PRISA Study of Door-to-needle Times for Patients with Ischaemic Stroke Treated with Alteplase by On-site and Off-site On-duty Neurologists
Journal: Advances in Medicine and Engineering Interdisciplinary Research DOI: 10.32629/ameir.v2i4.2755
Abstract
Background: Hospital on-call neurology shifts are frequently on-site, but some on-call services may be off-site or mixed. Intravenous tissue plasminogen activator (tPA) is one of the main reperfusion treatments for acute ischaemic stroke (AIS). This study assesses door-to-needle times (DNT) when the neurologist is on-site or off-site. Methods: We performed a prospective, observational study from 2012 to 2017, including patients with AIS and treated with tPA. Data were collected on sex, age, door-to-scan time, scan-to-needle time, and DNT. The on-duty neurologist was on-site from 08:00 to 20:00, and on-call but off-site from 20:00 to 8:00. Three groups were formed: on-site, off-site, and off-site with resident present. Results: Our sample included 138 patients. The mean age was 69.7 years, and 45.7% of patients were female. Ninety-six patients were admitted during the on-site shift, 25 during the off-site shift, and 17 during the off-site–resident present shift. Patients admitted during the on-site and off-site shifts presented DNTs of 59 and 72 minutes, respectively (P = 0.003). DNTs were 59, 74, and 68 minutes (P = 0.001), respectively, for the on-site, off-site, and off-site–resident present shifts; the difference between DNTs for on-site and off-site shifts was statistically significant. No differences were observed between DNTs according to time of day (morning, afternoon, or night), or between weekdays and weekends. Conclusion: DNT is influenced by whether the on-duty neurologist is on- or off-site at the time of code stroke activation. The presence of a neurology resident can reduce DNT.
Keywords
stroke; intravenous thrombolysis; door-to-needle time; recombinant tissue; plasminogen activator
Full Text
PDF - Viewed/Downloaded: 0 TimesReferences
[1] Alonso de Lecinana M, Egido JA, Casado I, Ribó M, Dávalos A, Masjuan J, et al. Guidelines for the treatment of acute ischaemic stroke. Neurologia. 2014;29:102-22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22152803.
[2] Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49:e46-110.
[3] Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372:2285-95. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25882376%5Cnhttp:// www.nejm.org/doi/abs/10.1056/NEJMoa1415061.
[4] Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:1-11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25882510.
[5] Yarbrough CK, Ong CJ, Beyer AB, Lipsey K, Derdeyn CP. Endovascular thrombectomy for anterior circulation stroke: systematic review and meta-analysis. Stroke. 2015;46:3177-83.
[6] Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019-30 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25671798.
[7] Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009-18 Available from: http://www.nejm.org/doi/abs/10.1056/NEJMoa1414792.
[8] Badhiwala JH, Nassiri F, Alhazzani W, Selim MH, Farrokhyar F, Spears J, et al. Endovascular thrombectomy for acute ischemic stroke. Jama. 2015;314:1832. Available from: http://jama.jamanetwork.com/article.aspx?doi=10.1001/ jama.2015.13767.
[9] Berkhemer O, Fransen P, Beumer D, van der Berg L, Lingsma H, Yoo A, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. New Engl J Med. 2014;372:11-20.
[10] Bluhmki E, Chamorro A, Dávalos A, Machnig T, Sauce C, Wahlgren N, et al. Stroke treatment with alteplase given 3.0-4.5 h after onset of acute ischaemic stroke (ECASS III): additional outcomes and subgroup analysis of a randomised controlled trial. Lancet Neurol. 2009;8:1095-102. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19850525.
[11] Saver JL, Yafeh B. Confirmation of tPA treatment effect by baseline severity-adjusted end point reanalysis of the NINDS-tPA stroke trials. Stroke. 2007;38:414-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17234987.
[12] Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Lancet. 1998;352:1245-51. Available from: http://linkinghub.elsevier.com/retrieve/pii/S01406736980 80209.
