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

The use of a pre-hospital questionnaire expedited the acute management of patients with ischemic stroke in a comprehensive stroke center

BACKGROUND

Delays in intravenous thrombolysis (IVT) treatment for acute ischemic stroke decrease the benefit of treatment. Difficulties determining a patient's clinical eligibility for IVT is a frequent cause of treatment delays.

OBJECTIVE

We aimed to assess the effectiveness of the "PROVIDENCE" datasheet, a pre- hospital assessment of contraindications for IVT use applied by emergency medical services personnel.

METHODS

We performed a single-center cohort study comparing IVT decision and treatment times between patients with PROVIDENCE datasheets and those without. Patients were eligible if they were over 18 years old and presented to our comprehensive stroke center from the field with stroke-like symptoms with onset within 4.5 hours.

RESULTS

We identified 465 records and included 166 records in our final analysis (54 in the study group and 112 in the control group). A subgroup of 85 patients received IVT (30 in the study group patients and 55 in the control group). The PROVIDENCE datasheet was associated with a faster median time by five minutes from the patient's initial presentation at the emergency department to the final decision regarding IVT eligibility (p = 0.032) and a faster time between the first encounter with a neurology provider and the decision regarding IVT administration by six minutes (p = 0.002) for the entire sample. In the subgroup that received IVT, the PROVIDENCE datasheet decreased the median decision time by seven minutes (p = 0.044) There was no significant difference in door-to-needle times between groups.

CONCLUSION

Using the PROVIDENCE datasheet, first responders can quickly identify potential contraindications for IVT treatment in patients with stroke-like symptoms. This tool expedited decision-making and led to faster IVT administration process at a comprehensive stroke center.

Effect of working hours on prognosis of acute ischemic stroke patients following alteplase intravenous thrombolysis

OBJECTIVE

To investigate the effect of hospital working hours on outcomes of patients with acute ischemic stroke 3 months after receiving alteplase intravenous thrombolysis.

METHODS

A retrospective analysis was performed on 254 individuals with acute ischemic stroke who received alteplase intravenous thrombolysis between January 2018 and December 2020 either during peak hospital working hours (08:00-17:59; Group A) or off-peak hours (18:00-07:59 the following day; Group B). Patients were also categorized according to which of four peak/off-peak-hour periods they received treatment in: Group 1 (08:00-11:59), Group 2 (12:00-17:59), Group 3 (18:00-21:59), Group 4 (22:00-07:59 the following day). Baseline data and 3-month prognosis were compared across groups. Logistic regression analysis was used to investigate the correlation between hospital working hours and 3-month prognosis.

RESULTS

There were no significant differences in door-to-needle time, onset-to-needle time, 24-hour National Institutes of Health Stroke Scale (NIHSS) score, 7-day NIHSS score or Modified Rankin Score between Groups 1 to 4 or between Groups A and B. Whether treatment was administered during peak or off-peak hours did not significantly affect 3-month prognosis.

CONCLUSION

At this hospital, differences in the time at which stroke patients were treated were not associated with outcomes.

Twenty Years of Get With The Guidelines-Stroke: Celebrating Past Successes, Lessons Learned, and Future Challenges

The Get With The Guidelines-Stroke program which, began 20 years ago, is one of the largest and most important nationally representative disease registries in the United States. Its importance to the stroke community can be gauged by its sustained growth and widespread dissemination of findings that demonstrate sustained increases in both the quality of care and patient outcomes over time. The objectives of this narrative review are to provide a brief history of Get With The Guidelines-Stroke, summarize its major successes and impact, and highlight lessons learned. Looking to the next 20 years, we discuss potential challenges and opportunities for the program.

Effects of immediate thrombolytic treatment in imaging area on functional outcome in patients with acute ischemic stroke

INTRODUCTION

Door-to-needle time (DNT) is an established predictor of outcome in acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT). Several strategies have been proposed to streamline in-hospital pathways, among which treatment at CT/MR bed.

AIM

To explore the impact of treatment at CT/MR bed, here defined as imaging area (IA), on functional outcome in stroke patients treated with IVT alone.

METHODS

All AIS patients treated with IVT alone at our center in 2020, 2021, and 2022 were included. Patients with any previous disability were excluded. The cohort was divided into two groups, depending on the treatment site. One group received IVT at IA, the other at emergency room or stroke unit (non-IA). Regression analysis assessed the association between treatment site and 3-month outcome.

RESULTS

A total of 327 patients who received IVT alone were included in the analysis. One hundred thirty-three (40.7%) were in the IA group and 194 (59.3%) in the non-IA group. The groups showed similar baseline characteristics. In the IA group, DNT was 45 min shorter. Despite similar rates of functional independence (mRS 0-2), the IA group showed higher rates of excellent outcome (mRS 0-1) compared to the non-IA group (60.1% vs 42.8%, p<0.01). Immediate treatment at IA was independently associated to excellent outcome (OR 1.78 [1.03-3.08]).

CONCLUSIONS

Thrombolytic treatment at IA lowers DNT and is an independent predictor of excellent outcome after AIS. Our study emphasizes the importance of immediate thrombolytic treatment at IA, soon after radiological eligibility is confirmed. Immediate treatment at IA should be a standard-of-care for AIS.

Trends in Stroke Thrombolysis Care Metrics and Outcomes by Race and Ethnicity, 2003-2021

Importance

Understanding is needed of racial and ethnic-specific trends in care quality and outcomes associated with the US nationwide quality initiative Target: Stroke (TS) in targeting thrombolysis treatment for acute ischemic stroke.

Objective

To examine whether the TS quality initiative was associated with improvement in thrombolysis metrics and outcomes across racial and ethnic groups.

Design, Setting, and Participants

This retrospective cohort study included patients who presented within 4.5 hours of ischemic stroke onset at hospitals participating in the Get With The Guidelines-Stroke initiative from January 1, 2003, to December 31, 2021. The data analysis was performed between December 15, 2022, and November 27, 2023.

Exposures

TS phases I (2010-2013), II (2014-2018), and III (2019-2021).

Main Outcomes and Measures

The primary outcomes were thrombolysis rates and time metrics. Patient function and mortality were secondary outcomes.

Results

Analyses included 1 189 234 patients, of whom 1 053 539 arrived to the hospital within 4.5 hours. The cohort included 50.4% female and 49.6% male patients and 2.8% Asian [median (IQR) age, 72 (61-82) years], 15.2% Black [median (IQR) age, 64 (54-75) years], 7.3% Hispanic [median (IQR) age, 68 (56-79) years], and 74.1% White [median (IQR) age, 75 (63-84) years] patients). Unadjusted thrombolysis rates increased in both the pre-TS (2003-2009) and TS periods in all racial and ethnic groups from 10% to 15% in 2003 to 43% to 46% in 2021, but disparities were observed in adjusted analyses and persisted in TS phase III, with Asian, Black, and Hispanic patients having significantly lower odds of receiving thrombolysis than White patients (adjusted odds ratio, 0.85 [95% CI, 0.81-0.90], 0.76 [95% CI, 0.74-0.78], and 0.86 [95% CI, 0.83-0.89], respectively). Door-to-needle (DTN) times improved in all racial and ethnic groups during TS, with DTN times of 60 minutes or less increasing from 26% to 28% in 2009 to 66% to 72% in 2021. However, in adjusted analyses, racial and ethnic disparities emerged. During TS phase III, compared with White patients, Asian, Black, and Hispanic patients had significantly lower odds of receiving thrombolysis with a DTN time of 60 minutes or less compared with White patients (risk-adjusted odds ratios, 0.91 [95% CI, 0.84-0.98], 0.78 [95% CI, 0.75-0.81], and 0.87 [95% CI, 0.83-0.92], respectively). During TS, clinical outcomes improved for all racial and ethnic groups from pre-TS, with TS phase III showing higher odds of ambulation at discharge among Asian, Black, Hispanic, and White patients. Asian, Black, and Hispanic patients were less likely to present within 4.5 hours.

Conclusions and Relevance

In this cohort study of patients with ischemic stroke, the TS quality initiative was associated with improvement in thrombolysis frequency, timeliness, and outcomes for all racial and ethnic groups. However, disparities persisted, indicating a need for further interventions.

