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Tejada Meza H, Saldaña Inda I, Serrano Ponz M, Ara JR, Marta Moreno J. Impact of a series of measures for optimisation hospital code stroke care on door-to-needle times. Neurologia 2023; 38:141-149. [PMID: 37059569 DOI: 10.1016/j.nrleng.2020.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/07/2020] [Indexed: 04/16/2023] Open
Abstract
INTRODUCTION Time continues to be a fundamental variable in reperfusion treatments for acute ischaemic stroke. Despite the recommendations made in clinical guidelines, only around one-third of these patients receive fibrinolysis within 60minutes. In this study, we describe our experience with the implementation of a specific protocol for patients with acute ischaemic stroke and evaluate its impact on door-to-needle times in our hospital. METHODS Measures were gradually implemented in late 2015 to shorten stroke management times and optimise the care provided to patients with acute ischaemic stroke; these measures included the creation of a specific on-call neurovascular care team. We compare stroke management times before (2013-2015) and after (2017-2019) the introduction of the protocol. RESULTS The study includes 182 patients attended before implementation of the protocol and 249 attended after. Once all measures were in effect, the overall median door-to-needle time was 45minutes (vs 74 minutes before, a 39% reduction; P<.001), with 73.5% of patients treated within 60minutes (a 47% increase; P<.001). Median overall time to treatment (onset-to-needle time) was reduced by 20minutes (P<.001). CONCLUSIONS The measures included in our protocol achieved a significant, sustained reduction in door-to-needle times, although there remains room for improvement. The mechanisms established for monitoring outcomes and for continuous improvement will enable further advances in this regard.
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Affiliation(s)
- H Tejada Meza
- Sección de Neurovascular, Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España; Sección de Neurointervencionismo, Servicio de Radiología, Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España.
| | - I Saldaña Inda
- Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - M Serrano Ponz
- Sección de Neurovascular, Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España; Departamento de Medicina, Psiquiatría y Dermatología, Facultad de Medicina, Universidad de Zaragoza, Zaragoza, España
| | - J R Ara
- Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España; Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - J Marta Moreno
- Sección de Neurovascular, Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España
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Leite KFDS, Faria MGBFD, Andrade RLDP, Sousa KDLD, Santos SRD, Ferreira KS, Rezende CEMD, Neto OMP, Monroe AA. Effect of implementing care protocols on acute ischemic stroke outcomes: a systematic review. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:173-185. [PMID: 36948202 PMCID: PMC10033200 DOI: 10.1055/s-0042-1759578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 01/13/2022] [Indexed: 03/24/2023]
Abstract
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.
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Affiliation(s)
- Karina Fonseca de Souza Leite
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| | - Mariana Gaspar Botelho Funari de Faria
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| | - Rubia Laine de Paula Andrade
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| | - Keila Diane Lima de Sousa
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| | - Samuel Ribeiro dos Santos
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| | - Kamila Santos Ferreira
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Hospital das Clínicas, Ribeirão Preto SP, Brazil.
| | - Carlos Eduardo Menezes de Rezende
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
- Ministério da Saúde, Agência Nacional de Saúde Suplementar, Brasília DF, Brazil.
| | - Octavio Marques Pontes Neto
- Universidade de São Paulo, Faculdade de Medicina de Ribeirao Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil.
| | - Aline Aparecida Monroe
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
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Botelho A, Rios J, Fidalgo AP, Ferreira E, Nzwalo H. Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192316357. [PMID: 36498429 PMCID: PMC9735885 DOI: 10.3390/ijerph192316357] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 06/01/2023]
Abstract
BACKGROUND After onset of acute ischemic stroke (AIS), there is a limited time window for delivering acute reperfusion therapies (ART) aiming to restore normal brain circulation. Despite its unequivocal benefits, the proportion of AIS patients receiving both types of ART, thrombolysis and thrombectomy, remains very low. The organization of a stroke care pathway is one of the main factors that determine timely access to ART. The knowledge on organizational factors influencing access to ART is sparce. Hence, we sought to systematize the existing data on the type and frequency of pre-hospital and in-hospital organizational factors that determine timely access to ART in patients with AIS. METHODOLOGY Literature review on the frequency and type of organizational factors that determine access to ART after AIS. Pubmed and Scopus databases were the primary source of data. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale. RESULTS A total of 128 studies were included. The main pre-hospital factors associated with delay or access to ART were medical emergency activation practices, pre-notification routines, ambulance use and existence of local/regional-specific strategies to mitigate the impact of geographic distance between patient locations and Stroke Unit (SU). The most common intra-hospital factors studied were specific location of SU and brain imaging room within the hospital, and the existence and promotion of specific stroke treatment protocols. Most frequent factors associated with increased access ART were periodic public education, promotion of hospital pre-notification and specific pre- and intra-hospital stroke pathways. In specific urban areas, mobile stroke units were found to be valid options to increase timely access to ART. CONCLUSIONS Implementation of different organizational factors and strategies can reduce time delays and increase the number of AIS patients receiving ART, with most of them being replicable in any context, and some in only very specific contexts.
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Affiliation(s)
- Ana Botelho
- Faculty of Economy, University of Algarve, 8005-139 Faro, Portugal
- Department of Physical Medicine and Rehabilitation, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
- Stroke Unit, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
| | - Jonathan Rios
- Department of Physical Medicine and Rehabilitation, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
| | - Ana Paula Fidalgo
- Stroke Unit, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
| | - Eugénia Ferreira
- Faculty of Economy, University of Algarve, 8005-139 Faro, Portugal
| | - Hipólito Nzwalo
- Stroke Unit, Algarve Hospital University Center-Faro, 8000-386 Faro, Portugal
- Faculty of Medicine and Biomedical Sciences, University of Algarve, 8005-139 Faro, Portugal
- Algarve Biomedical Research Institute, 8005-139 Faro, Portugal
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Leite KFDS, dos Santos SR, Andrade RLDP, de Faria MGBF, Saita NM, Arcêncio RA, Isaac ISDS, de Rezende CEM, Villa TCS, Pontes Neto OM, Monroe AA. Reducing care time after implementing protocols for acute ischemic stroke: a systematic review. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:725-740. [PMID: 36254446 PMCID: PMC9685828 DOI: 10.1055/s-0042-1755194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Abstract
Background The treatment of acute ischemic stroke with cerebral reperfusion therapy requires rapid care and recognition of symptoms.
Objective To analyze the effectiveness of implementing protocols for acute ischemic stroke in reducing care time.
Methods Systematic review, which was performed with primary studies in Portuguese, English, and Spanish published between 2011 and 2020. Inclusion criteria: study population should comprise people with acute ischemic stroke and studies should present results on the effectiveness of using urgent care protocols in reducing care time. The bibliographic search was conducted in June 2020 in the LILACS, MEDLINE, Embase, Scopus, CINAHL, Academic Search Premier, and SocINDEX databases. The articles were selected, and data were extracted by two independent reviewers; the synthesis of the results was performed narratively. The methodological quality of articles was evaluated through specific instruments proposed by the Joanna Briggs Institute.
Results A total of 11,226 publications were found, of which 35 were included in the study. Only one study reported improvement in the symptoms-onset-to-door time after protocol implementation. The effectiveness of the therapeutic approach protocols for ischemic stroke was identified in improving door-to-image, image-to-needle, door-to-needle and symptoms-onset-to-needle times. The main limitation found in the articles concerned the lack of clarity in relation to the study population.
Conclusions Several advances have been identified in in-hospital care with protocol implementation; however, it is necessary to improve the recognition time of stroke symptoms among those who have the first contact with the person affected by the stroke and among the professionals involved with the prehospital care.