[13] Ahmed N, Wahlgren N, Grond M, Hennerici M, Lees KR, Mikulik R, et al. Implementation and outcome of thrombolysis with alteplase 3-4.5 h after an acute stroke: an updated analysis from SITS-ISTR. Lancet Neurol. 2010;9:866-74. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20667790.
[14] Wahlgren N, Ahmed N, Dávalos A, Ford GA, Grond M, Hacke W, et al. Thrombolysis with alteplase for acute ischaemic stroke in the safe implementation of thrombolysis in stroke monitoring study (SITS-MOST): an observational study. Lancet. 2007;369:275-82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17258667.
[15] Lees KR, Bluhmki E, von Kummer R, Brott TG, Toni D, Grotta JC, et al. Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet. 2010;375:1695-703. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20472172.
[16] Kruyt ND, Nederkoorn PJ, Dennis M, Leys D, Ringleb PA, Rudd AG, et al. Door-to-needle time and the proportion of patients receiving intravenous thrombolysis in acute ischemic stroke: uniform interpretation and reporting. Stroke. 2013;44:3249-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24052509.
[17] Advani R, Naess H, Kurz MW. Evaluation of the implementation of a rapid response treatment protocol for patients with acute onset stroke: can we increase the number of patients treated and shorten the time needed? Cerebrovasc Dis Extra. 2014;4:115-21. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4093647&tool=pmcentrez&rendertype=abstract.
[18] van Dishoeck AM, Dippel DWJ, Dirks M, Looman CWN, Mackenbach JP, Steyerberg EW. Measuring quality improvement in acute ischemic stroke care: interrupted time series analysis of door-to-needle time. Cerebrovasc Dis Extra. 2014;4:149-55. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4105950&tool=pmcentrez&rendertype=abstract.
[19] Fonarow GC, Zhao X, Smith EE, Saver JL, Reeves MJ, Bhatt DL, et al. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. Jama. 2014;311:1632-40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24756513.
[20] Sauser K, Levine DA, Nickles AV, Reeves MJ. Hospital variation in thrombolysis times among patients with acute ischemic stroke: the contributions of door-to-imaging time and imaging-to-needle time. JAMA Neurol. 2014;71:1155-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25023407.
[21] Lorenzano S, Ahmed N, Tatlisumak T, Gomis M, Dávalos A, Mikulik R, et al. Within-day and weekly variations of thrombolysis in acute ischemic stroke: results from safe implementation of treatments in stroke-international stroke thrombolysis register. Stroke. 2014;45:176-84. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24262329.
[22] Xian Y, Smith EE, Zhao X, Peterson ED, Olson DM, Hernandez AF, et al. Strategies used by hospitals to improve speed of tissue-type plasminogen activator treatment in acute ischemic stroke. Stroke. 2014;45:1387-95. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24713527.
[23] Iglesias Mohedano AM, Garcia Pastor A, Diaz Otero F, Vazquez Alen P, Martin Gomez MA, Simon Campo P, et al. A new protocol reduces median door-to-needle time to the benchmark of 30 minutes in acute stroke treatment. Neurologia. 2018. Available from: http://dx.doi.org/10.1016/j.nrl.2018.04.001, pii: S0213-4853(18)30119-1.
[24] Schrock JW, Lum M. Drill down analysis of door-to-needle time of acute ischemic stroke patients treated with intravenous tissue plasminogen activator. Am J Emerg Med. 2014;32:1330-3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25195044.
[25] Hsieh CY, Chen WF, Chen CH, Wang CY, Chen CJ, Lai EC, et al. Efforts to reduce the door-to-needle time of thrombolysis in acute ischemic stroke: video-assisted therapeutic risk communication. J Formos Med Assoc. 2014;113:929-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24412584.
[26] Tan BYQ, Ngiam NJH, Sunny S, Kong WY, Tam H, Sim TB, et al. Improvement in door-to-needle time in patients with acute ischemic stroke via a simple stroke activation protocol. J Stroke Cerebrovasc Dis. 2018;27:1539-45.