Optimizing acute stroke treatment process: insights from sub-tasks durations in a prospective observational time and motion study

Background

Rapid treatment is critical in managing acute ischemic stroke (AIS) to improve patient outcomes. Various strategies have been used to optimize this treatment process, including the Acute Stroke Protocol (ASP) activation, and minimizing the duration of key performance metrices, such as door-to-needle time (DNT), CT-to-needle time (CTNT), CT-to-groin puncture time (CTGP), and door-to-groin puncture time (DGPT). However, identifying the delay-causing sub-tasks within the ASP could yield novel insights, facilitating optimization strategies for the AIS treatment process.

Methods

This two-phase prospective observational time and motion study aimed to identify sub-tasks and compare their respective durations involved in the treatment process for AIS patients within ASPs. The study compared sub-task durations between "routine working hours" and "evenings and weekends" (after-hours), as well as between stroke neurologists and non-stroke neurologists. Additionally, the established performance metrices of AIS were compared among the aforementioned groups.

Results

Phase 1 identified and categorized 34 sub-tasks into five broad categories, while Phase 2 analyzed the ASP for 389 patients. Among the 185 patients included in the study, 57 received revascularization treatment, with 30 receiving intravenous (IV) thrombolysis only, 20 receiving endovascular thrombectomy (EVT) only, and 7 receiving both IV thrombolysis and EVT. Significant delays were observed in sub-tasks including triage, registration, patient history sharing, treatment decisions, preparation of patients, preparation of thrombolytic agents, and angiosuite preparation. The majority of these significant delays (P < 0.05) were observed when were performed by a non-stroke neurologist and during after-hours operations. Furthermore, certain sub-tasks were exclusively performed during after-hours or when the treatment was provided by a non-stroke neurologist. Consequently, DNT, CTNT, and CTGP were significantly prolonged for both non-stroke neurologists and off-hours treatment. DGPT was significantly longer only when the ASP was conducted by non-stroke neurologists.

Conclusions

The study identified several sub-tasks that lead to significant delays during the execution of the ASP. These findings provide a premise to design targeted quality improvement interventions to optimize the ASP for these specific delay-causing sub-tasks, particularly for non-stroke neurologists and after-hours. This approach has the potential to significantly enhance the efficiency of the AIS treatment process.

Effect of implementing care protocols on acute ischemic stroke outcomes: a systematic review

BACKGROUND

Implementing stroke care protocols has intended to provide better care quality, favor early functional recovery, and achieving long-term results for the rehabilitation of the patient.

OBJECTIVE

To analyze the effect of implementing care protocols on the outcomes of acute ischemic stroke.

METHODS

Primary studies published from 2011 to 2020 and which met the following criteria were included: population should be people with acute ischemic stroke; studies should present results on the outcomes of using protocols in the therapeutic approach to acute ischemic stroke. The bibliographic search was carried out in June 2020 in 7 databases. The article selection was conducted by two independent reviewers and the results were narratively synthesized.

RESULTS

A total of 11,226 publications were retrieved in the databases, of which 30 were included in the study. After implementing the protocol, 70.8% of the publications found an increase in the rate of performing reperfusion therapy, such as thrombolysis and thrombectomy; 45.5% identified an improvement in the clinical prognosis of the patient; and 25.0% of the studies identified a decrease in the length of hospital stay. Out of 19 studies that addressed the rate of symptomatic intracranial hemorrhage, 2 (10.5%) identified a decrease. A decrease in mortality was mentioned in 3 (25.0%) articles out of 12 that evaluated this outcome.

CONCLUSIONS

We have identified the importance of implementing protocols in increasing the performance of reperfusion therapies, and a good functional outcome with improved prognosis after discharge. However, there is still a need to invest in reducing post-thrombolysis complications and mortality.

Reducing intravenous thrombolysis delay in acute ischemic stroke through a quality improvement program in the emergency department

Objective

This study aims to investigate the effectiveness of a quality improvement program for reducing intravenous thrombolysis (IVT) delay in acute ischemic stroke (AIS).

Materials and methods

We implement a quality improvement program consisting of 10 interventions for reducing IVT delay, including the establishment of an acute stroke team, standardized management of stroke teams, popularization of stroke and its treatment, emergency bypass route (BER), the achievement of computed tomography (CT) priority, no-delay CT interpretation, intravenous thrombolysis on the CT table, payment after treatment, whole recording, and incentive policy. We retrospectively analyzed the clinical time and outcome data of AIS patients treated with IVT in pre-intervention (108 patients) and post-intervention groups (598 patients), and further compared the differences between the non-emergency bypass route (NBER) and BER in the post-intervention group.

Results

The thrombolysis rate increased from ~29% in the pre-intervention group to 48% in the post-intervention group. Compared with the pre-intervention group, the median of door-to-needle time (DNT) was greatly shortened from 95 to 26 min (P < 0.001), door-to-CT time (DCT) was noticeably decreased from 20 to 18 min (P < 0.001), and onset-to-needle time (OTT) significantly declined from 206 to 133 min (P = 0.001). Under the new mode after the intervention, we further analyzed the IVT delay difference between the NBER (518 patients) and BER groups (80 patients) from the post-intervention group. The median values of DNT (18 vs. 27 min, P < 0.001), DCT (10 vs. 19 min, P < 0.001), and OTT (99 vs. 143 min, P < 0.001) showed significant reductions in the BER group. The quality improvement program under the emergency platform successfully controlled the median of DNT to within 26 min.

Conclusions

Collectively, the BER mode is a feasible scheme that greatly decreased DNT in AIS patients, and the secret to success was to accomplish as much as possible before the patient arrives at the emergency room.

Advancement of door-to-needle times in acute stroke treatment after repetitive process analysis: never give up!

Background:

In acute ischemic stroke, timely treatment is of utmost relevance. Identification of delaying factors and knowledge about challenges concerning hospital structures are crucial for continuous improvement of process times in stroke care.

Objective:

In this study, we report on our experience in optimizing the door-to-needle time (DNT) at our tertiary care center by continuous quality improvement.

Methods:

Five hundred forty patients with acute ischemic stroke receiving intravenous thrombolysis (IVT) at Hannover Medical School were consecutively analyzed in two phases. In study phase I, including 292 patients, process times and delaying factors were collected prospectively from May 2015 until September 2017. In study phase II, process times of 248 patients were obtained from January 2019 until February 2021. In each study phase, a new clinical standard operation procedure (SOP) was implemented, considering previously identified delaying factors. Pre- and post-SOP treatment times and delaying factors were analyzed to evaluate the new protocols.

Results:

In study phase I, SOP I reduced the median DNT by 15 min. The probability to receive treatment within 30 min after admission increased by factor 5.35 [95% confidence interval (CI): 2.46–11.66]. Further development of the SOP with implementation of a mobile thrombolysis kit led to a further decrease of DNT by 5 min in median in study phase II. The median DNT was 29 (25th–75th percentiles: 18–44) min, and the probability to undergo IVT within 15 min after admission increased by factor 4.2 (95% CI: 1.63–10.83) compared with study phase I.

Conclusion:

Continuous process analysis and subsequent development of targeted workflow adjustments led to a substantial improvement of DNT. These results illustrate that with appropriate vigilance, there is constantly an opportunity for improvement in stroke care.

Door-to-needle times for patients with ischaemic stroke treated with alteplase by on-site and off-site on-duty neurologists. PRISA study

BACKGROUND

Hospital on-call neurology shifts are frequently on-site, but some on-call services may be off-site or mixed. Intravenous tissue plasminogen activator (tPA) is one of the main reperfusion treatments for acute ischaemic stroke (AIS). This study assesses door-to-needle times (DNT) when the neurologist is on-site or off-site.

METHODS

We performed a prospective, observational study from 2012 to 2017, including patients with AIS and treated with tPA. Data were collected on sex, age, door-to-scan time, scan-to-needle time, and DNT. The on-duty neurologist was on-site from 08:00 to 20:00, and on call but off-site from 20:00 to 8:00. Three groups were formed: on-site, off-site, and off-site with resident present.

RESULTS

Our sample included 138 patients. The mean age was 69.7 years, and 45.7% of patients were women. Ninety-six patients were admitted during the on-site shift, 25 during the off-site shift, and 17 during the off-site-resident present shift. Patients admitted during the on-site and off-site shifts presented DNTs of 59 and 72minutes, respectively (P=.003). DNTs were 59, 74, and 68minutes (P=.001), respectively, for the on-site, off-site, and off-site-resident present shifts; the difference between DNTs for on-site and off-site shifts was statistically significant. No differences were observed between DNTs according to time of day (morning, afternoon, or night), or between weekdays and weekends.