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Affiliation(s)
- Karina Fonseca de Souza Leite
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Samuel Ribeiro dos Santos
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Rubia Laine de Paula Andrade
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Mariana Gaspar Botelho Funari de Faria
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Nanci Michele Saita
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Ricardo Alexandre Arcêncio
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Igor Simões da Silva Isaac
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Carlos Eduardo Menezes de Rezende
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
- Ministério da Saúde, Agência Nacional de Saúde Suplementar, Brasília DF, Brazil
| | - Tereza Cristina Scatena Villa
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Octavio Marques Pontes Neto
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
| | - Aline Aparecida Monroe
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
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Verma A, Sarda S, Jaiswal S, Batra A, Haldar M, Sheikh WR, Vishen A, Khanna P, Ahuja R, Khatai AA. Rapid Thrombolysis Protocol: Results from a Before-and-after Study. Indian J Crit Care Med 2022; 26:549-554. [PMID: 35719454 PMCID: PMC9160610 DOI: 10.5005/jp-journals-10071-24217] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective Intravenous thrombolysis within 4.5 hours from time of onset has proven benefit in stroke. Universal standard for the door-to-needle (DTN) time is within 60 minutes from the time of arrival of patients to the emergency department. Our rapid thrombolysis protocol (RTPr) was developed with an aim to reduce the DTN time to a minimum by modifying our stroke post-intervention processes. Materials and methods This before-and-after study was conducted at a single center on patients who received intravenous thrombolysis in the emergency department. Consecutive patients who were thrombolysed using our RTPr (post-intervention group) were compared to the pre-intervention group who were thrombolysed before the implementation of the protocol. The primary outcomes were DTN time, time to recovery, and modified ranking score (mRS) on discharge. Secondary outcomes were mortality, symptomatic intracerebral hemorrhage, and hospital and intensive care unit length of stay. Results Seventy-four patients were enrolled in each group. Mean DTN time in pre- and post-intervention group was 56.15 minutes (95% CI 49.98–62.31) and 34.91 minutes (95% CI 29.64–40.17) (p <0.001), respectively. In pre-intervention and post-intervention groups, 43.24% (95% CI 32.57–54.59) and 41.89% (95% CI 31.32–53.26) patients, respectively, showed neurological recovery in 24 hours. About 36.49% (95% CI 26.44–47.87) in pre-intervention group and 54.05% (95% CI 42.78–64.93) in post-intervention group had discharge mRS 0–2. Conclusion The RTPr can be adapted by clinicians and hospitals to bring down the DTN times and improve outcomes for stroke patients. How to cite this article Verma A, Sarda S, Jaiswal S, Batra A, Haldar M, Sheikh WR, et al. Rapid Thrombolysis Protocol: Results from a Before-and-after Study. Indian J Crit Care Med 2022;26(5):549–554.
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Affiliation(s)
- Ankur Verma
- Department of Emergency Medicine, Max Super Speciality Hospital, New Delhi, India
- Ankur Verma, Department of Emergency Medicine, Max Super Speciality Hospital, New Delhi, India, Phone: +91 9971779998, e-mail:
| | - Shivani Sarda
- Department of Emergency Medicine, Max Super Speciality Hospital, New Delhi, India
| | - Sanjay Jaiswal
- Department of Emergency Medicine, Max Super Speciality Hospital, New Delhi, India
| | - Amit Batra
- Department of Neurosciences, Max Super Speciality Hospital, New Delhi, India
| | - Meghna Haldar
- Department of Emergency Medicine, Max Super Speciality Hospital, New Delhi, India
| | - Wasil R Sheikh
- Department of Emergency Medicine, Max Super Speciality Hospital, New Delhi, India
| | - Amit Vishen
- Department of Emergency Medicine, Max Super Speciality Hospital, New Delhi, India
| | - Palak Khanna
- Department of Statistics, Amity Institute of Applied Sciences, Amity University, Noida, Uttar Pradesh, India
| | - Rinkey Ahuja
- Department of Emergency Medicine, Max Super Speciality Hospital, New Delhi, India
| | - Abbas A Khatai
- Department of Emergency Medicine, Max Super Speciality Hospital, New Delhi, India
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Olavarría VV, Hoffmeister L, Vidal C, Brunser AM, Hoppe A, Lavados PM. Temporal Trends of Intravenous Thrombolysis Utilization in Acute Ischemic Stroke in a Prospective Cohort From 1998 to 2019: Modeling Based on Joinpoint Regression. Front Neurol 2022; 13:851498. [PMID: 35463124 PMCID: PMC9028765 DOI: 10.3389/fneur.2022.851498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/02/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction The frequency of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) is lower than it should be in several regions of the world. It is unclear what interventions can produce significant improvements in IVT utilization. We aimed to investigate the temporal trends in IVT in AIS and identify changes in time that could be associated with specific interventions. Methods We included patients with AIS who were admitted from January 1998 to December 2019 in our institution. To analyze trends in utilization and time points in which they changed, we performed a Joinpoint regression analysis. Interventions were assigned to a specific category according to the Behavior Change Wheel framework intervention function criteria. Results A total of 3,361 patients with AIS were admitted, among which 538 (16%) received IVT. There were 245 (45.5%) women, and the mean age and median National Institutes of Health Stroke Scale (NIHSS) scores were 68.5 (17.2) years and 8 (interquartile range, 4–15), respectively. Thrombolysis use significantly increased by an average annual 7.6% (95% CI, 5.1–10.2), with one Joinpoint in 2007. The annual percent changes were.45% from 1998 to 2007 and 9.57% from 2007 to 2019, concurring with the stroke code organization, the definition of door-to-needle times as an institutional performance measure quality indicator, and the extension of the therapeutic window. Conclusions The IVT rates consistently increased due to a continuous process of protocol changes and multiple interventions. The implementation of a complex multidisciplinary intervention such as the stroke code, as well as the definition of a hospital quality control metric, were associated with a significant change in this trend.
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Affiliation(s)
- Verónica V. Olavarría
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Lorena Hoffmeister
- Escuela de Salud Pública, Facultad de Medicina, Universidad Mayor, Santiago, Chile
| | - Carolina Vidal
- Escuela de Salud Pública, Facultad de Medicina, Universidad Mayor, Santiago, Chile
| | - Alejandro M. Brunser
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Arnold Hoppe
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Pablo M. Lavados
- Unidad de Neurología Vascular, Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
- Unidad de Investigación y Ensayos Clínicos, Departamento de Desarrollo Académico e Investigación, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana Santiago, Universidad del Desarrollo, Santiago, Chile
- *Correspondence: Pablo M. Lavados
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Bulmer T, Volders D, Blake J, Kamal N. Discrete-Event Simulation to Model the Thrombolysis Process for Acute Ischemic Stroke Patients at Urban and Rural Hospitals. Front Neurol 2021; 12:746404. [PMID: 34777215 PMCID: PMC8586711 DOI: 10.3389/fneur.2021.746404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/30/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Effective treatment with tissue plasminogen activator (tPA) critically relies on rapid treatment. Door-to-needle time (DNT) is a key measure of hospital efficiency linked to patient outcomes. Numerous changes can reduce DNT, but they are difficult to trial and implement. Discrete-event simulation (DES) provides a way to model and determine the impact of process improvements. Methods: A conceptual framework was developed to illustrate the thrombolysis process; allowing for treatment processes to be replicated using a DES model developed in ARENA. Activity time duration distributions from three sites (one urban and two rural) were used. Five scenarios, three process changes, and two reductions in activity durations, were simulated and tested. Scenarios were tested individually and in combinations. The primary outcome measure is median DNT. The study goal is to determine the largest improvement in DNT at each site. Results: Administration of tPA in the imaging area resulted in the largest median DNT reduction for Site 1 and Site 2 for individual test scenarios (12.6%, 95% CI 12.4–12.8%, and 8.2%, 95% CI 7.5–9.0%, respectively). Ensuring that patients arriving via emergency medical services (EMS) remain on the EMS stretcher to imaging resulted in the largest median DNT improvement for Site 3 (9.2%, 95% CI 7.9–10.5%). Reducing both the treatment decision time and tPA preparation time by 35% resulted in a 11.0% (95% CI 10.0–12.0%) maximum reduction in median DNT. The lowest median and 90th percentile DNTs were achieved by combining all test scenarios, with a maximum reduction of 26.7% (95% CI 24.5–28.9%) and 17.1% (95% CI 12.5–21.7%), respectively. Conclusions: The detailed conceptual framework clarifies the intra-hospital logistics of the thrombolysis process. The most significant median DNT improvement at rural hospitals resulted from ensuring patients arriving via EMS remain on the EMS stretcher to imaging, while urban sites benefit more from administering tPA in the imaging area. Reducing the durations of activities on the critical path will provide further DNT improvements. Significant DNT improvements are achievable in urban and rural settings by combining process changes with reducing activity durations.
