ones with known evidence and hypothetical repercussions. Modifiable ones are noted for their importance in the design of future improvement interventions in stroke care. Some of them are: Variability in following established protocols, lack of procedures in some parts of the stroke-care chain, etc. CONCLUSION Knowledge of the current situation has just been the starting point, but it has been an essential requisite for the design and implementation of a quality improvement program to shorten in-hospital stroke code times.
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Affiliation(s)
- B Palazón-Cabanes
- Servicio de Neurología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España.
| | - J J López-Picazo-Ferrer
- Unidad de Calidad Asistencial, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - A Morales-Ortiz
- Servicio de Neurología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - N Tomás-García
- Unidad de Calidad Asistencial, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
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