[27] Van Schaik SM, Van der Veen B, Van den Berg-Vos RM, Weinstein HC, Bosboom WMJ. Achieving a door-to-needle time of 25 minutes in thrombolysis for acute ischemic stroke: a quality improvement project. J Stroke Cerebrovasc Dis. 2014;23:2900-6.
[28] Bhatt N, Marulanda-Londono ET, Atchaneeyasakul K, Malik AM, Asdaghi N, Akram N, et al. Target stroke: best practice strategies cut door to thrombolysis time to < 30 minutes in a large urban academic comprehensive stroke center. Neurohospitalist. 2018;9:22-5.
[29] Ajmi SC, Advani R, Fjetland L, Kurz KD, Lindner T, Qvindesland SA, et al. Reducing door-to-needle times in stroke thrombolysis to 13 min through protocol revision and simulation training: a quality improvement project in a Norwegian stroke centre. BMJ Qual Saf. 2019;28:939-48.
[30] Saver JL, Levine SR. Alteplase for ischaemic stroke-much sooner is much better. Lancet. 2010;375:1667-8.
[2] Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49:e46-110.
[3] Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372:2285-95. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25882376%5Cnhttp:// www.nejm.org/doi/abs/10.1056/NEJMoa1415061.
[4] Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:1-11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25882510.
[5] Yarbrough CK, Ong CJ, Beyer AB, Lipsey K, Derdeyn CP. Endovascular thrombectomy for anterior circulation stroke: systematic review and meta-analysis. Stroke. 2015;46:3177-83.
[6] Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019-30 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25671798.
[7] Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009-18 Available from: http://www.nejm.org/doi/abs/10.1056/NEJMoa1414792.
[8] Badhiwala JH, Nassiri F, Alhazzani W, Selim MH, Farrokhyar F, Spears J, et al. Endovascular thrombectomy for acute ischemic stroke. Jama. 2015;314:1832. Available from: http://jama.jamanetwork.com/article.aspx?doi=10.1001/ jama.2015.13767.
[9] Berkhemer O, Fransen P, Beumer D, van der Berg L, Lingsma H, Yoo A, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. New Engl J Med. 2014;372:11-20.
[10] Bluhmki E, Chamorro A, Dávalos A, Machnig T, Sauce C, Wahlgren N, et al. Stroke treatment with alteplase given 3.0-4.5 h after onset of acute ischaemic stroke (ECASS III): additional outcomes and subgroup analysis of a randomised controlled trial. Lancet Neurol. 2009;8:1095-102. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19850525.
[11] Saver JL, Yafeh B. Confirmation of tPA treatment effect by baseline severity-adjusted end point reanalysis of the NINDS-tPA stroke trials. Stroke. 2007;38:414-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17234987.
[12] Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Lancet. 1998;352:1245-51. Available from: http://linkinghub.elsevier.com/retrieve/pii/S01406736980 80209.
[13] Ahmed N, Wahlgren N, Grond M, Hennerici M, Lees KR, Mikulik R, et al. Implementation and outcome of thrombolysis with alteplase 3-4.5 h after an acute stroke: an updated analysis from SITS-ISTR. Lancet Neurol. 2010;9:866-74. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20667790.
[14] Wahlgren N, Ahmed N, Dávalos A, Ford GA, Grond M, Hacke W, et al. Thrombolysis with alteplase for acute ischaemic stroke in the safe implementation of thrombolysis in stroke monitoring study (SITS-MOST): an observational study. Lancet. 2007;369:275-82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17258667.
[15] Lees KR, Bluhmki E, von Kummer R, Brott TG, Toni D, Grotta JC, et al. Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet. 2010;375:1695-703. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20472172.
[16] Kruyt ND, Nederkoorn PJ, Dennis M, Leys D, Ringleb PA, Rudd AG, et al. Door-to-needle time and the proportion of patients receiving intravenous thrombolysis in acute ischemic stroke: uniform interpretation and reporting. Stroke. 2013;44:3249-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24052509.