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Affiliation(s)
- Tessa Bulmer
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - David Volders
- Interventional and Diagnostic Neuroradiology, QEII Health Sciences Centre, Nova Scotia Health, Halifax, NS, Canada.,Department of Radiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - John Blake
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
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Baskar PS, Chowdhury SZ, Bhaskar SMM. In-hospital systems interventions in acute stroke reperfusion therapy: a meta-analysis. Acta Neurol Scand 2021; 144:418-432. [PMID: 34101170 DOI: 10.1111/ane.13476] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/07/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The value of in-hospital systems-based interventions in streamlining treatment delays associated with reperfusion therapy delivery in acute ischaemic stroke (AIS), in the emergency department (ED), is poorly understood. This systematic review and meta-analysis aimed to assess and quantify the value of in-hospital systems-based interventions in streamlining reperfusion therapy delivery following AIS. MATERIAL & METHODS Articles from the following databases were retrieved: Medline, Embase and Cochrane Central Register of Controlled Trials. The primary endpoint was in-hospital time metrics between the intervention and control group. The secondary endpoint included the rate of good functional outcome at 90 days. RESULTS 393 Systems intervention studies published after 2015 were screened, and 231 full articles were then read. In total, 35 studies with 35,815 patients were included in the final systematic review and 26 studies with 7,089 patients were used in the meta-analysis. The greatest time reductions from in-hospital system interventions were achieved in door-to-needle (DTN) time (SMD: -2.696, 95% CI: -2.976, -2.416, z = 3.03, p = 0.002). Systems interventions were also associated with a statistically significant improvement in mortality (RR: 0.25, 95% CI: 0.18, 0.38), rate of symptomatic intracerebral haemorrhage (RR: 0.07, 95% CI: 0.04, 0.1) and ≤60-minute reperfusion rates (RR: 0.63, 95% CI: 0.51, 0.79). CONCLUSIONS The use of in-hospital workflow optimization is imperative to expedite reperfusion therapy delivery and improving patient outcomes. To reduce the morbidity and mortality of stroke globally, in-hospital workflow guidelines should be adhered to and incorporated including the optimal elements identified in this study.
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Affiliation(s)
- Prithvi Santana Baskar
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research Clinical Sciences Stream Sydney NSW Australia
- South Western Sydney Clinical School UNSW Medicine University of New South Wales (UNSW Sydney NSW Australia
| | - Seemub Zaman Chowdhury
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research Clinical Sciences Stream Sydney NSW Australia
- South Western Sydney Clinical School UNSW Medicine University of New South Wales (UNSW Sydney NSW Australia
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research Clinical Sciences Stream Sydney NSW Australia
- Liverpool Hospital & South West Sydney Local Health District (SWSLHD) Department of Neurology & Neurophysiology Sydney NSW Australia
- Ingham Institute for Applied Medical Research Stroke & Neurology Research Group Sydney NSW Australia
- NSW Brain Clot Bank NSW Health Statewide Biobank and NSW Health Pathology Sydney NSW Australia
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A new protocol reduces median door-to-needle time to the benchmark of 30 minutes in acute stroke treatment. NEUROLOGÍA (ENGLISH EDITION) 2021; 36:487-494. [PMID: 34537162 DOI: 10.1016/j.nrleng.2018.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 04/15/2018] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Recent analyses emphasise that The Benchmark Stroke Door-to-Needle Time (DNT) should be 30min. This study aimed to determine if a new in-hospital IVT protocol is effective in reducing door-to-needle time and correcting previously identified factors associated with delays. MATERIAL AND METHODS In 2014, we gradually introduced a series of measures aimed to reduce door-to-needle time for patients receiving IVT, and compared it before (2009-2012) and after (2014-2017) the new protocol was introduced. RESULTS The sample included 239 patients before and 222 after the introduction of the protocol. Median overall door-to-needle time was 27min after the protocol was fully implemented (a 48% reduction on previous door-to-needle time [52min], P<.001)]. Median door-to-needle time was lower when pre-hospital code stroke was activated (22min). We observed a 26-min reduction in the median time from onset to treatment (P<.001). After the protocol was implemented, the "3-hour-effect" did not affect door-to-needle time (P=.98). Computed tomography angiography studies performed before IVT were associated with increased door-to-needle time (P<.001); however, the test was performed after IVT was started in most cases. CONCLUSIONS Hospital reorganisation and multidisciplinary collaboration brought median door-to-needle time below 30min and corrected previously identified delay factors. Furthermore, overall time from onset to treatment was also reduced and more stroke patients were treated within 90min of symptom onset.
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Iglesias Mohedano A, García Pastor A, Díaz Otero F, Vázquez Alen P, Martín Gómez M, Simón Campo P, Salgado Cámara P, Esteban de Antonio E, Lázaro García E, Funes Molina C, del Valle Diéguez M, Saura Lorente J, Fernández Bullido Y, Gil Nuñez A. Un nuevo protocolo intrahospitalario reduce el tiempo puerta-aguja en el ictus agudo tratado con trombolisis intravenosa a menos de 30 minutos. Neurologia 2021. [DOI: 10.1016/j.nrl.2018.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Decrease in intravenous thrombolysis and poor short-term functional prognosis for acute ischemic stroke during the COVID-19 pandemic. J Neurol 2021; 269:597-602. [PMID: 34379199 PMCID: PMC8355571 DOI: 10.1007/s00415-021-10740-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 01/17/2023]
Abstract
Background and purpose Since the outbreak of the coronavirus pandemic in 2019 (COVID-19), healthcare systems around the world have been hit to varying degrees. As a neurologist team, for patients with acute ischemic stroke (AIS), we compared the situations of intravenous thrombolysis (IVT) treatment from 2019 to 2020 to investigate the influence of COVID-19 pandemic on the attendance and prognosis of the IVT patients. Methods We collected the messages of objects who had received IVT (Bridging surgery was ruled out) during 2019–2020. We analyzed differences in age, gender, time from onset to start IVT, door to needle time (DNT), pretreatment NIHSS score, postoperative NIHSS score, and so on. Statistical tests were also performed to respectively compare the discharged modified Rankin score (mRS) and discharged NIHSS score between two years. Results Since the onset of COVID-19 restrictions in Wenzhou, we observed a significant reduction of 24.7% (p = 0.023) from 267(2019) to 201(2020) of received IVT on hospital admission. We compared the DNT between two years and it reflected that the DNT (min) in 2020 was obviously longer than in 2019 (51.60 ± 23.80 vs 46.80 ± 21.90, p = 0.026). We also compared the discharged mRS, which reflected much more IVT patients in 2020 during the COVID-19 pandemic had a poor short-term functional prognosis (38.2% vs 29.2%, p = 0.043). Conclusions The COVID-19 pandemic caused the decrease of admissions and prolonged the time of the green channel for stroke, which led to the worse short-term prognosis of AIS patients during the pandemic. It’s necessary to ensure an effective green channel and provide adequate medical resources during the pandemic period to reduce the damage caused by COVID-19.
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Santana Baskar P, Cordato D, Wardman D, Bhaskar S. In-hospital acute stroke workflow in acute stroke - Systems-based approaches. Acta Neurol Scand 2021; 143:111-120. [PMID: 32882056 DOI: 10.1111/ane.13343] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/20/2020] [Accepted: 08/27/2020] [Indexed: 12/21/2022]
Abstract
Clinical outcomes of acute ischaemic stroke patients have significantly improved with the advent of reperfusion therapy. However, time continues to be a critical factor. Reducing treatment delays by improving workflows can improve the efficacy of acute reperfusion therapy. Systems-based approaches have improved in-hospital temporal parameters, maximizing the utility of reperfusion therapies and improving clinical benefit to patients. However, studies aimed at optimizing and hence reducing treatment delays in emergency department (ED) settings are limited. The aim of this article is to discuss existing systems-based approaches to optimize ED acute stroke workflows and its value in reducing treatment delays and identify gaps in existing workflows that need optimization. Identifying gaps in acute stroke workflow, variations in processes and challenges in implementation, in the in-hospital settings, is essential for systems-based interventions to be effective in delivering improved outcomes for patients with acute ischaemic stroke.