CONCLUSION

DNT is influenced by whether the on-duty neurologist is on- or off-site at the time of code stroke activation. The presence of a neurology resident can reduce DNT.

Evaluation of a multicomponent intervention to shorten thrombolytic door-to-needle time in stroke patients in China (MISSION): A cluster-randomized controlled trial

BACKGROUND

Rapid intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) is crucial for improving outcomes. However, few randomized trials of interventions aimed at reducing in-hospital delay have been carried out in China. We aimed to evaluate the effect of a multicomponent intervention on thrombolytic door-to-needle time (DNT) of AIS patients via video teleconference based on the Behavior Change Wheel (BCW) method.

METHODS AND FINDINGS

This cluster-randomized trial, conducted between January 1, 2019 and December 31, 2019, randomly allocated 22 hospitals equally to PEITEM (Persuasion Environment reconstruction Incentivization Training Education Modeling) intervention or routine care plus stroke registry and subsequently enrolled 1,634 AIS patients receiving IVT within 4.5 hours upon stroke onset from participant hospitals. The PEITEM group received a 1-year PEITEM 6-component intervention based on the behavioral theory monthly via video teleconference. The primary outcome was the proportion of patients with a DNT of 60 minutes or less. A total of 987 patients participated in the PEITEM group (mean age, 69 years; female, 411 [41.6%]) and 647 patients in the control group (mean age, 70 years; female, 238 [36.8%]). Of all participants, the proportion of DNT ≤60 minutes in the PEITEM group was higher than in the control group (82.0% versus 73.3%; adjusted odds ratio, 1.77; 95% confidence interval (CI), 1.17 to 2.70; ICC, 0.04; P = 0.007). Among secondary outcomes, the average DNT was 43 minutes in the PEITEM group and 50 minutes in the control group (adjusted mean difference: -8.83; 95% CI, -14.03 to -3.64; ICC, 0.12; P = 0.001). Favorable functional outcome (score of 0 to 1 on the modified Rankin scale (mRS)) was achieved in 55.6% patients of the PEITEM group and 50.4% of the control group (adjusted odds ratio, 1.38; 95% CI, 1.00 to 1.90; ICC, 0.01; P = 0.049). Main study limitations include non-blinding of clinicians, and that specific interventions component responsible for the observed changes could not be determined.

CONCLUSIONS

The teleconference-delivered PEITEM intervention resulted in a moderate but clinically relevant shorter DNT and better functional outcome in AIS patients receiving IVT.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03317639.

Quality improvement project to improve patient outcomes by reducing door to CT and door to needle time and increasing appropriate referrals for endovascular thrombectomy

This paper describes a stroke quality improvement (QI) project in a primary stroke centre in a 431-bed hospital serving a local population of 114 000 people. Approximately 170 acute strokes are treated each year in a seven-bed stroke unit managed by three geriatricians with a subspecialty interest in stroke. 24-hour CT radiology service is available. Endovascular thrombectomy (EVT) is performed by neuro-interventional radiology at one of two comprehensive stroke centres located 90–120 min away.

In 2018, as part of a national collaborative QI initiative a new national thrombectomy referral pathway was introduced with an aim that all eligible patients be referred for EVT. This initiative included maximising timely access to CT and thrombolysis. Review of local data highlighted significant deficits in these areas.

A local QI team convened and a multidisciplinary approach was employed to map the existing process for CT access and time to thrombolysis decision.

We describe how focused timesaving interventions such as; new emergency and radiology department ‘pre-alerts’, dedicated acute stroke pagers, new ‘FAST’ registration by clerical staff, new CT ordering codes and new ‘FAST packs’ (including tissue plasminogen activator, paper National Institute of Health Stroke Scale scoring tools, consent forms and EVT patient selection tools) were created and incorporated into a multidisciplinary detailed clinical stroke care pathway.

We describe how we achieved our SMART aims; to reduce our door to CT time and to reduce our door to needle time to the national target of less than 30 min. A third aim was to increase the number of patients referred for EVT from our centre.

This project is an accurate description of how a multidisciplinary approach combined with teamwork and effective communication can create sustainable improved patient care and is generalisable to all institutions that require timely referral to external centres for EVT.

Impact of an emergency medicine pharmacist on door to needle alteplase time and patient outcomes in acute ischemic stroke

PURPOSE

Time is a critical metric in the emergency department (ED) for acute ischemic stroke and thrombolytic therapy. National guidelines have emphasized tracking time from stroke onset to treatment and decreasing door to needle (DTN) time [1, 2]. Multidisciplinary teamwork is encouraged but, there is limited evidence demonstrating the value of the pharmacist on the stroke response team. The goal of this study is to compare DTN times in the ED with or without a pharmacist at bedside and examine the impact on subsequent patient outcomes.

METHODS

This was a single-center retrospective cohort study. Investigators identified patients who presented to the ED between August 2016 - May 2020 with signs of ischemic stroke and subsequently received intravenous alteplase. Patients were excluded if they refused alteplase or received alteplase off-campus before being transferred. Pharmacist documentation of clinical interventions was used to identify participation on the stroke response team. The primary outcome was median DTN time. Secondary outcomes included severity of deficits measured by the National Institutes of Health Stroke Scale (NIHSS), hospital length of stay (LOS), 90-day Modified Rankin Scale (mRS), incidence of intracranial hemorrhage (ICH), and inpatient all-cause mortality.

RESULTS

Of the 164 patients included, 31 had an emergency medicine pharmacist at bedside (EMP group) and 133 did not (No EMP group). The median DTN time was significantly shorter at 35 min EMP [interquartile range (IQR) 29-44] vs 42 min No EMP [IQR 34-55]; p = 0.003. The number of cases achieving a DTN time of 30 min or less was significantly higher when a pharmacist was involved (35.5% vs.16.5%; p = 0.018) as well as the number of patients receiving alteplase within 45 min (80.7% vs. 57.1%; p = 0.015). NIHSS scores at discharge were lower in the EMP group (2 [IQR 0-5] vs. 4 [IQR 0-8.25]; p = 0.049). In patients with magnetic resonance imaging (MRI) confirmed stroke, a difference was not observed in the secondary outcomes.

CONCLUSION

Patients with an emergency medicine pharmacist as part of their stroke response team had significantly lower DTN times. A higher proportion of these cases met benchmark DTN times less than 45 min and 30 min. An emergency medicine pharmacist on a stroke response team has the potential to improve patient care.

Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention

BACKGROUND AND PURPOSE

The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines.

METHODS

We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010-2013) and Target: Stroke Phase II (2014-2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018.

RESULTS

Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60-98) preintervention, to 66 minutes (51-87) during Phase I, and 50 minutes (37-66) during Phase II (P<0.001). Proportions of patients with DTN ≤60 minutes increased from 26.4% to 42.7% to 68.6% (P<0.001). Proportions of patients with DTN ≤45 minutes increased from 10.1% to 17.7% to 41.4% (P<0.001). By the end of the second intervention, 75.4% and 51.7% patients achieved 60-minute and 45-minute DTN goals. Compared with the preintervention period, hospitals during the second intervention period (2014-2018) achieved higher rates of tPA use (11.7% versus 5.6%; adjusted odds ratio, 2.43 [95% CI, 2.31-2.56]), lower in-hospital mortality (6.0% versus 10.0%; adjusted odds ratio, 0.69 [0.64-0.73]), fewer bleeding complication (3.4% versus 5.5%; adjusted odds ratio, 0.68 [0.62-0.74]), and higher rates of discharge to home (49.6% versus 35.7%; adjusted odds ratio, 1.43 [1.38-1.50]). Similar findings were found in sensitivity analyses of 185 501 patients receiving tPA within 4.5 hours of symptom onset.

CONCLUSIONS

A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.

Cost-effectiveness of a quality improvement project, including simulation-based training, on reducing door-to-needle times in stroke thrombolysis

BACKGROUND

Rapid revascularisation in acute ischaemic stroke is crucial to reduce its total burden including societal costs. A quality improvement (QI) project that included streamlining the stroke care pathway and simulation-based training was followed by a significant reduction in median door-to-needle time (27 to 13 min) and improved patient outcomes after stroke thrombolysis at our centre. Here, we present a retrospective cost-effectiveness analysis of the QI project.

METHODS

Costs for implementing and sustaining QI were assessed using recognised frameworks for economic evaluations. Effectiveness was calculated from previously published outcome measures. Cost-effectiveness was presented as incremental cost-effectiveness ratios including costs per minute door-to-needle time reduction per patient, and costs per averted death in the 13-month post-intervention period. We also estimated incremental cost-effectiveness ratios for a projected 5-year post-intervention period and for varying numbers of patients treated with thrombolysis. Furthermore, we performed a sensitivity analysis including and excluding costs of unpaid time.

