1
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Ademola A, Bala F, Menon BK, Thornton J, Casetta I, Nannoni S, Goyal M, Herlihy D, Fainardi E, Power S, Saia V, Hegarty A, Pracucci G, Demchuk A, Mangiafico S, Boyle K, Michel P, Hildebrand KA, Sajobi TT, Hill MD, Toni D, Murphy S, Kim BJ, Almekhlafi MA. Workflow and Outcome of Thrombectomy in Late Time Window: A Pooled Multicenter Analysis. Can J Neurol Sci 2024:1-7. [PMID: 38639107 DOI: 10.1017/cjn.2024.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
BACKGROUND We investigated the impact of workflow times on the outcomes of patients treated with endovascular thrombectomy (EVT) in the late time window. METHODS Individual patients' data who underwent EVT in the late time window (onset to imaging >6 hours) were pooled from seven registries and randomized clinical trials. Multiple time intervals were analyzed. Mixed-effects logistic regression was used to estimate the likelihood of functional independence at 90 days (modified Rankin Scale 0-2). Mixed-effects negative binomial regression was used to evaluate the relationship between patient characteristics and workflow time intervals. RESULTS 608 patients were included. The median age was 70 years (IQR: 58-71), 307 (50.5%) were female, and 310 (53.2%) had wake-up strokes. Successful reperfusion was achieved in 493 (81.2%) patients, and 262 (44.9%) achieved 90-day mRS 0-2. The estimated odds of functional independence decreased by 13% for every 30 minute delay from emergency department (ED) arrival to imaging time and by 7% from ED arrival to the end of EVT in the entire cohort. Also, the estimated odds of functional independence decreased by 33% for every 30 minute delay in the interval from arterial puncture to end of EVT, 16% in the interval from arrival in ED to end of EVT and 6% in the interval from stroke onset to end of EVT among patients who had a wake-up stroke. CONCLUSION Faster workflow from ED arrival to end of EVT is associated with improved functional independence among stroke patients treated in the late window.
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Affiliation(s)
- Ayoola Ademola
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- McCaig Institute of Bone and Joint, University of Calgary, Calgary, Canada
| | - Fouzi Bala
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Bijoy K Menon
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - John Thornton
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ilaria Casetta
- Clinica Neurologica, University of Ferrara, Ferrara, Italy
| | - Stefania Nannoni
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Darragh Herlihy
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Italy
| | - Sarah Power
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | - Valentina Saia
- Stroke Unit, Santa Corona Hospital, Pietra Ligure, Italy
| | - Aidan Hegarty
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | | | - Andrew Demchuk
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | | | - Karl Boyle
- Department of Geriatric and Stroke Medicine, Beaumont Hospital, Dublin, Ireland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Kevin A Hildebrand
- McCaig Institute of Bone and Joint, University of Calgary, Calgary, Canada
- Department of Surgery, University of Calgary, Calgary, Canada
| | - Tolulope T Sajobi
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Michael D Hill
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Danilo Toni
- Emergency Department, Stroke Unit, Sapienza University Hospital, Rome, Italy
| | - Sean Murphy
- Department of Geriatric and Stroke Medicine, The Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Mohammed A Almekhlafi
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
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2
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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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3
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Qiang H, Jin‐mei S, Yan‐fei H, Yong‐bo Z. Early arrival did not ensure the early acquisition of intravenous thrombosis for acute ischemic stroke during the COVID-19 pandemic. Brain Behav 2023; 13:e2977. [PMID: 36974385 PMCID: PMC10175972 DOI: 10.1002/brb3.2977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 03/03/2023] [Accepted: 03/14/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) is a time-dependent treatment with a narrow therapeutic time window, in which the time delay could result from the deadline effect. METHODS One hospital-based cohort was recruited to detect the factors contributing to the deadline effect, where patients with the deadline effect were defined as those who were presented with the onset-to-door time (ODT) in the first 50%, while the door-to-needle time (DNT) was in the last quartile. DNT (in-hospital delay) was further subdivided into several time intervals [door-to-examination time (DET), door-to-imaging time (DIT), door-to-laboratory time (DLT), and decision-making time (DMT) of the patients or their proxies. RESULTS A total of 186 IVT cases were enrolled, of which 17.2% (32/186) suffered a delay of the deadline effect. The median age was 66 years, and 35.5% were female. Baseline characteristics were similar between the two groups (all p > .05). For the comparisons of the time intervals, DIT (26 versus 15 min, p = .001) was significantly longer in the group with deadline effect, while the differences of DET, DLT, DMT, and ONT did not reach statistical significance (all p > .05). Upon multivariable adjustment in the binary logistic regression model, longer DIT [odds ratio (OR), 1.076; 95% confidence interval (CI), 1.036-1.118; p < .001], and history of coronary heart disease (OR, 3.898; 95%CI, 1.415-10.735; p = .008) were independently associated with deadline effect in the binary logistic regression model, while admitted in the working day (OR, 0.674; 95%CI, 0.096-0.907; p = .033), and having medical insurance (OR, 0.350; 95% CI, 0.132-0.931; p = .035) were negatively associated with the deadline effect. CONCLUSIONS A speed-safety tradeoff phenomenon from the deadline effect was observed in 17.2% of IVT cases during the COVID-19 pandemic, where longer DIT contributed a lot to this time delay. Patients without medical insurance, or admitted in official holidays were more likely to experience a delay of the deadline effect.