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Affiliation(s)
- Prithvi Santana Baskar
- South Western Sydney Clinical School University of New South Wales (UNSW) Sydney NSW Australia
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research, Clinical Sciences Stream Sydney NSW Australia
- Thrombolysis and Endovascular WorkFLOw Network (TEFLON) Sydney NSW Australia
| | - Dennis Cordato
- South Western Sydney Clinical School University of New South Wales (UNSW) Sydney NSW Australia
- Thrombolysis and Endovascular WorkFLOw Network (TEFLON) Sydney NSW Australia
- Department of Neurology and Neurophysiology Liverpool Hospital and South West Sydney Local Health District (SWSLHD) Sydney NSW Australia
- Stroke and Neurology Research Group Ingham Institute for Applied Medical Research Sydney NSW Australia
| | - Daniel Wardman
- South Western Sydney Clinical School University of New South Wales (UNSW) Sydney NSW Australia
- Thrombolysis and Endovascular WorkFLOw Network (TEFLON) Sydney NSW Australia
- Department of Neurology and Neurophysiology Liverpool Hospital and South West Sydney Local Health District (SWSLHD) Sydney NSW Australia
- Stroke and Neurology Research Group Ingham Institute for Applied Medical Research Sydney NSW Australia
| | - Sonu Bhaskar
- South Western Sydney Clinical School University of New South Wales (UNSW) Sydney NSW Australia
- Neurovascular Imaging Laboratory Ingham Institute for Applied Medical Research, Clinical Sciences Stream Sydney NSW Australia
- Thrombolysis and Endovascular WorkFLOw Network (TEFLON) Sydney NSW Australia
- Department of Neurology and Neurophysiology Liverpool Hospital and South West Sydney Local Health District (SWSLHD) Sydney NSW Australia
- Stroke and Neurology Research Group Ingham Institute for Applied Medical Research Sydney NSW Australia
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Costerus JM, Lemmens CMC, van de Beek D, Brouwer MC. Cranial Imaging and Lumbar Puncture in Patients With Suspected Central Nervous System Infection. Clin Infect Dis 2021; 70:2469-2475. [PMID: 31437271 PMCID: PMC7286381 DOI: 10.1093/cid/ciz694] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/19/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Performing cranial imaging prior to lumbar punctures (LPs) in patients with suspected central nervous system (CNS) infections has been associated with delayed treatments and poor outcomes. Various guidelines provide different criteria for cranial imaging prior to LP. METHODS We describe the use of cranial imaging in a cohort of adult patients with suspected CNS infections, and evaluated adherence to the recommendations made in the Infectious Disease Society of America (IDSA), European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Swedish, and Dutch guidelines. We also analyzed the association between cranial imaging and the time between emergency department entrance and intravenous antibiotic administration. RESULTS From 2012-2015, 203 patients with suspected CNS infections were included, of whom 56 (27%) were diagnosed with CNS infections and 16 were diagnosed with bacterial meningitis (8%). Cranial imaging, in all cases computed tomography (CT), was performed in 130 patients (64%) and led to the deferral of LPs in 7 (5%). Criteria by the IDSA, ESCMID, Swedish, and Dutch guidelines showed indications for imaging in 64%, 39%, 39%, and 40% of patients, respectively. The times between emergency department arrivals and the start of antibiotic therapy between patients with and without CT before LP were similar (median 134 [interquartile range (IQR) 58-292] vs. 141 minutes [IQR 52-227], respectively; Mann-Whitney U P = .74). CONCLUSIONS A cranial CT prior to LP was done in the majority of patients with a suspected CNS infection, irrespective of guideline indications. The ESCMID, Swedish, and Dutch guidelines were more restrictive in advising imaging, compared to the IDSA guidelines. Performing cranial imaging prior to LP was not associated with treatment delays in this Dutch cohort study.
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Affiliation(s)
- Joost M Costerus
- Amphia Ziekenhuis, Department of Neurology, Breda, The Netherlands
| | - Cynthia M C Lemmens
- Amsterdam University Medical Centers, University of Amsterdam, Department of Neurology, Amsterdam Neuroscience, The Netherlands
| | - Diederik van de Beek
- Amsterdam University Medical Centers, University of Amsterdam, Department of Neurology, Amsterdam Neuroscience, The Netherlands
| | - Matthijs C Brouwer
- Amsterdam University Medical Centers, University of Amsterdam, Department of Neurology, Amsterdam Neuroscience, The Netherlands
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Kompanje EJO, van Dijck JTJM, Chalos V, van den Berg SA, Janssen PM, Nederkoorn PJ, van der Jagt M, Citerio G, Stocchetti N, Dippel DWJ, Peul WC. Informed consent procedures for emergency interventional research in patients with traumatic brain injury and ischaemic stroke. Lancet Neurol 2020; 19:1033-1042. [PMID: 33098755 DOI: 10.1016/s1474-4422(20)30276-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 11/30/2022]
Abstract
Health-care professionals and researchers have a legal and ethical responsibility to inform patients before carrying out diagnostic tests or treatment interventions as part of a clinical study. Interventional research in emergency situations can involve patients with some degree of acute cognitive impairment, as is regularly the case in traumatic brain injury and ischaemic stroke. These patients or their proxies are often unable to provide informed consent within narrow therapeutic time windows. International regulations and national laws are criticised for being inconclusive or restrictive in providing solutions. Currently accepted consent alternatives are deferred consent, exception from consent, or waiver of consent. However, these alternatives appear under-utilised despite being ethically permissible, socially acceptable, and regulatorily compliant. We anticipate that, when the requirements for medical urgency are properly balanced with legal and ethical conduct, the increased use of these alternatives has the potential to improve the efficiency and quality of future emergency interventional studies in patients with an inability to provide informed consent.
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Affiliation(s)
- Erwin J O Kompanje
- Department of Intensive Care Adult, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Ethics and Philosophy of Medicine, Erasmus University, Rotterdam, The Netherlands.
| | - Jeroen T J M van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center & Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Vicky Chalos
- Department of Public Health, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Radiology and Nuclear Science, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Sophie A van den Berg
- Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Department of Neurology, Amsterdam UMC, The Netherlands
| | - Paula M Janssen
- Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | | | - Mathieu van der Jagt
- Department of Intensive Care Adult, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Diederik W J Dippel
- Department of Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Wilco C Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center & Haga Teaching Hospital, Leiden and The Hague, The Netherlands
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Tejada Meza H, Saldaña Inda I, Serrano Ponz M, Ara JR, Marta Moreno J. Impact of a series of measures for optimisation hospital code stroke care on door-to-needle times. Neurologia 2020; 38:S0213-4853(20)30273-5. [PMID: 33069450 DOI: 10.1016/j.nrl.2020.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/17/2020] [Accepted: 07/07/2020] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Time continues to be a fundamental variable in reperfusion treatments for acute ischaemic stroke. Despite the recommendations made in clinical guidelines, only around one-third of these patients receive fibrinolysis within 60minutes. In this study, we describe our experience with the implementation of a specific protocol for patients with acute ischaemic stroke and evaluate its impact on door-to-needle times in our hospital. METHODS Measures were gradually implemented in late 2015 to shorten stroke management times and optimise the care provided to patients with acute ischaemic stroke; these measures included the creation of a specific on-call neurovascular care team. We compare stroke management times before (2013-2015) and after (2017-2019) the introduction of the protocol. RESULTS The study includes 182 patients attended before implementation of the protocol and 249 attended after. Once all measures were in effect, the overall median door-to-needle time was 45minutes (vs 74 minutes before, a 39% reduction; P<.001), with 73.5% of patients treated within 60minutes (a 47% increase; P<.001). Median overall time to treatment (onset-to-needle time) was reduced by 20minutes (P<.001). CONCLUSIONS The measures included in our protocol achieved a significant, sustained reduction in door-to-needle times, although there remains room for improvement. The mechanisms established for monitoring outcomes and for continuous improvement will enable further advances in this regard.
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Affiliation(s)
- H Tejada Meza
- Sección de Neurovascular, Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España; Sección de Neurointervencionismo, Servicio de Radiología, Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España.
| | - I Saldaña Inda
- Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - M Serrano Ponz
- Sección de Neurovascular, Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España; Departamento de Medicina, Psiquiatría y Dermatología, Facultad de Medicina, Universidad de Zaragoza, Zaragoza, España
| | - J R Ara
- Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España; Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - J Marta Moreno
- Sección de Neurovascular, Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España
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Vanhoucke J, Hemelsoet D, Achten E, De Herdt V, Acou M, Vereecke E, Hachimi-Idrissi S. Impact of a code stroke protocol on the door-to-needle time for IV thrombolysis: a feasibility study. Acta Clin Belg 2020; 75:267-274. [PMID: 31081471 DOI: 10.1080/17843286.2019.1607991] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Stroke is a development of an acute focal neurological deficit with an ischemic or hemorrhagic origin. Thrombolysis within 4.5 h of ischemic stroke onset improves outcome. Guidelines recommend administration of intravenous recombinant tissue plasminogen activator within 60 min upon arrival at the hospital, meaning the door-to-needle time (DNT) should be less than 60 min. In this study, a stroke protocol was introduced at the emergency department of the Ghent University Hospital with a primary goal to shorten the DNT. METHODOLOGY This study was an uncontrolled before-after cohort study. A 'Code Stroke' protocol (CSP) was implemented and the results from the pre-code stroke protocol period (Pre-CSP period, from 15 August 2016 until 5 March 2017) were compared with the results from the post-code stroke protocol period (Post-CSP period, from 6 March 2017 until 16 July 2017). RESULTS The median DNT decreased significantly from 57 min in the Pre-CSP period to 33 min in the Post-CSP period (p < 0.001). The door-to-triage time (DTT), triage-to-emergency physician time (TET), emergency physician-to-CT time (ECT) and CT-to needle time (CNT) decreased significantly Post-CSP compared to Pre-CSP. When adjusting the results for other variables that might have an influence on these time intervals, the TET, ECT and CNT also decreased significantly. There was a statistically significant effect of the implementation of the CSP on the number of patients treated with a DNT within 20, 30, 45 and 60 min (p = 0.008). CONCLUSION A significant decrease in DNT can be achieved with the implementation of this stroke protocol.