RESULTS

All costs including fixed costs for implementing the QI project totalled US$44 802, while monthly costs were US$2141. We calculated a mean reduction in door-to-needle time of 13.1 min per patient and 6.36 annual averted deaths. Across different scenarios, the estimated costs per minute reduction in door-to-needle time per patient ranged from US$13 to US$29, and the estimated costs per averted death ranged from US$4679 to US$10 543.

CONCLUSIONS

We have shown that a QI project aiming to improve stroke thrombolysis treatment at our centre can be implemented and sustained at a relatively low cost with increasing cost-effectiveness over time. Our work builds on the emerging theory and practice for economic evaluations in QI projects and simulation-based training. The presented cost-effectiveness data might help guide healthcare leaders planning similar interventions.

Socioeconomic Influence on Emergency Medical Services Utilization for Acute Stroke: Think Nationally, Act Locally

Background and Purpose

Rates of emergency medical services (EMS) utilization for acute stroke remain low nationwide, despite the time-sensitive nature of the disease. Prior research suggests several demographic and social factors are associated with EMS use. We sought to evaluate which demographic or socioeconomic factors are associated with EMS utilization in our region, thereby informing future education efforts.

Methods

We performed a retrospective analysis of patients for whom the stroke code system was activated at 2 hospitals in our region. Univariate and logistic regression analysis was performed to identify factors associated with use of EMS versus private vehicle.

Results

EMS use was lower in patients who were younger, had higher income, were married, more educated and in those who identified as Hispanic. Those arriving by EMS had significantly faster arrival to code, arrival to imaging, and arrival to thrombolytic treatment times.

Conclusion

Analysis of regional data can identify specific populations underutilizing EMS services for acute stroke symptoms. Factors effecting EMS utilization varies by region and this information may be useful for targeted education programs promoting EMS use for acute stroke symptoms. EMS use results in more rapid evaluation and treatment of stroke patients.

Door-to-needle times in patients treated by on-site and off-site on-call neurologists. PRISA study

BACKGROUND

Hospital on-call neurology shifts are frequently on-site, but some on-call services may be off-site or mixed. Intravenous tissue plasminogen activator (tPA) is one of the main reperfusion treatments for acute ischaemic stroke (AIS). This study assesses door-to-needle times (DNT) when the neurologist is on-site or off-site.

METHODS

We performed a prospective, observational study from 2012 to 2017, including patients with AIS and treated with tPA. Data were collected on sex, age, door-to-scan time, scan-to-needle time, and DNT. The on-duty neurologist was on-site from 08:00 to 20:00, and on call but off-site from 20:00 to 8:00. Three groups were formed: on-site, off-site, and off-site with resident present.

RESULTS

Our sample included 138 patients. The mean age was 69.7 years, and 45.7% of patients were women. Ninety-six patients were admitted during the on-site shift, 25 during the off-site shift, and 17 during the off-site-resident present shift. Patients admitted during the on-site and off-site shifts presented DNTs of 59 and 72 minutes, respectively (P =  .003). DNTs were 59, 74, and 68 minutes (P =  .001), respectively, for the on-site, off-site, and off-site-resident present shifts; the difference between DNTs for on-site and off-site shifts was statistically significant. No differences were observed between DNTs according to time of day (morning, afternoon, or night), or between weekdays and weekends.

CONCLUSION

DNT is influenced by whether the on-duty neurologist is on- or off-site at the time of code stroke activation. The presence of a neurology resident can reduce DNT.

The Quest to Reduce Stroke Treatment Delays at A Melbourne Metropolitan Primary Stroke Centre over the Last Two Decades

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.

Changes in Informed Consent Policy and Treatment Delays in Stroke Thrombolysis

OBJECTIVES

The efficacy of thrombolytic therapy with tissue plasminogen activator (tPA) is highly time dependent. Although clinical guidelines do not recommend written informed consent as it may cause treatment delays, local policy can supersede and require it. From 2014 to 2017, three out of five public hospitals in Singapore changed from written to verbal consent at different time points. We aimed to examine the association of hospital policy changes regarding informed consent on door-to-needle (DTN) times.

MATERIALS AND METHODS

Using data from the Singapore Stroke Registry and surveys of local practice, we analyzed data of 915 acute ischemic stroke patients treated with tPA within 3 hours in all public hospitals between July 2014 to Dec 2017. Patient-level DTN times before and after policy changes were examined while adjusting for clinical characteristics, within-hospital clustering, and trends over time.

RESULTS

Patient characteristics and stroke severity were similar before and after the policy changes. Overall, the median DTN times decreased from 68 to 53 minutes after the policy changes. After risk adjustment, changing from written to verbal informed consent was associated with a 5.6 minutes reduction (95% CI 1.1-10.0) in DTN times. After the policy changed, the percentage of patients with DTN ≤60 minutes and ≤45 minutes increased from 35.6% to 66.1% (adjusted OR 1.75; 95% CI 1.12-2.74) and 9.3% to 36.0% (adjusted OR 2.42; 95% CI 1.37-4.25), respectively.

CONCLUSION

Changing from written to verbal consent is associated with significant improvement in the timeliness of tPA administration in acute ischemic stroke.

Target: Stroke Was Associated With Faster Intravenous Thrombolysis and Improved One-Year Outcomes for Acute Ischemic Stroke in Medicare Beneficiaries

BACKGROUND

The benefit of intravenous thrombolytic therapy for acute ischemic stroke is time dependent. To assist hospitals in providing faster thrombolytic treatment, the American Heart Association launched target: stroke quality initiative in January 2010 which disseminated feasible strategies to shorten door-to-needle times for thrombolytic therapy. This study aimed to examine whether target: stroke was associated with improved door-to-needle times and 1-year outcomes.

METHODS

We analyzed Medicare beneficiaries aged ≥65 years receiving intravenous thrombolytic treatment for acute ischemic stroke at 1490 Get With The Guidelines-Stroke hospitals during January 2006 and December 2009 (preintervention, n=10 804) and January 2010 and December 2014 (postintervention, n=31 249). The median age was 80 years and 42.7% were male.

RESULTS

The median door-to-needle times decreased from 80 minutes for the preintervention to 68 minutes for the postintervention (P<0.001). The proportion of patients receiving intravenous thrombolysis with door-to-needle times 45 minutes and 60 minutes increased from 9.6% and 24.8% for preintervention to 17.1% and 40.6% for postintervention, respectively (P<0.001). The annual rate of increase in the door-to-needle times of 60 minutes or less accelerated from 0.20% (95% CI, -0.43% to 0.83%) per each 4 quarters for preintervention to 5.68% (95% CI, 5.23%-6.13%) for postintervention (P<0.001) which was further confirmed in piecewise multivariable generalized estimating analysis (adjusted odds ratio, 1.27 [95% CI, 1.19-1.35]). Cox proportional hazards analysis, after adjusting for patient and hospital characteristics and within-hospital clustering, showed that target: stroke was associated with lower all-cause readmission (40.4% versus 44.1%; hazard ratio, 0.91 [95% CI, 0.88-0.95]), cardiovascular readmission (19.7% versus 22.9%; hazard ratio, 0.85 [95% CI, 0.80-0.89]), and composite of all-cause mortality or readmission (56.0% versus 58.4%; hazard ratio, 0.96 [95% CI, 0.93-1.00]). The risk decline in all-cause mortality dissipated after risk adjustment (adjusted hazard ratio, 0.98 [95% CI, 0.94-1.02]).

CONCLUSIONS

Target: stroke quality initiative was associated with faster thrombolytic treatment times for acute ischemic stroke and modestly lower 1-year all-cause and cardiovascular readmissions.

Defect-free care trends in the Paul Coverdell National Acute Stroke Program, 2008-2018

BACKGROUND

In an effort to improve stroke quality of care and patient outcomes, quality of care metrics are monitored to assess utilization of evidence-based stroke care processes as part of the Paul Coverdell National Acute Stroke Program (PCNASP). We aimed to assess temporal trends in defect-free care (DFC) received by stroke patients in the PCNASP between 2008 and 2018.