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Affiliation(s)
- Huang Qiang
- Department of NeurologyBeijing Friendship Hospital, Capital Medical UniversityBeijingPeople's Republic of China
| | - Sun Jin‐mei
- Department of NeurologyBeijing Friendship Hospital, Capital Medical UniversityBeijingPeople's Republic of China
| | - Han Yan‐fei
- Department of NeurologyBeijing Friendship Hospital, Capital Medical UniversityBeijingPeople's Republic of China
| | - Zhang Yong‐bo
- Department of NeurologyBeijing Friendship Hospital, Capital Medical UniversityBeijingPeople's Republic of China
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4
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Samavedam S. If Time is Neuron, What Are We Waiting for? Indian J Crit Care Med 2023; 27:87-88. [PMID: 36865521 PMCID: PMC9973065 DOI: 10.5005/jp-journals-10071-24412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
How to cite this article: Samavedam S. If Time is Neuron, What Are We Waiting for? Indian J Crit Care Med 2023;27(2):87-88.
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Affiliation(s)
- Srinivas Samavedam
- Department of Critical Care, Virinchi Hospitals, Hyderabad, Telangana, India
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5
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Identification and analysis of key risk factors for prehospital delay in patients with stroke. Int Emerg Nurs 2022; 62:101156. [DOI: 10.1016/j.ienj.2022.101156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 01/27/2022] [Accepted: 02/11/2022] [Indexed: 01/18/2023]
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6
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Zhang X, Tang H, Zuo Q, Xue G, Duan G, Xu Y, Hong B, Zhao R, Yang P, Liu J, Huang Q. Treatment delay from aneurysmal subarachnoid hemorrhage to endovascular treatment: a high-volume hospital experience. Chin Neurosurg J 2021; 7:43. [PMID: 34610849 PMCID: PMC8493710 DOI: 10.1186/s41016-021-00262-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/17/2021] [Indexed: 12/21/2022] Open
Abstract
Background Early treatment for patients with aneurysmal subarachnoid hemorrhage (aSAH) could significantly reduce the risk of re-bleeding and improve clinical outcomes. We assessed the different time intervals from the initial hemorrhage, admission, and endovascular treatment and identified the risk factors contributing to delay. Methods Between February 2017 and December 2019, 422 consecutive aSAH patients treated in a high-volume hospital were collected and reviewed. Risk factors contributing to admission delay and treatment delay were analyzed with univariate and multivariate analysis. Results One hundred twenty-two (28.9%) were admitted to the high-volume hospital at the day of symptom onset and 386 (91.5%) were treated with endovascular management at the same day of admission. The multivariate analysis found that younger age (P = 0.022, OR = 0.981, 95% CI 0.964–0.997) and good Fisher score (P = 0.002, OR = 0.420, 95% CI 0.245–0.721) were independent risk factors of admission delay. None was found to be related with treatment delay. Multivariate analysis (OR (95% CI)) showed that higher age 1.027 (1.004–1.050), poorer Fisher score 3.496 (1.993–6.135), larger aneurysmal size 1.112 (1.017–1.216), and shorter interval between onset to admission 1.845 (1.018–3.344) were independent risk factors of poorer clinical outcome. Conclusion Treatment delay was mainly caused by pre-hospital delay including delayed admission and delayed transfer. Our experience showed that cerebrovascular team could provide early treatment for aSAH patients. Younger age and good Fisher score were significantly related with admission delay. However, admission delay was further significantly correlated with better clinical outcome.