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Affiliation(s)
- Joke Vanhoucke
- Department of Emergency Medicine, Ghent University Hospital, Gent, Belgium
| | | | - Eric Achten
- Department of Radiology, Ghent University Hospital, Gent, Belgium
| | - Veerle De Herdt
- Department of Neurology, Ghent University Hospital, Gent, Belgium
| | - Marjan Acou
- Department of Radiology, Ghent University Hospital, Gent, Belgium
| | - Elke Vereecke
- Department of Radiology, Ghent University Hospital, Gent, Belgium
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Bresler AY, Bavier R, Kalyoussef E, Baredes S, Park RCW. The “July effect”: Outcomes in microvascular reconstruction during resident transitions. Laryngoscope 2020; 130:893-898. [DOI: 10.1002/lary.27988] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/27/2019] [Accepted: 03/18/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Amishav Y. Bresler
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical School Newark New Jersey U.S.A
| | - Richard Bavier
- Rutgers New Jersey Medical School Newark New Jersey U.S.A
| | - Evelyne Kalyoussef
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical School Newark New Jersey U.S.A
| | - Soly Baredes
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical School Newark New Jersey U.S.A
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New JerseyRutgers New Jersey Medical School Newark New Jersey U.S.A
| | - Richard Chan Woo Park
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical School Newark New Jersey U.S.A
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Collateral augmentation treatment with a combination of acetazolamide and head-down tilt in a rat ischemic stroke model. J Clin Neurosci 2020; 73:252-258. [PMID: 32037062 DOI: 10.1016/j.jocn.2020.01.079] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/27/2020] [Indexed: 11/24/2022]
Abstract
Cerebral collaterals is crucially important in the pathophysiology of acute ischemic stroke and associated with outcome after reperfusion therapy. We explored the effectiveness of collateral augmentation treatment with a combination of acetazolamide (ACZ) and head-down tilt (HDT) in the transient middle cerebral artery occlusion (MCAO) rat model. Transient MCAO was induced in all animals for 1.5 h, followed by reperfusion for 22.5 h. Seventy-two male Wistar rats were divided into four treatment groups: control, ACZ, HDT, and combination. Twenty sham rats, which underwent surgery, were randomly allocated to these groups. Twenty-four hours after MCAO or sham surgery, we measured the infarction volume, brain edema (aquaporin-4 [AQP4], and brain water content), and neurological deficits (Garcia and Longa tests). Collateral augmentation treatments were associated with reduced infarction volume, less brain edema, and better neurological outcomes compared with untreated animals. More specifically, ACZ and HDT treatments resulted in small infarction volumes, and HDT was associated with a low AQP4 expression and improved neurological score, while the combination of ACZ and HDT improved neurological scores and reduced brain water content. This study shows that collateral augmentation treatments are associated with a better stroke prognosis compared with untreated animals after transient MCAO. The combination of ACZ and HDT seems to have some synergistic effect, but was not proven to be superior to HDT treatment alone.
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Lahr MMH, van der Zee DJ, Luijckx GJ, Buskens E. Optimising acute stroke care organisation: a simulation study to assess the potential to increase intravenous thrombolysis rates and patient gains. BMJ Open 2020; 10:e032780. [PMID: 31964668 PMCID: PMC7045180 DOI: 10.1136/bmjopen-2019-032780] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To assess potential increases in intravenous thrombolysis (IVT) rates given particular interventions in the stroke care pathway. DESIGN Simulation modelling was used to compare the performance of the current pathway, best practices based on literature review and an optimised model. SETTING Four hospitals located in the North of the Netherlands, as part of a centralised organisational model. PARTICIPANTS Ischaemic stroke patients prospectively ascertained from February to August 2010. INTERVENTION The interventions investigated included efforts aimed at patient response and mode of referral, prehospital triage and intrahospital delays. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measure was thrombolysis utilisation. Secondary measures were onset-treatment time (OTT) and the proportion of patients with excellent functional outcome (modified Rankin scale (mRS) 0-1) at 90 days. RESULTS Of 280 patients with ischaemic stroke, 125 (44.6%) arrived at the hospital within 4.5 hours, and 61 (21.8%) received IVT. The largest improvements in IVT treatment rates, OTT and the proportion of patients with mRS scores of 0-1 can be expected when patient response is limited to 15 min (IVT rate +5.8%; OTT -6 min; excellent mRS scores +0.2%), door-to-needle time to 20 min (IVT rate +4.8%; OTT -28 min; excellent mRS scores+3.2%) and 911 calls are increased to 60% (IVT rate +2.9%; OTT -2 min; excellent mRS scores+0.2%). The combined implementation of all potential best practices could increase IVT rates by 19.7% and reduce OTT by 56 min. CONCLUSIONS Improving IVT rates to well above 30% appears possible if all known best practices are implemented.
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Affiliation(s)
- Maarten M H Lahr
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
| | - Gert-Jan Luijckx
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Erik Buskens
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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Tran D, Zhu Z, Shafie M, Abcede H, Stradling D, Yu W. Three easily-implementable changes reduce median door-to-needle time for intravenous thrombolysis by 23 minutes. BMC Neurol 2019; 19:300. [PMID: 31771530 PMCID: PMC6878675 DOI: 10.1186/s12883-019-1527-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/13/2019] [Indexed: 01/01/2023] Open
Abstract
Background The benefit of intravenous thrombolysis (IVT) for acute ischemic stroke is time dependent. Despite great effort, the median door-to-needle time (DNT) was 60 min at the United States stroke centers. We investigated the effect of a simple quality improvement initiative on DNT for IVT. Methods This is a single-center study of patients treated with IVT between 2013 and 2017. A simple quality improvement initiative was implemented in January 2015 to allow the Stroke team to manage hypertension in the emergency room, to make decision for IVT before getting blood test results unless patients were taking oral anticoagulants, and to give IVT in the CT suite. Baseline characteristics, DNT and outcomes at hospital discharge were compared between pre- and post-intervention groups. Results Ninety and 136 patients were treated with IVT in pre- and post-intervention groups, respectively. The rate of IVT was significantly higher in the post-intervention group (20% vs. 14.4%, p = 0.007). The median DNT with interquartile range (IQR) was reduced significantly by 23 min (63[53–81] vs. 40[29–53], p < 0.001) with more patients in the post-intervention group receiving IVT within 60 min (81.6% vs. 46.7%) and 45 min (64.0% vs.17.8%). There was no significant difference in symptomatic intracerebral hemorrhage rate (1.5% vs. 1.1%), modified Rankin Scale 0–1 (29.4% vs. 23.3%), and hospital mortality (7.4% vs. 6.7%) between the 2 groups. Conclusions Three easily-implementable quality improvement initiative increases IVT rate and reduces DNT significantly without increasing the rate of IVT-related complications in our comprehensive stroke center.
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Affiliation(s)
- Demi Tran
- Department of Neurology, University of California, Irvine, CA, USA
| | - Zhu Zhu
- Department of Neurology, University of California, Irvine, CA, USA.,Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Mohammad Shafie
- Department of Neurology, University of California, Irvine, CA, USA
| | | | - Dana Stradling
- Department of Neurology, University of California, Irvine, CA, USA
| | - Wengui Yu
- Department of Neurology, University of California, Irvine, CA, USA. .,, Orange, USA.