METHODS

Quality of care data for 10 performance measures were available for 849,793 patients aged ≥18 years who were admitted to a participating hospital with a clinical diagnosis of stroke between 2008 and 2018. A patient who receives care according to all performance measures for which they are eligible, receives "defect-free care" (DFC) (eg, appropriate medications, assessments, and education). Generalized estimating equations were used to examine the factors associated with receipt of DFC.

RESULTS

DFC among ischemic stroke patients increased from 38.0% in 2008 to 80.8% in 2018 (P < .0001), with the largest improvement seen in receipt of stroke education (relative percent change, RPC = 64%). Similarly, DFC for hemorrhagic stroke and transient ischemic attack patients increased from 46.7% to 82.6% (RPC = 76.9%) and 39.9% to 85.0% (RPC = 113.0%) (P < .001), respectively. Among ischemic stroke patients, the adjusted odds for receiving DFC were lower for women, patients aged 18 to 54 years, Medicaid or Medicare participants, and patients with atrial fibrillation (P < .05).

CONCLUSIONS

From 2008 to 2018, receipt of DFC by ischemic stroke patients significantly increased in the PCNASP; however certain subgroups were less likely to receive this level of care. Targeted quality improvement initiatives could result in even further improvements among all stroke patients and help reduce disparities in care.

Implementation of regional Acute Stroke Care Map increases thrombolysis rates for acute ischaemic stroke in Chinese urban area in only 3 months

Background

The rate of intravenous thrombolysis for acute ischaemic stroke remains low in China. We investigated whether the implementation of a citywide Acute Stroke Care Map (ASCaM) is associated with an improvement of acute stroke care quality in a Chinese urban area.

Methods

The ASCaM comprises 10 improvement strategies and has been implemented through a network consisting of 20 tertiary hospitals. We identified 7827 patients with ischaemic stroke admitted from April to October 2017, and 506 patients underwent thrombolysis were finally included for analysis.

Results

Compared with ‘pre-ASCaM period’, we observed an increased rate of administration of tissue plasminogen activator within 4.5 hours (65.4% vs 54.5%; adjusted OR, 1.724; 95% CI 1.21 to 2.45; p=0.003) during ‘ASCaM period’. In multivariate analysis models, ‘ASCaM period’ was associated with a significant reduction in onset-to-door time (114.1±55.7 vs 135.7±58.4 min, p=0.0002) and onset-to-needle time (ONT) (169.2±58.1 vs 195.6±59.3 min, p<0.0001). Yet no change was found in door-to-needle time. Clinical outcomes such as symptomatic intracranial haemorrhage, favourable functional outcome (modified Rankin Scale ≤2) and in-hospital mortality remained unchanged.

Conclusion

The implementation of ASCaM was significantly associated with increased rates of intravenous thrombolysis and shorter ONT. The ASCaM may, in proof-of-principle, serve as a model to reduce treatment delay and increase thrombolysis rates in Chinese urban areas and possibly other highly populated Asian regions.

Provincial Door-to-Needle Improvement Initiative Results in Improved Patient Outcomes Across an Entire Population

Background and Purpose:

Improving door-to-needle times (DNTs) for thrombolysis of acute ischemic stroke patients improves outcomes, but participation in DNT improvement initiatives has been mostly limited to larger, academic medical centers with an existing interest in stroke quality improvement. It is not known whether quality improvement initiatives can improve DNT at a population level, including smaller community hospitals. This study aims to determine the effect of a provincial improvement collaborative intervention on improvement of DNT and patient outcomes.

Methods:

A pre post cohort study was conducted over 10 years in the Canadian province of Alberta with 17 designated stroke centers. All ischemic stroke patients who received thrombolysis in the Canadian province of Alberta were included in the study. The quality improvement intervention was an improvement collaborative that involved creation of interdisciplinary teams from each stroke center, participation in 3 workshops and closing celebration, site visits, webinars, and data audit and feedback.

Results:

Two thousand four hundred eighty-eight ischemic stroke patients received thrombolysis in the pre- and postintervention periods (630 in the post period). The mean age was 71 years (SD, 14.6 years), and 46% were women. DNTs were reduced from a median of 70.0 minutes (interquartile range, 51–93) to 39.0 minutes (interquartile range, 27–58) for patients treated per guideline ( P <0.0001). The percentage of patients discharged home from acute care increased from 45.6% to 59.5% ( P <0.0001); the median 90-day home time increased from 43.3 days (interquartile range, 27.3–55.8) to 53.6 days (interquartile range, 36.8–64.6) ( P =0.0015); and the in-hospital mortality decreased from 14.5% to 10.5% ( P =0.0990).

Conclusions:

The improvement collaborative was likely the key contributing factor in reducing DNTs and improving outcomes for ischemic stroke patients across Alberta.

Contemporary Management of Acute Ischemic Stroke Across the Continuum: From TeleStroke to Intra-Arterial Management

In this comprehensive contemporary review of acute ischemic stroke management, what is new and different will be highlighted beginning with prehospital stroke systems of care, emergency medical systems, and mobile stroke units, followed by hospital stroke teams, emergency evaluation, telemedicine, and brain and vascular imaging, and finishing with emergency treatments including thrombolysis and mechanical thrombectomy.

Time to acute stroke treatment in-hours was more than halved after the introduction of the Helsinki Model at Westmead Hospital

BACKGROUND

Management of acute ischaemic stroke is time critical. Reducing time to treatment with thrombolysis is strongly associated with improved outcomes in properly selected patients. However, there are barriers to ensuring timely treatment in the hospital setting.

AIM

To determine if simple, no-cost protocol changes could improve time to treatment for acute ischaemic stroke at a busy tertiary hospital.

METHODS

Prospectively collected routine clinical data were compared retrospectively before and after a protocol change designed to mirror the successful model from Helsinki University Central Hospital. Consecutive patients who activated a 'code stroke' (presentation consistent with acute stroke, eligible for acute stroke therapy) during working hours were included.

RESULTS

Prior to the protocol change, 143 patients activated a code stroke, and 30 patients received thrombolysis. Following the protocol change, 134 patients activated a code stroke, and 14 patients received thrombolysis. The median time to administer thrombolysis was reduced from 76 min (interquartile range 54-91) to 33 min (27-44), P < 0.01. The median time to perform diagnostic computed tomography was unchanged between the two groups, 23 (14-54) min versus 22 (9-49) min, P = 0.12. However, this was reduced on subgroup analysis of patients whose arrival was pre-notified by the ambulance service, 16 (9-22) min versus 8 (4-14) min, P < 0.01.

CONCLUSION

Time to treatment in acute stroke was dramatically improved with a simple intervention. This was achieved without a large stroke team or additional funding, making it highly accessible to other health services also seeking to improve their stroke service.

Door-to-needle time for thrombolysis: a secondary analysis of the TIPS cluster randomised controlled trial

OBJECTIVE

The current study aimed to evaluate the effects of a multi-component in-hospital intervention on the door-to-needle time for intravenous thrombolysis in acute ischaemic stroke.

DESIGN

This study was a post hoc analysis of door-to-needle time data from a cluster-randomised controlled trial testing an intervention to boost intravenous thrombolysis implementation.

SETTING

The study was conducted among 20 hospitals from three Australian states.

PARTICIPANT

Eligible hospitals had a Stroke Care Unit or staffing equivalent to a stroke physician and a nurse, and were in the early stages of implementing thrombolysis.

INTERVENTION

The intervention was multifaceted and developed using the behaviour change wheel and informed by breakthrough collaborative methodology using components of the health behaviour change wheel.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome for this analysis was door-to-needle time for thrombolysis and secondary outcome was the proportion of patients received thrombolysis within 60 min of hospital arrival.

RESULTS

The intervention versus control difference in the door-to-needle times was non-significant overall nor significant by hospital classification. To provide additional context for the findings, we also evaluated the results within intervention and control hospitals. During the active-intervention period, the intervention hospitals showed a significant decrease in the door-to-needle time of 9.25 min (95% CI: -16.93 to 1.57), but during the post-intervention period, the result was not significant. During the active intervention period, control hospitals also showed a significant decrease in the door-to-needle time of 5.26 min (95% CI: -8.37 to -2.14) and during the post-intervention period, this trend continued with a decrease of 12.13 min (95% CI: -17.44 to 6.81).

CONCLUSION

Across these primary stroke care centres in Australia, a secular trend towards shorter door-to-needle times across both intervention and control hospitals was evident, however the TIPS (Thrombolysis ImPlementation in Stroke) intervention showed no overall effect on door-to-needle times in the randomised comparison.