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Affiliation(s)
- Xiaoxi Zhang
- Department of Neurosurgery, Changhai Hospital, Naval Military Medical University, 168 Changhai Rd, Shanghai, 200433, People's Republic of China
| | - Haishuang Tang
- Department of Neurosurgery, Changhai Hospital, Naval Military Medical University, 168 Changhai Rd, Shanghai, 200433, People's Republic of China.,Naval Medical Center of PLA, Naval Military Medical University, Shanghai, 200050, People's Republic of China
| | - Qiao Zuo
- Department of Neurosurgery, Changhai Hospital, Naval Military Medical University, 168 Changhai Rd, Shanghai, 200433, People's Republic of China
| | - Gaici Xue
- Department of Neurosurgery, Changhai Hospital, Naval Military Medical University, 168 Changhai Rd, Shanghai, 200433, People's Republic of China
| | - Guoli Duan
- Department of Neurosurgery, Changhai Hospital, Naval Military Medical University, 168 Changhai Rd, Shanghai, 200433, People's Republic of China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Naval Military Medical University, 168 Changhai Rd, Shanghai, 200433, People's Republic of China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Naval Military Medical University, 168 Changhai Rd, Shanghai, 200433, People's Republic of China
| | - Rui Zhao
- Department of Neurosurgery, Changhai Hospital, Naval Military Medical University, 168 Changhai Rd, Shanghai, 200433, People's Republic of China
| | - Pengfei Yang
- Department of Neurosurgery, Changhai Hospital, Naval Military Medical University, 168 Changhai Rd, Shanghai, 200433, People's Republic of China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Naval Military Medical University, 168 Changhai Rd, Shanghai, 200433, People's Republic of China
| | - Qinghai Huang
- Department of Neurosurgery, Changhai Hospital, Naval Military Medical University, 168 Changhai Rd, Shanghai, 200433, People's Republic of China.
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7
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Zheng S, Lyu TJ, Li Z, Gu H, Yang X, Wang C, Li H, Jiang Y, Shen H, Wang Y. GRP per capita and hospital characteristics associated with intravenous tissue plasminogen activator adherence rate: evidence from the Chinese Stroke Center Alliance. Stroke Vasc Neurol 2021; 6:337-343. [PMID: 33431514 PMCID: PMC8485228 DOI: 10.1136/svn-2020-000633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/22/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022] Open
Abstract
Background Timely delivery of intravenous tissue plasminogen activator (IV-rt PA) is pivotal to eligible patients who had a stroke while achieving higher rates of IV-rt PA has been problematic. This paper focuses on investigating influential factors associated with the administration of IV-rt PA, primarily per capita gross regional product (GRP) and healthcare system factors. Methods The study included 980 hospitals in the Chinese Stroke Center Alliance where 158 003 patients who had an acute ischaemic stroke received IV-rt PA between August 2015 and August 2019. The adherence rate to IV-rt PA within 4.5 hours time window in each hospital was the primary outcome. Influential factors were grouped into two categories: macroeconomic status and hospital characteristics. The outcome was analysed using multivariable linear regression. Results GRP per capita (β=2.37, p<0.001), hospital stroke centre certification (β=3.77, p<0.001), number of neurologists (β=0.12, p<0.001), existence of emergency services for neurological treatment (β=7.43, p=0.014), presence of emergency department (β=10.03, p=0.019) and cooperating with emergency centre (β=4.65, p=0.029) were significantly positively associated with the adherence rate to IV-rt PA. Conclusions Higher GRP per capita, affluent neurological personnel, well-equipped emergency services for neurological treatment and routine cooperation with the emergency centre were important for enhancing the adherence rate to IV-rt PA among patients who had an acute ischaemic stroke in China.