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Kuhrij LS, Marang-van de Mheen PJ, van den Berg-Vos RM, de Leeuw FE, Nederkoorn PJ. Determinants of extended door-to-needle time in acute ischemic stroke and its influence on in-hospital mortality: results of a nationwide Dutch clinical audit. BMC Neurol 2019; 19:265. [PMID: 31684901 PMCID: PMC6827229 DOI: 10.1186/s12883-019-1512-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 10/24/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intravenous thrombolysis (IVT) plays a prominent role in the treatment of acute ischemic stroke (AIS). The sooner IVT is administered, the higher the odds of a good outcome. Therefore, registering the in-hospital time to treatment with IVT, i.e. the door-to-needle time (DNT), is a powerful way to measure quality improvement. The aim of this study was to identify determinants that are associated with extended DNT. METHODS Patients receiving IVT in 2015 and 2016 registered in the Dutch Acute Stroke Audit were included. DNT and onset-to-door time (ODT) were dichotomized using the median (i.e. extended DNT) and the 90th percentile (i.e. severely extended DNT). Logistic regression was performed to identify determinants associated with (severely) extended DNT/ODT and its effect on in-hospital mortality. A linear model with natural spline was used to investigate the association between ODT and DNT. RESULTS Included were 9518 IVT treated patients from 75 hospitals. Median DNT was 26 min (IQR 20-37). Determinants associated with a higher likelihood of extended DNT were female sex (OR 1.17, 95% CI 1.05-1.31) and admission during off-hours (OR 1.12, 95% CI 1.01-1.25). Short ODT correlated with longer DNT, whereas longer ODT correlated with shorter DNT. Young age (OR 1.38, 95% CI 1.07-1.76) and admission to a comprehensive stroke center (OR 1.26, 1.10-1.45) were associated with severely extended DNT, which was associated with in-hospital mortality (OR 1.54, 95%CI 1.19-1.98). CONCLUSIONS Even though DNT in the Netherlands is short compared to other countries, lowering the DNT may be achievable by focusing on specific subgroups.
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Affiliation(s)
- Laurien S Kuhrij
- Department of Neurology, Amsterdam University Medical Center, location Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands. .,Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333 AA, Leiden, the Netherlands.
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | | | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Medical Center, Houtlaan 4, Nijmegen, 6525 XZ, the Netherlands.,Donders Center of Medical Neuroscience, Donders Institute for Brain, Cognition and Behaviour, Geert Grooteplein Zuid 10, 6526, GA, Nijmegen, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Center, location Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
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22
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van den Berg SA, Dippel DWJ, Hofmeijer J, Fransen PSS, Caminada K, Siegers A, Kruyt ND, Kerkhoff H, de Leeuw FE, Nederkoorn PJ, van der Worp HB. Multicentre Randomised trial of Acute Stroke treatment in the Ambulance with a nitroglycerin Patch (MR ASAP): study protocol for a randomised controlled trial. Trials 2019; 20:383. [PMID: 31242931 PMCID: PMC6595565 DOI: 10.1186/s13063-019-3419-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 05/09/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Some studies have suggested that transdermal administration of glyceryl trinitrate (GTN; nitroglycerin) in the first few hours after symptom onset increases the chance of a favourable outcome after ischaemic stroke or intracerebral haemorrhage, possibly through an increase in intracranial collateral blood flow and a reduction in blood pressure. The Multicentre Randomised trial of Acute Stroke treatment in the Ambulance with a nitroglycerin Patch (MR ASAP) aims to assess the effect of transdermal GTN, started within 3 h after stroke onset in the prehospital setting, on functional outcome at 90 days in patients with acute ischaemic stroke or intracerebral haemorrhage. METHODS MR ASAP is a phase III, multicentre, randomised, open-label clinical trial with a blinded outcome assessment. A total of 1400 adult patients with suspected stroke and a systolic blood pressure ≥ 140 mmHg will be randomised to transdermal GTN (5 mg/day), administered as a transdermal patch by paramedics in the prehospital setting within 3 h of stroke onset and continued for 24 h or to standard care. The primary outcome is the score on the modified Rankin Scale (mRS) at 90 days, analysed with ordinal logistic regression. Secondary outcomes include blood pressure and collateral circulation at hospital admission, neurological deficit measured with the National Institutes of Health Stroke Scale at 24 h, and mortality and poor outcome (mRS score 3 to 6) at 90 days. This trial will be conducted in the Netherlands and will use a deferred consent procedure. The trial is part of the Collaboration for New Treatments of Acute Stroke (CONTRAST) programme. DISCUSSION MR ASAP will assess whether very early administration of GTN improves outcome after stroke in a setting where rates of intravenous thrombolysis and endovascular treatment for acute ischaemic stroke are high. The deferred consent procedure facilitates prompt GTN treatment and will prevent delay to revascularisation therapies. If early transdermal GTN treatment proves to be effective, this low-cost treatment can be readily implemented into daily clinical practice. TRIAL REGISTRATION ISRCTN Registry, ISRCTN99503308 . Registered on 2 January 2018.
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Affiliation(s)
- Sophie A. van den Berg
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Diederik W. J. Dippel
- Department of Neurology, Erasmus MC University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
| | - Puck S. S. Fransen
- Department of Neurology, Isala, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Klaartje Caminada
- Regional Ambulance Service IJsselland, Voltastraat 3-A, 8013 PM Zwolle, The Netherlands
- Department of Emergency Medicine, Isala, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Arjen Siegers
- Ambulance Amsterdam, Karperweg 19-25, 1075 LB Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Nyika D. Kruyt
- Department of Neurology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Paul J. Nederkoorn
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - H. Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - on behalf of the MR ASAP Investigators
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Department of Neurology, Erasmus MC University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
- Department of Neurology, Rijnstate, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
- Department of Neurology, Isala, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
- Regional Ambulance Service IJsselland, Voltastraat 3-A, 8013 PM Zwolle, The Netherlands
- Department of Emergency Medicine, Isala, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
- Ambulance Amsterdam, Karperweg 19-25, 1075 LB Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Department of Neurology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Neurology, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands
- Department of Neurology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Department of Neurology and Neurosurgery, Brain Center University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Kuhrij LS, Wouters MW, van den Berg-Vos RM, de Leeuw FE, Nederkoorn PJ. The Dutch Acute Stroke Audit: Benchmarking acute stroke care in the Netherlands. Eur Stroke J 2018; 3:361-368. [PMID: 31236484 PMCID: PMC6571504 DOI: 10.1177/2396987318787695] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 06/10/2018] [Indexed: 12/20/2022] Open
Abstract
Introduction In the nationwide Dutch Acute Stroke Audit (DASA), consecutive patients with acute ischaemic stroke (AIS) and intracranial haemorrhage (ICH) are prospectively registered. Acute stroke care is a rapidly evolving field in which intravenous thrombolysis (IVT) and intra-arterial thrombectomy (IAT) play a crucial role in increasing odds of favourable outcome. The DASA can be used to assess the variation in care between hospitals and develop 'best practice' in acute stroke care. Patients and methods: We describe the initiation and design of the DASA as well as the results from 2015 and 2016. Results In 2015 and 2016, 55,854 patients with AIS and 7727 patients with ICH were registered in the DASA. Treatment with IVT was administered to 10,637 patients (with an increase of 1.3% in 2016) and 1740 patients underwent IAT (with an increase of 1% in 2016). Median door-to-needle time for IVT and median door-to-groin time for IAT have decreased from 27 to 25 min and 66 to 64 min, respectively. Mortality during admission was 4.9% in patients with AIS, whereas 26% of patients with ICH died. Modified Rankin Scale score at three months was registered in 49% of AIS patients and 45% of ICH patients. Discussion During the nationwide DASA, time to treatment is reduced for IVT as well as IAT. With the rapidly evolving treatment of acute stroke care, the DASA can be used to monitor the quality provided on patient- and hospital level. Conclusion Increasing completeness of registration of the outcome, in combination with adjustment for patient-related factors, is necessary to define and further improve the quality of the acute stroke care.