TRIAL REGISTRATION NUMBER

Trial Registration-URL: http://www.anzctr.org.au/ Unique Identifier: ACTRN 12613000939796.

A Decade of Improvement in Door-to-Needle Time Among Acute Ischemic Stroke Patients, 2008 to 2017

BACKGROUND

The clinical benefit of intravenous (IV) alteplase in acute ischemic stroke is time dependent. We assessed the overall temporal changes in door-to-needle (DTN) time and examine the factors associated with DTN time ≤60 and ≤45 minutes.

METHODS AND RESULTS

A total of 496 336 acute ischemic stroke admissions were identified in the Paul Coverdell National Acute Stroke Program from 2008 to 2017. We used generalized estimating equations models to examine the factors associated with DTN time ≤60 and ≤45 minutes, and calculated adjusted odds ratios and 95% CI. Between 2008 and 2017, the percentage of acute ischemic stroke patients who received IV alteplase including those transferred, increased from 6.4% to 15.3%. After excluding those who received IV alteplase at an outside hospital, a total of 39 737 (8%) acute ischemic stroke patients received IV alteplase within 4.5 hours of the time the patient last known to be well. Significant increases were seen in DTN time ≤60 minutes (26.4% in 2008 to 66.2% in 2017, P<0.001), as well as DTN time ≤45 minutes (10.7% in 2008 to 40.5% in 2017, P<0.001). Patients aged 55 to 84 years were more likely to receive IV alteplase within 60 minutes, while those aged 55 to 74 years were more likely to receive IV alteplase within 45 minutes, as compared with those aged 18 to 54 years. Arrival by emergency medical service, and patients with severe stroke were more likely to receive IV alteplase within 60 and 45 minutes. Conversely, women, black patients as compared with white, and patients with a medical history of diseases associated with stroke were less likely to receive DTN time ≤60 or 45 minutes.

CONCLUSIONS

Rapid improvements in DTN time were observed in the Paul Coverdell National Acute Stroke Program; however, opportunities to reduce disparities remain.

Weekday Versus Weekend Presentation in the Acute Management of Ischemic Stroke Through Telemedicine

A "weekend effect" resulting in higher mortality rates for patients with stroke admitted on weekends has been reported. We examine this phenomenon for patients with acute ischemic stroke (AIS) presenting to telestroke (TS) sites to determine its effect on stroke alert process times and outcomes. From October 2015 to June 2017, we reviewed patients with AIS receiving intravenous alteplase within our TS network. We compared patients presenting to TS sites on weekdays (Monday 07:00 to Friday 18:59) to those presenting on weekends (Friday 19:00 to Monday 06:59). We analyzed door-to-alert activation, alert activation-to-TS evaluation, door-to-imaging, and door-to-needle times. Rates of favorable outcome (modified Rankin Scale score ≤2) and death at 90 days were compared. We identified 89 (54 weekday and 35 weekend) patients (mean age: 71.8 ± 13.3 years, 47.2% women) during the study period. Median door-to-alert activation (P = .01) and door-to-needle (P = .004) times were significantly longer for patients presenting on weekends compared to weekdays. There were no significant differences in median door-to-imaging (P = .1) and alert activation-to-TS evaluation (P = .07) times. Rates of favorable outcome (P = .19) and death (P = .56) at 90 days did not differ. While there were no significant differences in outcomes, patients presenting on weekends had longer door-to-alert activation and door-to-needle times. Efforts to improve methods in efficiency of care on weekends should be considered.

Identification of barriers and enablers to rapid diagnosis along the paediatric stroke chain of recovery using Value-Focused Process Engineering

Coordinated systems of care are required to improve access to reperfusion therapies in paediatric stroke. A conceptual model was developed to map the process-of-care from symptom onset to confirmation of diagnosis. Value-Focused Process Engineering with event-driven process modelling was used to identify barriers and enablers to timely and accurate paediatric stroke diagnosis. Stakeholder interviews were conducted to inform model design, development, demonstration and validation. Barriers included: (i) ambulance dispatcher failure to allocate high-priority response, (ii) childrens' exclusion from paramedic clinical practice guidelines, (ii) non-allocation of high triage category on hospital arrival, (iii) absence of emergency department guidelines for focal neurological deficits, and (iv) computed tomography as the first imaging investigation. Enablers included: (i) public awareness programs, (ii) childrens' inclusion in prehospital emergency stroke algorithms, (iii) re-organisation of health services, with primary paediatric stroke centres, (iv) implementation of triage and neuroimaging decision support tools, and (iv) rapid stroke MRI imaging protocols.

Reducing door-to-needle times in stroke thrombolysis to 13 min through protocol revision and simulation training: a quality improvement project in a Norwegian stroke centre

Background

In eligible patients with acute ischaemic stroke, rapid revascularisation is crucial for good outcome. At our treatment centre, we had achieved and sustained a median door-to-needle time of under 30 min. We hypothesised that further improvement could be achieved through implementing a revised treatment protocol and in situ simulation-based team training sessions. This report describes a quality improvement project aiming to reduce door-to-needle times in stroke thrombolysis.

Methods

All members of the acute stroke treatment team were surveyed to tailor the interventions to local conditions. Through a review of responses and available literature, the improvement team suggested changes to streamline the protocol and designed in situ simulation-based team training sessions. Implementation of interventions started in February 2017. We completed 14 simulation sessions from February to June 2017 and an additional 12 sessions from November 2017 to March 2018. Applying Kirkpatrick’s four-level training evaluation model, participant reactions, clinical behaviour and patient outcomes were measured. Statistical process control charts were used to demonstrate changes in treatment times and patient outcomes.

Results

A total of 650 consecutive patients, including a 3-year baseline, treated with intravenous thrombolysis were assessed. Median door to needle times were significantly reduced from 27 to 13 min and remained consistent after 13 months. Risk-adjusted cumulative sum charts indicate a reduced proportion of patients deceased or bedridden after 90 days. There was no significant change in balancing measures (stroke mimics, fatal intracranial haemorrhage and prehospital times).

Conclusions

Implementing a revised treatment protocol in combination with in situ simulation-based team training sessions for stroke thrombolysis was followed by a considerable reduction in door-to-needle times and improved patient outcomes. Additional work is needed to assess sustainability and generalisability of the interventions.

Improving Door-to-needle Times in the Treatment of Acute Ischemic Stroke Across a Canadian Province: Methodology

BACKGROUND

Alteplase is a proven medical treatment for acute ischemic stroke; however, the effectiveness of this treatment is highly time dependent. Therefore, it is imperative that hospitals treat acute ischemic stroke patients as quickly as possible. The measure, door-to-needle time, is the time from hospital arrival to when alteplase administration begins.

OBJECTIVE

The goal in the Canadian province of Alberta was to reduce the door-to-needle time to a median of 30 minutes and to increase the percent of patients treated within 60 minutes to 90%.

OVERVIEW OF METHODOLOGY

A modified version of Institute for Healthcare Improvement Breakthrough Series Collaborative was used. All stroke centers self-enrolled into the collaborative after initial contact, and sites created interdisciplinary teams to participate in the Collaborative. Leadership and faculty were highly experienced in quality improvement and acute stroke. There were 3 daylong face-to-face learning sessions that were attended by enrolled teams, which included presentation about the evidence, site presentations to promote cross-site learning, and time to plan changes with their teams. The sites were also supported by site visits, webinars, and data feedback.

Reducing Door-to-Needle Times for Ischaemic Stroke to a Median of 30 Minutes at a Community Hospital

BACKGROUND

Alteplase is an effective treatment for ischaemic stroke patients, and it is widely available at all primary stroke centres. The effectiveness of alteplase is highly time-dependent. Large tertiary centres have reported significant improvements in their door-to-needle (DTN) times. However, these same improvements have not been reported at community hospitals.

METHODS

Red Deer Regional Hospital Centre (RDRHC) is a community hospital of 370 beds that serves approximately 150,000 people in their acute stroke catchment area. The RDRHC participated in a provincial DTN improvement initiative, and implemented a streamlined algorithm for the treatment of stroke patients. During this intervention period, they implemented the following changes: early alert of an incoming acute stroke patient to the neurologist and care team, meeting the patient immediately upon arrival, parallel work processes, keeping the patient on the Emergency Medical Service stretcher to the CT scanner, and administering alteplase in the imaging area. Door-to-needle data were collected from July 2007 to December 2017.