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Affiliation(s)
- Suxi Zheng
- Innvotion and Information Management, HKU Business School, The University of Hong Kong, Hong Kong, China
| | - Tian Jie Lyu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Chinese Institute for Brain Research, Beijing, China
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Yang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunjuan Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haipeng Shen
- Innvotion and Information Management, HKU Business School, The University of Hong Kong, Hong Kong, China .,Shenzhen Institute of Research and Innovation, The University of Hong Kong, Shenzhen, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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8
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Factors delaying intravenous thrombolytic therapy in acute ischaemic stroke: a systematic review of the literature. J Neurol 2020; 268:2723-2734. [PMID: 32206899 DOI: 10.1007/s00415-020-09803-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND/AIMS This review examined factors that delay thrombolysis and what management strategies are currently employed to minimise this delay, with the aim of suggesting future directions to overcome bottlenecks in treatment delivery. METHODS A systematic review was performed according to PRISMA guidelines. The search strategy included a combination of synonyms and controlled vocabularies from Medical Subject Headings (MeSH) and EmTree covering brain ischemia, cerebrovascular accident, fibrinolytic therapy and Alteplase. The search was conducted using Medline (OVID), Embase (OVID), PubMed and Cochrane Library databases using truncations and Boolean operators. The literature search excluded review articles, trial protocols, opinion pieces and case reports. Inclusion criteria were: (1) The article directly related to thrombolysis in ischaemic stroke, and (2) The article examined at least one factor contributing to delay in thrombolytic therapy. RESULTS One hundred and fifty-two studies were included. Pre-hospital factors resulted in the greatest delay to thrombolysis administration. In-hospital factors relating to assessment, imaging and thrombolysis administration also contributed. Long onset-to-needle times were more common in those with atypical, or less severe, symptoms, the elderly, patients from lower socioeconomic backgrounds, and those living alone. Various strategies currently exist to reduce delays. Processes which have achieved the greatest improvements in time to thrombolysis are those which integrate out-of-hospital and in-hospital processes, such as the Helsinki model. CONCLUSION Further integrated processes are required to maximise patient benefit from thrombolysis. Expansion of community education to incorporate less common symptoms and provision of alert pagers for patients may provide further reduction in thrombolysis times.
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9
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He XW, Zhao R, Li GF, Zheng B, Wu YL, Shi YH, Liu YS, Zhuang MT, Yin JW, Cui GH, Liu JR. Lack of Correlation Between Intracranial Carotid Artery Modified Woodcock Calcification Score and Prognosis of Patients With Acute Ischemic Stroke After Intravenous Thrombolysis. Front Neurol 2019; 10:696. [PMID: 31312173 PMCID: PMC6614196 DOI: 10.3389/fneur.2019.00696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 06/13/2019] [Indexed: 01/01/2023] Open
Abstract
There have been few studies about the association between intracranial carotid artery calcification (ICAC) and acute ischemic stroke (AIS) prognosis after intravenous thrombolysis (IVT). We aimed to analyze the association between ICAC and prognosis (including symptomatic intracranial hemorrhage (sICH), functional outcome and death) of AIS patients treated with IVT. In this retrospective study, we consecutively included 232 AIS patients treated with IVT between April 2012 and December 2018. ICAC was evaluated using the modified Woodcock calcification visual score on non-enhanced cranial computed tomography scans. Poor functional outcome was defined as a modified Rankin Scale score > 2 at 3 months. We found that the modified Woodcock calcification score was associated with ICH, poor outcome, and death in univariable analyses on the symptomatic side and/or bilaterally. However, after adjustment for other different covariates, the results showed no significant difference. We documented that the presence and severity of ICAC did not significantly modify the beneficial effects of rtPA treatment in AIS.
