Reducing in-hospital delay to 20 minutes in stroke thrombolysis
Abstract
Objectives:
Efficacy of thrombolytic therapy for ischemic stroke decreases with time elapsed from symptom onset. We analyzed the effect of interventions aimed to reduce treatment delays in our single-center observational series.
Methods:
All consecutive ischemic stroke patients treated with IV alteplase (tissue plasminogen activator [tPA]) were prospectively registered in the Helsinki Stroke Thrombolysis Registry. A series of interventions to reduce treatment delays were implemented over the years 1998 to 2011. In-hospital delays were analyzed as annual median door-to-needle time (DNT) in minutes, with interquartile range.
Results:
A total of 1,860 patients were treated between June 1995 and June 2011, which included 174 patients with basilar artery occlusion (BAO) treated mostly beyond 4.5 hours from symptom onset. In the non-BAO patients, the DNT was reduced annually, from median 105 minutes (65–120) in 1998, to 60 minutes (48–80) in 2003, further on to 20 minutes (14–32) in 2011. In 2011, we treated with tPA 31% of ischemic stroke patients admitted to our hospital. Of these, 94% were treated within 60 minutes from arrival. Performing angiography or perfusion imaging doubled the in-hospital delays. Patients with in-hospital stroke or arriving very soon from symptom onset had longer delays because there was no time to prepare for their arrival.
Conclusions:
With multiple concurrent strategies it is possible to cut the median in-hospital delay to 20 minutes. The key is to do as little as possible after the patient has arrived at the emergency room and as much as possible before that, while the patient is being transported.
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Copyright © 2012 by AAN Enterprises, Inc.
Publication History
Received: October 6, 2011
Accepted: December 1, 2011
Published online: May 23, 2012
Published in print: July 24, 2012
Disclosure
A. Meretoja has received honoraria for speaking in educational symposia and compensation for expert consultancy with Boehringer Ingelheim, and travel expenses from H. Lundbeck A/S. D. Strbian and S. Mustanoja report no disclosures. T. Tatlisumak has research contracts with Boehringer-Ingelheim, Sanofi Aventis, H. Lundbeck A/S, Mitsubishi Pharma, Schering Plough, Concentric Medical, PhotoThera, and BrainsGate. He has received a grant from Boehringer Ingelheim and has served on advisory boards or as a consultant for Boehringer-Ingelheim, Mitsubishi Pharma, and BrainsGate. P. Lindsberg reports no disclosures. M. Kaste has received honoraria and his travel expenses have been covered for participating in the Steering Committee meetings of the DIAS-4 trial, and for serving as a consultant for Boehringer-Ingelheim and H. Lundbeck A/S. Go to Neurology.org for full disclosures.
Authors
Author Contributions
A. Meretoja conceived and designed the study, drafted the manuscript, and performed the statistical analyses. M. Kaste and T. Tatlisumak supervised and coordinated the study and obtained study funding. All authors acquired the data, analyzed and interpreted the data, and edited the manuscript for intellectual content.
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