RESULTS

A total of 289 patients were treated from July 2007 to December 2017. In the pre-intervention period, 165 patients received alteplase and the median DTN time was 77 minutes [interquartile range (IQR): 60-103 minutes]; in the post-intervention period, 104 patients received alteplase and the median DTN time was 30 minutes (IQR: 22-42 minutes) (p &lt; 0.001). The annual number of patients that received alteplase increased from 9 to 29 in the pre-intervention period to annual numbers of 41 to 63 patients in the post-intervention period.

CONCLUSION

Community hospitals staffed with community neurologists can achieve median DTN times of 30 minutes or less.

Ideal telestroke time targets: Telestroke-based treatment times in the United States stroke belt

Background

Studying critical time interval requirements can enhance thrombolytic treatment for stroke patients in telestroke networks. We retrospectively examined 12 concurrent months of targeted time interval information in the South Central US telemedicine programme, Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES).Hypothesis: We hypothesised that consult data analysis would highlight areas for improvement to shorten overall door to Intra venous (IV) tissue plasminogen activator (tPA) administration time.

Methods

We analysed critical time targets for 238 consecutive telestroke neurology consults obtained over 12 months from AR SAVES spoke sites when tPA was administered. The following time intervals were analysed: emergency department (ED) door to Computed Tomography (D-CT); ED door to call centre (D-CC) for initiation of consult; ED door to neurology call (D-NC); neurology call to camera (NC-Cam); tele consult time (Con); ED door to tissue plasminogen activator (tPA)/needle (DTN).

Results

The median times of D-CT (13 min, inter quartile range (IQR) 6–22 min), D-CC (34 min, IQR 20–45 min), D-NC (40 min, IQR 21–71 min), NC-Cam (4 min, IQR 2–8 min), and Con (25 min, IQR 17–37 min) all contributed to a DTN median time of 71 min (IQR 50–104 min). A total of 238 patients received tPA with a 29.4% treatment rate and a DTN time of ≤60 min was achieved in 25.2% of patients.

Conclusions

Focusing on reducing D-CC and Con times may help to achieve the DTN time of < 60 min for the majority of patients. Having ideal time targets for telestroke patients akin to traditional patients will help identify and improve the overall goal of a DTN time < 60 min.

Nebulization of Single-Chain Tissue-Type and Single-Chain Urokinase Plasminogen Activator for Treatment of Inhalational Smoke-Induced Acute Lung Injury

Single-chain tissue-type plasminogen activator (sctPA) and single-chain urokinase plasminogen activator (scuPA) have attracted interest as enzymes for the treatment of inhalational smoke-induced acute lung injury (ISALI). In this study, the pulmonary delivery of commercial human sctPA and lyophilized scuPA and their reconstituted solution forms were demonstrated using vibrating mesh nebulizers (Aeroneb® Pro (active) and EZ Breathe® (passive)). Both the Aeroneb® Pro and EZ Breathe® vibrating mesh nebulizers produced atomized droplets of protein solution of similar size of less than about 5 μm, which is appropriate for pulmonary delivery. Enzymatic activities of scuPA and of sctPA were determined after nebulization and both remained stable (88.0% and 93.9%). Additionally, the enzymatic activities of sctPA and tcuPA were not significantly affected by excipients, lyophilization or reconstitution conditions. The results of these studies support further development of inhaled formulations of fibrinolysins for delivery to the lungs following smoke-induced acute pulmonary injury.

In-hospital delays to stroke thrombolysis: Out of hours versus regular hours and reduction in treatment times through the creation of a 24/7 mobile thrombolysis team

BACKGROUND

The main aim of this study was to evaluate the impact of the implementation of a mobile thrombolysis team (MTT) on time to thrombolysis treatment depending on patient admission time: regular hours (RH) or out of hours (OH).

METHODS

504 consecutive patients treated with IV tPA or with combined IV tPA and mechanical thrombectomy for acute ischemic stroke were retrospectively included between 1st January 2013 and 31st December 2017. Three sub-periods were identified: 2013-2014, 2015-2016, and 2017 during which patients were treated with the usual care (UC), by the MTT or with UC according to their time of admission, or by the MTT, in the three time periods respectively. We compared in-hospital delays according to patient admission time.

RESULTS

In 2013-2014, 133 patients were included. Both median door-to-needle (DTN) and imaging to needle (ITN) times were shorter for patients admitted during RH than OH, respectively 75 min versus 85 min and 52 min versus 57 min (P < 0.05), and the proportion of patients with DTN ≤ 60 min was 23% versus 9% (P < 0.05), respectively. In 2015-2016, 223 patients were included. DTN and ITN times were shorter for patients admitted during RH and treated by the MTT than during OH with UC, respectively 54 min versus 78 min and 24 min versus 47 min (P < 0.001), and the proportion of patients with DTN ≤ 60 min was 64% versus 21% (P < 0.001), respectively. In 2017, there was no difference concerning in-hospital delays regardless of patient admission time (P > 0.05).

DISCUSSION

DTN time was significantly longer for patients admitted OH. We suggest that the implementation of an around-the-clock MTT would allow a reduction of in-hospital delays and similar times to thrombolysis treatment regardless of admission time.

Prehospital Notification Procedure Improves Stroke Outcome by Shortening Onset to Needle Time in Chinese Urban Area

Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) can improve clinical outcome in eligible patients with acute ischemic stroke (AIS). However, its efficacy is strongly time-dependent. This study was aimed to examine whether prehospital notification by emergency medical service (EMS) providers could reduce onset to needle time (ONT) and improve neurological outcome in AIS patients who received IVT. We prospectively collected the consecutive clinical and time data of AIS patients who received IVT during one year after the initiation of prehospital notification procedure (PNP). Patients were divided into three groups, including patients that transferred by EMS with and without PNP and other means of transportation (non-EMS). We then compared the effect of EMS with PNP and EMS use only on ONT, and the subsequent neurological outcome. Good outcome was defined as modified Rankin Scale score of 0-2 at 3-months. In 182 patients included in this study, 77 (42.3%) patients were transferred by EMS, of whom 41 (53.2%) patients entered PNP. Compared with non-EMS group, EMS without PNP group greatly shortened the onset to door time (ODT), but EMS with PNP group showed both a significantly shorter DNT (41.3 ± 10.7 min vs 51.9±23.8 min, t=2.583, p=0.012) and ODT (133.2 ± 90.2 min vs 174.8 ± 105.1 min, t=2.228, p=0.027) than non-EMS group. Multivariate analysis showed that the use of EMS with PNP (OR=2.613, p=0.036), but not EMS (OR=1.865, p=0.103), was independently associated with good outcome after adjusting for age and baseline NIHSS score. When adding ONT into the regression model, ONT (OR=0.994, p=0.001), but not EMS with PNP (OR=1.785, p=0.236), was independently associated with good outcome. EMS with PNP, rather than EMS only, improved stroke outcome by shortening ONT. PNP could be a feasible strategy for better stroke care in Chinese urban area.

Target Door-to-Needle Time for Tissue Plasminogen Activator Treatment with Magnetic Resonance Imaging Screening Can Be Reduced to 45 min

Objective: The purpose of this study was to demonstrate that the median door-to-needle (DTN) time for intravenous tissue plasminogen activator (tPA) treatment can be reduced to 45 min in a primary stroke centre with MRI-based screening for acute ischaemic stroke (AIS). Methods: From February 2015 to February 2017, the stroke unit of Perpignan general hospital, France, implemented a quality-improvement (QI) process. During this period, patients who received tPA within 4.5 h after AIS onset were included in the QI cohort. Their clinical characteristics and timing metrics were compared each semester and also with those of 135 consecutive patients with AIS treated by tPA during the 1-year pre-QI period (pre-QI cohort). Results: In the QI cohort, 274 patients (92.5%) underwent MRI screening. While the demographic and baseline characteristics were not significantly different between cohorts, the median DTN time was significantly lower in the QI than in the pre-QI cohort (52 vs. 84 min; p < 0.00001). Within the QI cohort, the median DTN time for each semester decreased from 65 to 44 min (p < 0.00001) and the proportion of treated patients with a DTN time ≤45 min increased from 25 to 58.9% (p < 0.0001). Overall, DTN time improvement was associated with a better outcome at 3 months (patients with a modified Rankin Scale score between 0 and 2: 61.8% in the QI vs. 39.3% in the pre-QI cohort; p < 0.0001). Conclusions: A QI process can reduce the DTN within 45 min with MRI as a screening tool.

Thrombolysis: Improving door-to-needle times for ischemic stroke treatment - A narrative review

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.