[17] Advani R, Naess H, Kurz MW. Evaluation of the implementation of a rapid response treatment protocol for patients with acute onset stroke: can we increase the number of patients treated and shorten the time needed? Cerebrovasc Dis Extra. 2014;4:115-21. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4093647&tool=pmcentrez&rendertype=abstract.
[18] van Dishoeck AM, Dippel DWJ, Dirks M, Looman CWN, Mackenbach JP, Steyerberg EW. Measuring quality improvement in acute ischemic stroke care: interrupted time series analysis of door-to-needle time. Cerebrovasc Dis Extra. 2014;4:149-55. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4105950&tool=pmcentrez&rendertype=abstract.
[19] Fonarow GC, Zhao X, Smith EE, Saver JL, Reeves MJ, Bhatt DL, et al. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. Jama. 2014;311:1632-40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24756513.
[20] Sauser K, Levine DA, Nickles AV, Reeves MJ. Hospital variation in thrombolysis times among patients with acute ischemic stroke: the contributions of door-to-imaging time and imaging-to-needle time. JAMA Neurol. 2014;71:1155-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25023407.
[21] Lorenzano S, Ahmed N, Tatlisumak T, Gomis M, Dávalos A, Mikulik R, et al. Within-day and weekly variations of thrombolysis in acute ischemic stroke: results from safe implementation of treatments in stroke-international stroke thrombolysis register. Stroke. 2014;45:176-84. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24262329.
[22] Xian Y, Smith EE, Zhao X, Peterson ED, Olson DM, Hernandez AF, et al. Strategies used by hospitals to improve speed of tissue-type plasminogen activator treatment in acute ischemic stroke. Stroke. 2014;45:1387-95. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24713527.
[23] Iglesias Mohedano AM, Garcia Pastor A, Diaz Otero F, Vazquez Alen P, Martin Gomez MA, Simon Campo P, et al. A new protocol reduces median door-to-needle time to the benchmark of 30 minutes in acute stroke treatment. Neurologia. 2018. Available from: http://dx.doi.org/10.1016/j.nrl.2018.04.001, pii: S0213-4853(18)30119-1.
[24] Schrock JW, Lum M. Drill down analysis of door-to-needle time of acute ischemic stroke patients treated with intravenous tissue plasminogen activator. Am J Emerg Med. 2014;32:1330-3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25195044.
[25] Hsieh CY, Chen WF, Chen CH, Wang CY, Chen CJ, Lai EC, et al. Efforts to reduce the door-to-needle time of thrombolysis in acute ischemic stroke: video-assisted therapeutic risk communication. J Formos Med Assoc. 2014;113:929-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24412584.
[26] Tan BYQ, Ngiam NJH, Sunny S, Kong WY, Tam H, Sim TB, et al. Improvement in door-to-needle time in patients with acute ischemic stroke via a simple stroke activation protocol. J Stroke Cerebrovasc Dis. 2018;27:1539-45.
[27] Van Schaik SM, Van der Veen B, Van den Berg-Vos RM, Weinstein HC, Bosboom WMJ. Achieving a door-to-needle time of 25 minutes in thrombolysis for acute ischemic stroke: a quality improvement project. J Stroke Cerebrovasc Dis. 2014;23:2900-6.
[28] Bhatt N, Marulanda-Londono ET, Atchaneeyasakul K, Malik AM, Asdaghi N, Akram N, et al. Target stroke: best practice strategies cut door to thrombolysis time to < 30 minutes in a large urban academic comprehensive stroke center. Neurohospitalist. 2018;9:22-5.
[29] Ajmi SC, Advani R, Fjetland L, Kurz KD, Lindner T, Qvindesland SA, et al. Reducing door-to-needle times in stroke thrombolysis to 13 min through protocol revision and simulation training: a quality improvement project in a Norwegian stroke centre. BMJ Qual Saf. 2019;28:939-48.
[30] Saver JL, Levine SR. Alteplase for ischaemic stroke-much sooner is much better. Lancet. 2010;375:1667-8.
Copyright © 2024 A. Gallardo-Tur, L. Carazo-Barrios, C. de la Cruz-Cosme
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License