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Affiliation(s)
- Laurien S Kuhrij
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands.,Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | | | | | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
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Tsivgoulis G, Kargiotis O, Rudolf J, Komnos A, Tavernarakis A, Karapanayiotides T, Ellul J, Katsanos AH, Giannopoulos S, Gryllia M, Safouris A, Papamichalis P, Vadikolias K, Mitsias P, Hadjigeorgiou G. Intravenous thrombolysis for acute ischemic stroke in Greece: the Safe Implementation of Thrombolysis in Stroke registry 15-year experience. Ther Adv Neurol Disord 2018; 11:1756286418783578. [PMID: 30034535 PMCID: PMC6048606 DOI: 10.1177/1756286418783578] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/06/2018] [Indexed: 01/08/2023] Open
Abstract
Background: Intravenous thrombolysis (IVT) remains the only approved systemic reperfusion
treatment for acute ischemic stroke (AIS), however there are scarce data
regarding outcomes and complications of IVT in Greece. We evaluated safety
and efficacy outcomes of IVT for AIS in Greece using the Safe Implementation
of Thrombolysis in Stroke: International Stroke Thrombolysis Register
(SITS-ISTR) dataset. Methods: All AIS patients treated with IVT in Greece between December 2002 and July
2017 and recorded in the SITS-ISTR were evaluated. Demographics, risk
factors, baseline stroke severity [defined using National Institutes of
Health Stroke Scale (NIHSS)], and onset-to-treatment time (OTT) were
recorded. Safety outcomes included symptomatic intracranial hemorrhage
(sICH) and 3-month mortality rates. The efficacy outcomes evaluated a
reduction in baseline NIHSS score at 2 and 24 h following IVT onset, 3-month
favorable functional outcome [FFO; modified Rankin scale (mRS) scores of
0–1] and 3-month functional independence (FI; mRS-scores of 0–2). The safety
and efficacy outcomes were assessed comparatively with previously published
data from SITS national and international registries. Results: A total of 523 AIS patients were treated with IVT in 12 Greek centers
participating in the SITS-ISTR during the study period (mean age 62.4 ±
12.7; 34.6% women; median baseline NIHSS score: 11 points; median OTT: 150
min). The rates of sICH were 1.4%, 2.3%, and 3.8% according to the
SIST-MOST, ECASS II, and NINDS criteria respectively. The median reduction
in NIHSS score at 2 and 24 h was 3 [interquartile range (IQR): 1–5] and 5
(IQR: 2–8) points respectively. The 3-month FI, FFO and mortality were
66.5%, 55.6% and 7.9%. All safety and efficacy outcomes were comparable with
available data from SITS-ISTR in other European countries. Conclusions: Our study underscores the safety and efficacy of IVT for AIS in Greece.
Additional action is necessary in order to increase the availability of IVT
in the Greek population and to include more centers in the SITS-ISTR.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Jobst Rudolf
- Department of Neurology, Papageorgiou Hospital, Thessaloniki, Greece
| | | | | | - Theodoros Karapanayiotides
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Aristeidis H Katsanos
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Maria Gryllia
- Department of Neurology, Athens General Hospital G. Gennimatas, Athens, Greece
| | - Apostolos Safouris
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | | | - Konstantinos Vadikolias
- Department of Neurology, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Panayiotis Mitsias
- Department of Neurology Medical School, University of Crete, Heraklion, Crete, Greece
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25
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Koster GT, Nguyen TTM, Groot AED, Coutinho JM, Bosch J, den Hertog HM, van Walderveen MAA, Algra A, Wermer MJH, Roos YB, Kruyt ND. A Reduction in Time with Electronic Monitoring In Stroke (ARTEMIS): study protocol for a randomised multicentre trial. BMJ Open 2018; 8:e020844. [PMID: 29950465 PMCID: PMC6020955 DOI: 10.1136/bmjopen-2017-020844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Time is the most crucial factor limiting efficacy of intravenous thrombolysis (IVT) and intra-arterial thrombectomy (IAT). The delay between alarming the Emergency Medical Services (EMS) dispatch office and IVT/IAT initiation, that is, the 'total system delay' (TSD), depends on logistics and team effort. A promising method to reduce TSD is real-time audio-visual feedback to caregivers involved. With 'A Reduction in Time with Electronic Monitoring in Stroke' (ARTEMIS), we aim to investigate the effect of real-time audio-visual feedback on actual TSD to IVT/IAT to caregivers. METHODS AND ANALYSIS ARTEMIS is a multiregional, multicentre, randomised open end-point trial including patients ≥18 years considered IVT/IAT-eligible by the EMS dispatch office or on-site EMS personnel. Patients are electronically tracked and randomised for real-time audio-visual feedback on TSD to caregivers via premounted handhelds and tablets throughout the TSD trajectory. Primary outcome is TSD to IVT/IAT. Secondary outcomes comprise proportion of IVT/IAT-treated patients, symptomatic intracerebral haemorrhage, IVT/IAT-treated stroke mimics, clinical outcome after three months and cost-effectiveness. Separate analyses for IAT-patients with or without prior IVT, within or out of office hours and EMS region will be performed. With 75 IAT-patients and 225 IVT-patients in each arm, we will be able to demonstrate a 20 min difference in TSD to IAT and a 10 min difference in TSD to IVT (p=0.05 and power=0.8). ETHICS AND DISSEMINATION Study findings will be disseminated through peer-reviewed journals and (inter)national conference presentations. TRIAL REGISTRATION NUMBER NCT02808806; Pre-results.
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Affiliation(s)
- Gaia T Koster
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - T Truc My Nguyen
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Adrien E D Groot
- Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jan Bosch
- Department of Research and Development, Regional Emergency Medical Services Hollands Midden, Leiden, The Netherlands
| | - Heleen M den Hertog
- Department of Neurology, Medical Spectrum Twente, Enschede, The Netherlands
- Department of Neurology, Isala Clinics, Zwolle, the Netherlands
| | | | - Ale Algra
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Yvo B Roos
- Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
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26
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Tsivgoulis G, Kargiotis O, Alexandrov AV. Intravenous thrombolysis for acute ischemic stroke: a bridge between two centuries. Expert Rev Neurother 2018. [PMID: 28644924 DOI: 10.1080/14737175.2017.1347039] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intravenous tissue-plasminogen activator (tPA) remains the only approved systemic reperfusion therapy suitable for most patients presenting timely with acute ischemic stroke. Accumulating real-word experience for over 20 years regarding tPA safety and effectiveness led to re-appraisal of original contraindications for intravenous thrombolysis (IVT). Areas covered: This narrative review focuses on fast yet appropriate selection of patients for safe administration of tPA per recently expanded indications. Novel strategies for rapid patient assessment will be discussed. The potential for mobile stroke units (MSU) that shorten onset-to-needle time and increase tPA treatment rates is addressed. The use of IVT in the era of non-vitamin K antagonist oral anticoagulants (NOACs) is highlighted. The continuing role of IVT in large vessel occlusion (LVO) patients eligible for mechanical thrombectomy (MT) is discussed with regards to 'drip and ship' vs. 'mothership' treatment paradigms. Promising studies of penumbral imaging to extend IVT beyond the 4.5-hour window and in wake-up strokes are summarized. Expert commentary: This review provides an update on the role of IVT in specific conditions originally considered tPA contraindications. Novel practice challenges including NOAC's, MSU proliferation and bridging therapy (IVT&MT) for LVO patients, and the potential extension of IVT time-window using penumbral imaging are emerging as safe and potentially effective IVT applications.
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Affiliation(s)
- Georgios Tsivgoulis
- a Second Department of Neurology , National & Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital , Athens , Greece.,b Department of Neurology , University of Tennessee Health Science Center , Memphis , TN , USA
| | | | - Andrei V Alexandrov
- b Department of Neurology , University of Tennessee Health Science Center , Memphis , TN , USA
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27
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Wu TY, Coleman E, Wright SL, Mason DF, Reimers J, Duncan R, Griffiths M, Hurrell M, Dixon D, Weaver J, Meretoja A, Fink JN. Helsinki Stroke Model Is Transferrable With "Real-World" Resources and Reduced Stroke Thrombolysis Delay to 34 min in Christchurch. Front Neurol 2018; 9:290. [PMID: 29760676 PMCID: PMC5937050 DOI: 10.3389/fneur.2018.00290] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/16/2018] [Indexed: 01/01/2023] Open
Abstract
Background Christchurch hospital is a tertiary hospital in New Zealand supported by five general neurologists with after-hours services provided mainly by onsite non-neurology medical residents. We assessed the transferrability and impact of the Helsinki Stroke model on stroke thrombolysis door-to-needle time (DNT) in Christchurch hospital. Methods Key components of the Helsinki Stroke model were implemented first in 2015 with introduction of patient pre-notification and thrombolysis by the computed tomography (CT) suite, followed by implementation of direct transfer to CT on ambulance stretcher in May 2017. Data from the prospective thrombolysis registry which began in 2012 were analyzed for the impact of these interventions on median DNT. Results Between May and December 2017, 46 patients were treated with alteplase, 25 (54%) patients were treated in-hours (08:00–17:00 non-public holiday weekdays) and 21 (46%) patients were treated after-hours. The in-hours, after-hours, and overall median (interquartile range) DNTs were 34 (28–43), 47 (38–60), and 40 (30–51) minutes. The corresponding times in 2012–2014 prior to interventions were 87 (68–106), 86 (72–116), and 87 (71–112) minutes, representing median DNT reduction of 53, 39, and 47 minutes, respectively (p-values <0.01). The interventions also resulted in significant reductions in the overall median door-to-CT time (from 49 to 19 min), CT-to-needle time (32 to 20 min) and onset-to-needle time (168 to 120 min). Conclusion The Helsinki stroke model is transferrable with real-world resources and reduced stroke DNT in Christchurch by over 50%.