Emergency Medicine Pharmacist Impact on Door-to-Needle Time in Patients With Acute Ischemic Stroke

Background and Purpose

Decreased door-to-needle (DTN) time with tissue plasminogen activator (tPA) for acute ischemic stroke is associated with improved patient outcomes. Emergency medicine pharmacists (EMPs) can expedite the administration of tPA by assessing patients for contraindications, preparing, and administering tPA. The purpose of this study was to determine the impact of EMPs on DTN times and clinical outcomes in patients with acute ischemic stroke who receive tPA in the emergency department.

Methods

A retrospective, single-center, cohort study of patients who received tPA between August 1, 2012, and August 30, 2014, was conducted to compare DTN times with or without EMP involvement in stroke care. Secondary outcomes included changes in neurological status as measured by the National Institutes of Health Stroke Scale (NIHSS), length of hospital stay, discharge disposition, symptomatic intracranial hemorrhage, and in-hospital all-cause mortality.

Results

A total of 100 patients were included. The EMPs were involved in the care of 49 patients. The EMP involvement was associated with a significant improvement in DTN time (median 46 [interquartile range IQR: 34.5-67] vs 58 [IQR: 45-79] minutes; P = .019) and with receiving tPA within 45 minutes of arrival (49% vs 25%, odds ratio [OR]: 2.81 [95% confidence interval [CI]: 1.21-6.52]). National Institutes of Health Stroke Scale scores were significantly improved at 24 hours post-tPA in favor of the EMP group (median NIHSS 1 [IQR: 0-4] vs 2 [IQR: 1-9.25]; P = .047).

Conclusions

The EMP involvement in initial stroke care was associated with a significant improvement in DTN time.

The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care

The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.

A System-Based Intervention to Improve Access to Hyperacute Stroke Care

BACKGROUND

Hyperacute stroke is a time-sensitive emergency for which outcomes improve with faster treatment. When stroke systems are accessed via emergency medical services (EMS), patients are routed to hyperacute stroke centres and are treated faster. But over a third of patients with strokes do not come to the hospital by EMS, and may inadvertently arrive at centres that do not provide acute stroke services. We developed and studied the impact of protocols to quickly identify and move "walk-in" patients from non-hyperacute hospitals to regional stroke centres (RSCs).

METHODS AND RESULTS

Protocols were developed by a multi-disciplinary and multi-institutional working group and implemented across 14 acute hospital sites within the Greater Toronto Area in December of 2012. Key metrics were recorded 18 months pre- and post-implementation. The teams regularly reviewed incident reports of protocol non-adherence and patient flow data. Transports increased by 80% from 103 to 185. The number of patients receiving tissue plasminogen activator (tPA) increased by 68% from 34 to 57. Total EMS transport time decreased 17 minutes (mean time of 54.46 to 37.86 minutes, p<0.0001). Calls responded to within 9 minutes increased from 34 to 59%.

CONCLUSIONS

A systems-based approach that included a multi-organizational collaboration and consensus-based protocols to move patients from non-hyperacute hospitals to RSCs resulted in more patients receiving hyperacute stroke interventions and improvements in EMS response and transport times. As hyperacute stroke care becomes more centralized and endovascular therapy becomes more broadly implemented, the protocols developed here can be employed by other regions organizing patient flow across systems of stroke care.

Clinical Evaluation of the Patient With Acute Stroke

PURPOSE OF REVIEW

This article reviews the clinical evaluation of the patient with acute stroke, including key questions in the focused stroke history, important aspects of the National Institutes of Health Stroke Scale and focused neurologic examination, and the significance of the basic head CT scan in informing a timely treatment decision.

RECENT FINDINGS

Advances in both stroke treatment and enhanced diagnostics support an evolving paradigm for acute stroke care, ranging from the prehospital setting to the rehabilitative setting. An international emphasis on best practice strategies promotes efficiency and standardization in stroke systems of care.

SUMMARY

Despite continual changes and augmentations to the field of acute stroke, several fundamentals remain. Central among these is in-depth knowledge of neurovascular anatomy, clinical stroke syndromes, and common mimics, which are foundational to the bedside evaluation of the patient with acute stroke.

The Door to Needle Time Metric Can Be Achieved via Telestroke

The administration of intravenous (IV) alteplase to patients with stroke via telestroke (TS) can be safe and effective. It remains unclear how quickly IV alteplase occurs during TS evaluations. We sought to compare door to needle times (DNTs) between patients receiving IV alteplase who present directly to our comprehensive stroke center (CSC) and those presenting to community hospitals in our TS network. Consecutive patients with acute ischemic stroke (AIS) who presented to emergency departments and received IV alteplase between August 2014 and June 2015 were identified at our CSC and TS network. Median DNTs with interquartile ranges were calculated in each cohort. During the study period, 117 patients with AIS (mean age 71 ± 15 years, 47% women) receiving IV alteplase were included in the analysis (65 CSC and 52 TS). Median DNT at our CSC was significantly shorter compared to TS sites (CSC: 43 [35-55] minutes vs TS: 54 [41-71] minutes, P < .01). The proportion of patients receiving IV alteplase ≤60 minutes of presentation was significantly higher at our CSC compared to our TS network (CSC 84.6% vs TS 63.5%, P = .02). Differences in favorable discharge to home were not significant (CSC 60% vs TS 46%, P = .14). Guideline-recommended DNTs ≤60 minutes can be achieved in community hospitals with TS guidance. Initiatives are required to better resemble DNTs found at stroke centers.

Results of a 1-year quality-improvement process to reduce door-to-needle time in acute ischemic stroke with MRI screening

OBJECTIVE

To determine the effects of a 1-year quality-improvement (QI) process to reduce door-to-needle (DTN) time in a secondary general hospital in which multimodal MRI screening is used before tissue plasminogen activator (tPA) administration in patients with acute ischemic stroke (AIS).

METHODS

The QI process was initiated in January 2015. Patients who received intravenous (iv) tPA<4.5h after AIS onset between 26 February 2015 to 25 February 2016 (during implementation of the QI process; the "2015 cohort") were identified (n=130), and their demographic and clinical characteristics and timing metrics compared with those of patients treated by iv tPA in 2014 (the "2014 cohort", n=135).

RESULTS

Of the 130 patients in the 2015 cohort, 120 (92.3%) of them were screened by MRI. The median DTN time was significantly reduced by 30% (from 84min in 2014 to 59min; P<0.003), while the proportion of treated patients with a DTN time≤60min increased from 21% to 52% (P<0.0001). Demographic and baseline characteristics did not significantly differ between cohorts, and the improvement in DTN time was associated with better outcomes after discharge (patients with a 0-2 score on the modified rankin scale: 59% in the 2015 cohort vs 42.4% in the 2014 cohort; P<0.01). During the 1-year QI process, the median DTN time decreased by 15% (from 65min in the first trimester to 55min in the last trimester; P≤0.04) with a non-significant 1.5-fold increase in the proportion of treated patients with a DTN time≤60min (from 41% to 62%; P=0.09).

CONCLUSION

It is feasible to deliver tPA to patients with AIS within 60min in a general hospital, using MRI as the routine screening modality, making this QI process to reduce DTN time widely applicable to other secondary general hospitals.

E-Mail Is an Effective Tool for Rapid Feedback in Acute Stroke

OBJECTIVE

To determine whether e-mail is a useful mechanism to provide prompt, case-specific data feedback and improve door-to-needle (DTN) time for acute ischemic stroke treated with intravenous tissue plasminogen activator (IV-tPA) in the emergency department (ED) at a high-volume academic stroke center.

METHODS

We instituted a quality improvement project at Columbia University Medical Center where clinical details are shared via e-mail with the entire treatment team after every case of IV-tPA administration in the ED. Door-to-needle and component times were compared between the prefeedback (January 2013 to March 2015) and postfeedback intervention (April 2015 to June 2016) periods.

RESULTS

A total of 273 cases were included in this analysis, 102 (37%) in the postintervention period. Median door-to-stroke code activation (2 vs 0 minutes, P < .01), door-to-CT Scan (21 vs 18 minutes, P < .01), and DTN (54 vs 49 minutes, P = .17) times were shorter in the postintervention period, although the latter did not reach statistical significance. The proportion of cases with the fastest DTN (≤45 minutes) was higher in the postintervention period (29.2% vs 42.2%, P = .03).

CONCLUSION

E-mail is a simple and effective tool to provide rapid feedback and promote interdisciplinary communication to improve acute stroke care in the ED.