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Affiliation(s)
- Xin-Wei He
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rong Zhao
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ge-Fei Li
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bo Zheng
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi-Lan Wu
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan-Hui Shi
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi-Sheng Liu
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mei-Ting Zhuang
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia-Wen Yin
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guo-Hong Cui
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian-Ren Liu
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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10
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Ding Y, Ji Z, Ma L, Zhai T, Gu Z, Niu J, Liu Y. Interhospital transfer on intravenous thrombolysis in patients with acute ischemic stroke in three chinese municipal stroke centers. J Thromb Thrombolysis 2019; 48:580-586. [DOI: 10.1007/s11239-019-01912-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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11
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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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12
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Huang Q, Song HQ, Ma QF, Song XW, Wu J. Effects of time delays on the therapeutic outcomes of intravenous thrombolysis for acute ischemic stroke in the posterior circulation: An observational study. Brain Behav 2019; 9:e01189. [PMID: 30614220 PMCID: PMC6379513 DOI: 10.1002/brb3.1189] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 11/16/2018] [Accepted: 11/23/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We aim to demonstrate the effects of time delays on the therapeutic outcomes of intravenous thrombolysis (IVT) in acute posterior circulation stroke (PCS) patients. METHODS Consecutive PCS cases treated with IVT alone were retrospectively examined. The primary end point was set to be a favorable outcome (modified Rankin Scale [mRS] ≤2) at 3 months, and angiographic recanalization was set to be the secondary outcome. RESULTS A total of 95 PCS cases with IVT were recruited. The patients with favorable outcomes and those without favorable outcomes had similar baseline characteristics, except for significantly lower National Institute of Health Stroke Scale (NIHSS) scores (5 vs. 12, respectively; p < 0.001) and less hyperdense basilar artery signs in head CTs (26.5% vs. 70.4%, respectively; p < 0.001) for those with favorable outcomes. For patients with an onset-to-treatment time (OTT) of 0-90 min (n = 5), 91-180 min (n = 38), 181-270 min (n = 37), or ≧271 min (n = 15), the rate of favorable outcome was 100.0%, 71.1%, 67.6%, or 73.3%, respectively, and the Cochran-Armitage trend test showed no linear trend between the OTT and the clinical prognosis of IVT in PCS (p = 0.501) patients. In addition, the rates of recanalization were 100.0%, 68.4%, 64.9%, and 46.7%, and the Cochran-Armitage trend test suggested a linear trend between the OTT and recanalization (p = 0.046); that is, the proportion of PCS patients who underwent recanalization decreased with increasing OTTs. In the multivariate logistic regression analysis, after adjusting for confounding factors with p ≦ 0.20 in the univariate analysis, baseline NIHSS scores and hyperdense basilar artery signs were negatively associated with favorable outcomes, with odds ratios (OR) of 0.884 (95% confidence interval [CI], 0.804-0.971; p = 0.010) and 0.208 (95% CI, 0.062-0.693; p = 0.011), respectively. In addition, there was a negative association between recanalization, OTTs (OR, 0.993, 95% CI, 0.987-0.999; p = 0.029), and baseline NIHSS scores (OR, 0.881, 95% CI, 0.802-0.967; p = 0.008). CONCLUSION Irrespective of stroke severity, the therapeutic effects of recanalization after IVT decreased significantly with longer time delays in PCS patients.
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Affiliation(s)
- Qiang Huang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Hai-Qing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qing-Feng Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiao-Wei Song
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jian Wu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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Sadeghi-Hokmabadi E, Farhoudi M, Taheraghdam A, Rikhtegar R, Ghafouri RR, Asadi R, Far EM, Ghaemian N, Mehrara M, Mirnour R. Prehospital notification can effectively reduce in-hospital delay for thrombolysis in acute stroke. FUTURE NEUROLOGY 2018. [DOI: 10.2217/fnl-2017-0031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: To reduce in-hospital intervals by developing a prehospital notification (PHN) protocol which directly notifies a neurologist to prepare for possible treatment. Methods: A 24/7 connection was established between emergency medical services dispatch and the on-call neurologist. A database of all patients with in-hospital stroke code activation was developed, door-to-computed tomography (CT) time and door-to-needle time was recorded from January 2013 to December 2016. The statistical results were considered significant at p < 0.05. Result: PHN resulted in a significant reduction in door-to-CT time (median 14 vs 20; p < 0.001). Among patients who were treated with intravenous thrombolysis, door-to-needle time was significantly shorter in patients with PHN compared with non-PHN group (median 42 vs 70; p < 0.001). Conclusion: PHN effectively reduced door-to-CT and door-to-needle times.