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Affiliation(s)
- Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Erin Coleman
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Sarah L Wright
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Deborah F Mason
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Jon Reimers
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Roderick Duncan
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Mary Griffiths
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Michael Hurrell
- Department of Radiology, Christchurch Hospital, Christchurch, New Zealand
| | - David Dixon
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - James Weaver
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - John N Fink
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
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28
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Grobman WA, Bailit J, Sandoval G, Reddy UM, Wapner RJ, Varner MW, Thorp JM, Caritis SN, Prasad M, Tita ATN, Saade GR, Sorokin Y, Rouse DJ, Blackwell SC, Tolosa JE. The Association of Decision-to-Incision Time for Cesarean Delivery with Maternal and Neonatal Outcomes. Am J Perinatol 2018; 35:247-253. [PMID: 28915515 PMCID: PMC5801156 DOI: 10.1055/s-0037-1606641] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of this study was to estimate whether the decision-to-incision (DTI) time for cesarean delivery (CD) is associated with differences in maternal and neonatal outcomes. METHODS This analysis is of data from women at 25 U.S. medical centers with a term, singleton, cephalic nonanomalous gestation and no prior CD, who underwent an intrapartum CD. Perinatal and maternal outcomes associated with DTI intervals of ≤ 15, 16 to 30, and > 30 minutes were compared. RESULTS Among 3,482 eligible women, median DTI times were 46 and 27 minutes for arrest and fetal indications for CD, respectively (p < 0.01). Women with a fetal indication whose DTI interval was > 30 minutes had similar odds to the referent group (DTI of 16-30 minutes) for the adverse neonatal and maternal composites (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.40-1.71 and OR: 0.89, 95% CI: 0.63-1.27). For arrest disorders, the odds of the adverse neonatal composite were lower among women with a DTI of > 30 minutes (OR: 0.25, 95% CI: 0.08-0.77), and the adverse maternal composite was no different (OR: 1.15, 95% CI: 0.81-1.63). CONCLUSION In this analysis, DTI times longer than 30 minutes were not associated with worse maternal or neonatal outcomes.
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Affiliation(s)
- William A Grobman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Jennifer Bailit
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Grecio Sandoval
- Biostatistics Center, George Washington University, Washington, District of Columbia
| | - Uma M Reddy
- Department of Obstetrics and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - John M Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Steve N Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mona Prasad
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Alan T N Tita
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - George R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
| | - Dwight J Rouse
- Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
| | - Sean C Blackwell
- Department of Obstetrics and Gynecology, Children's Memorial Hermann Hospital, University of Texas Health Science Center at Houston, Houston, Texas
| | - Jorge E Tolosa
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
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Toudou Daouda M, Bouchal S, Chtaou N, Midaoui A, Souirti Z, Belahsen F. Thrombolysis Alert in Hassan II University Teaching Hospital of Fez (Morocco): A Prospective Study of 2 Years. J Stroke Cerebrovasc Dis 2018; 27:1100-1106. [PMID: 29290532 DOI: 10.1016/j.jstrokecerebrovasdis.2017.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 11/05/2017] [Accepted: 11/18/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Thrombolysis alert (TA) is a procedure triggered every time a patient consults for sudden focal neurological deficit within 4.5 hours. OBJECTIVE We aimed to determine firstly the etiological profile of TA and secondly to evaluate the delays in the management not only of thrombolyzed patients but also of nonthrombolyzed patients to determine the intrahospital delays to optimize. METHODS Patients aged over 18 years who consulted for sudden focal neurological deficit within 4.5 hours for whom a TA has been triggered were included. Patients admitted within 4.5 hours for which a TA has not been triggered were not included. Patients with sudden focal neurological deficit who consulted more than 4.5 hours, but for whom TA has been triggered, were also included. RESULTS We included 313 patients. The average onset-to-door time was 125.59 ± 62.78 minutes with an average National Institutes of Health Stroke Scale scores of 11.29 ± 5.98. The average door-to-imaging time was 28.36 ± 20.62 minutes. Ischemic stroke (IS) was the most common cause (70.3%), followed by hemorrhagic stroke (11.8%). Other nonstroke causes (stroke mimics) represented 17.9% of cases. They were seizures (46.4%), conversion disorders (26.8%), hypoglycemia (10.7%), brain tumors (10.7%), chronic subdural hematoma (1.8%), carbon monoxide intoxication (1.8%), and cavernoma (1.8%). Forty-six patients had been thrombolyzed. The average door-to-needle time was 90.89 ± 34.48 minutes. After 3 months, 52.1% of thrombolyzed patients were autonomous (modified Rankin scale between 0 and 2). Two patients had died (4.3%), all in the first week after the IS. CONCLUSION Our study shows that efforts need to be made at the extra-hospital and intra-hospital level to improve delays to increase the proportion of the thrombolyzed patients.
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Affiliation(s)
| | - Siham Bouchal
- Department of Neurology, Hassan II University Teaching Hospital, Fez, Morocco
| | - Naima Chtaou
- Department of Neurology, Hassan II University Teaching Hospital, Fez, Morocco; Laboratory of Epidemiology, Clinical Research, and Health Community, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdallah University, Fez, Morocco
| | - Aouatef Midaoui
- Department of Neurology, Hassan II University Teaching Hospital, Fez, Morocco; Laboratory of Epidemiology, Clinical Research, and Health Community, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdallah University, Fez, Morocco
| | - Zouahyr Souirti
- Department of Neurology, Hassan II University Teaching Hospital, Fez, Morocco; Clinical Neuroscience Laboratory, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fez, Morocco; Sleep Medicine Center, Hassan II University Teaching Hospital, Fez, Morocco
| | - Faouzi Belahsen
- Department of Neurology, Hassan II University Teaching Hospital, Fez, Morocco; Laboratory of Epidemiology, Clinical Research, and Health Community, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdallah University, Fez, Morocco
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Kamal N, Smith EE, Jeerakathil T, Hill MD. Thrombolysis: Improving door-to-needle times for ischemic stroke treatment - A narrative review. Int J Stroke 2017; 13:268-276. [PMID: 29140185 DOI: 10.1177/1747493017743060] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The effectiveness of thrombolysis is highly time dependent. For this reason, short target times have been set to reduce time to treatment from hospital arrival, which is called door-to-needle time. Summary of review There has been considerable work done at single centers and across multiple hospitals to improve door-to-needle time. There have been reductions of 8 to 47 min when applying one or more improvement strategies at single centers, and there have been many multi-hospital initiatives. The delays to treatment have been attributed to both patient and hospital factors, and strategies to address these delays have been proven to reduce door-to-needle time. The most effective strategies include pre-notification of arrival by Emergency Medical Services (EMS), single-call activation of stroke team, rapid registration process, moving the patient to computed tomography on EMS stretcher, and administration of alteplase in the scanner. There are many exciting areas of future direction including reduction of door-to-needle time in developing countries, improving pre-hospital response times, and improving the efficiency of endovascular treatment. Conclusions There is now a broad understanding of the causes of delays to fast treatment and the strategies that can be employed to improve door-to-needle time such that most centers could achieve median door-to-needle time of 30 min.
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Affiliation(s)
- Noreen Kamal
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Eric E Smith
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,2 Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | | | - Michael D Hill
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,2 Department of Community Health Sciences, University of Calgary, Calgary, Canada.,4 Department of Medicine, University of Calgary, Calgary, Canada.,5 Department of Radiology, University of Calgary, Calgary, Canada
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