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Affiliation(s)
- Elyar Sadeghi-Hokmabadi
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Farhoudi
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Aliakbar Taheraghdam
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Rikhtegar
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rouzbeh Rajaei Ghafouri
- Emergency medicine research team, Emergency Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rogayyeh Asadi
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Elham Mehdizadeh Far
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Neda Ghaemian
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehrdad Mehrara
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reshad Mirnour
- Neurosciences Research Center (NSRC), Neurology Department, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
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Positive impact of the participation in the ENCHANTED trial in reducing Door-to-Needle Time. Sci Rep 2017; 7:14168. [PMID: 29074964 PMCID: PMC5658430 DOI: 10.1038/s41598-017-14164-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/05/2017] [Indexed: 11/09/2022] Open
Abstract
Door-to-needle time (DNT) is a key performance indicator for efficient use of intravenous thrombolysis in acute ischemic stroke (AIS). We aimed to determine whether DNT improved over time in the Enhanced Control of Hypertension and Acute Stroke Study (ENCHANTED) and the clinical predictors of DNT. Temporal trends in DNT were assessed across fourths of time since activation of study centers using generalized linear model. Predictors of long DNT (>60 min) were determined in logistic regression models. Overall mean DNT (min) was 71.8 (95% confidence interval [CI] 70.4–73.2), but decreased significantly over time (fourths): 77.9 (74.9–80.9), 69.3 (66.7–72.0), 69.1 (66.5–71.8) and 71.4 (68.7–74.2) (P for trend, 0.003). The reduction in DNT was particularly marked in China (P for trend, 0.001), but was not significant across the other participating countries (P for trend, 0.065). Independent predictors of long DNT were recruitment from China, short onset-to-door time, lower numbers of patients treated per center, higher diastolic blood pressure, off-hour admission, and absence of proximal clot occlusion. DNT in ENCHANTED declined progressively during the trial, especially in China. However, DNT in China is still longer than the key performance parameter of ≤60 minutes recommended in guidelines. Effective national programs are needed to improve DNT in China.
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Zhou Y, Xu Z, Liao J, Feng F, Men L, Xu L, He Y, Li G. New standardized nursing cooperation workflow to reduce stroke thrombolysis delays in patients with acute ischemic stroke. Neuropsychiatr Dis Treat 2017; 13:1215-1220. [PMID: 28533683 PMCID: PMC5431707 DOI: 10.2147/ndt.s128740] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE We assessed the effectiveness of a new standardized nursing cooperation workflow in patients with acute ischemic stroke (AIS) to reduce stroke thrombolysis delays. PATIENTS AND METHODS AIS patients receiving conventional thrombolysis treatment from March to September 2015 were included in the control group, referred to as T0. The intervention group, referred to as T1 group, consisted of AIS patients receiving a new standardized nursing cooperation workflow for intravenous thrombolysis (IVT) at the emergency department of Shanghai East Hospital (Shanghai, People's Republic of China) from October 2015 to March 2016. Information was collected on the following therapeutic techniques used: application or not of thrombolysis, computed tomography (CT) time, and door-to-needle (DTN) time. A nursing coordinator who helped patients fulfill the medical examinations and diagnosis was appointed to T1 group. In addition, a nurse was sent immediately from the stroke unit to the emergency department to aid the thrombolysis treatment. RESULTS The average value of the door-to-CT initiation time was 38.67±5.21 min in the T0 group, whereas it was 14.39±4.35 min in the T1 group; the average values of CT completion-to-needle time were 55.06±4.82 and 30.26±3.66 min; the average values of DTN time were 100.43±6.05 and 55.68±3.62 min, respectively; thrombolysis time was improved from 12.8% (88/689) in the T0 group to 32.5% (231/712) in the T1 group (all P<0.01). In addition, the new standardized nursing cooperation workflow decreased the National Institutes of Health Stroke Scale (NIHSS) scores at 24 h (P<0.01) (T0: prethrombolysis, 6.97±3.98; 24 h postthrombolysis, 3.33±2.09; 2 weeks postthrombolysis, 2.25±1.01 and T1: prethrombolysis, 7.00±3.89; 24 h postthrombolysis, 2.60±1.66; 2 weeks postthrombolysis, 2.21±1.02). CONCLUSION The new standardized nursing cooperation workflow reduced stroke thrombolysis delays in patients with AIS.
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Affiliation(s)
- Yan Zhou
- Nursing Department, Shanghai East Hospital, Tongji University School of Medicine, Shanghai
| | - Zhuojun Xu
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Jiali Liao
- Nursing Department, Shanghai East Hospital, Tongji University School of Medicine, Shanghai
| | - Fangming Feng
- Nursing Department, Shanghai East Hospital, Tongji University School of Medicine, Shanghai
| | - Lai Men
- Paddington Dental Practice, London, UK
| | - Li Xu
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Yanan He
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Gang Li
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
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Huang Q, Song HQ, Ji XM, Cheng WY, Feng J, Wu J, Ma QF. Generalization of the Right Acute Stroke Prevention Strategies in Reducing in-Hospital Delays. PLoS One 2016; 11:e0154972. [PMID: 27152854 PMCID: PMC4859531 DOI: 10.1371/journal.pone.0154972] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 04/21/2016] [Indexed: 11/19/2022] Open
Abstract
The aim of this study was to reduce the door-to-needle (DTN) time of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) through a comprehensive, hospital-based implementation strategy. The intervention involved a systemic literature review, identifying barriers to rapid IVT treatment at our hospital, setting target DTN time intervals, and building an evolving model for IVT candidate selection. The rate of non-in-hospital delay (DTN time ≤ 60 min) was set as the primary endpoint. A total of 348 IVT cases were enrolled in the study (202 and 146 in the pre- and post-intervention group, respectively). The median age was 61 years in both groups; 25.2% and 26.7% of patients in the pre- and post-intervention groups, respectively, were female. The post-intervention group had higher rates of dyslipidemia and minor stroke [defined as National Institutes of Health Stroke Scale (NIHSS) ≤ 3]; less frequent atrial fibrillation; higher numbers of current smokers, heavy drinkers, referrals, and multi-model head imaging cases; and lower NIHSS scores and blood sugar level (all P < 0.05). All parameters including DTN, door-to-examination, door-to-imaging, door-to-laboratory, and final-test-to-needle times were improved post-intervention (all P < 0.05), with net reductions of 63, 2, 4, 28, and 23 min, respectively. The rates of DTN time ≤ 60 min and onset-to-needle time ≤ 180 min were significantly improved by the intervention (pre: 9.9% vs. post: 60.3%; P < 0.001 and pre: 23.3% vs. post: 53.4%; P < 0.001, respectively), which was accompanied by an increase in the rate of neurological improvement (pre: 45.5% vs. post: 59.6%; P = 0.010), while there was no change in incidence of mortality or systemic intracranial hemorrhage at discharge (both P > 0.05). These findings indicate that it is possible to achieve a DTN time ≤ 60 min for up to 60% of hospitals in the current Chinese system, and that this logistical change can yield a notable improvement in the outcome of IVT patients.
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Affiliation(s)
- Qiang Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hai-qing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xun-ming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei-yang Cheng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Juan Feng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Wu
- Department of neurology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Beijing, China
- * E-mail: (QM); (JW)
| | - Qing-feng Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- * E-mail: (QM); (JW)
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Effective management of patients with acute ischemic stroke based on lean production on thrombolytic flow optimization. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2016; 39:987-996. [PMID: 27094731 DOI: 10.1007/s13246-016-0442-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 04/04/2016] [Indexed: 10/21/2022]
Abstract
The efficacy of thrombolytic therapy for acute ischemic stroke (AIS) decreases when the administration of tissue plasminogen activator (tPA) is delayed. Derived from Toyota Production System, lean production aims to create top-quality products with high-efficiency procedures, a concept that easily applies to emergency medicine. In this study, we aimed to determine whether applying lean principles to flow optimization could hasten the initiation of thrombolysis. A multidisciplinary team (Stroke Team) was organized to implement an ongoing, continuous loop of lean production that contained the following steps: decomposition, recognition, intervention, reengineering and assessment. The door-to-needle time (DNT) and the percentage of patients with DNT ≤ 60 min before and after the adoption of lean principles were used to evaluate the efficiency of our flow optimization. Thirteen patients with AIS in the pre-lean period and 43 patients with AIS in the lean period (23 in lean period I and 20 patients in lean period II) were consecutively enrolled in our study. After flow optimization, we reduced DNT from 90 to 47 min (p < 0.001¤). In addition, the percentage of patients treated ≤60 min after hospital arrival increased from 38.46 to 75.0 % (p = 0.015¤). Adjusted analysis of covariance confirmed a significant influence of optimization on delay of tPA administration (p < 0.001). The patients were more likely to have a good prognosis (mRS ≤ 2 at 90 days) after the flow optimization (30.77-75.00 %, p = 0.012¤). Our study may offer an effective approach for optimizing the thrombolytic flow in the management of AIS.
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