Use of Strategies to Improve Door-to-Needle Times with Tissue Plasminogen Activator in Acute
Ischemic Stroke by US Hospitals: Findings from the Target: Stroke Survey
Gregg C. Fonarow1; Eric E. Smith2; Xin Zhao3; Eric D. Peterson3; Ying Xian3; DaiWai M. Olson3,4; Adrian F. Hernandez3; Deepak L. Bhatt5; Jeffrey L. Saver6; Lee H. Schwamm7
1Division
of Cardiology, University of California, Los Angeles, CA; 2Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; 3Duke Clinical Research
Institute, Durham, NC; 4University of Texas Southwestern Medical Center, Dalls, TX; 5VA Boston Healthcare System, Boston, MA; 6Department of Neurology, University of California, Los Angeles, CA;
7Department of Neurology, Massachusetts General Hospital, Boston, MA
Background
• The benefits of intravenous tissueplasminogen activator (IV tPA) in acute
ischemic stroke are time-dependent
• National guidelines recommend door-toneedle time ≤60 minutes. However, fewer
than 1/3 of patients treated with IV tPA are
treated within guideline recommended doorto-needle time
• Several strategies have been reported to be
associated with more rapid door-to-needle
(DTN) times. However, the extent to which
hospitals are utilizing these strategies has
not been well studied.
Methods
• Target: Stroke is a national initiative
sponsored by the AHA/ASA to assist
hospitals in increasing the proportion of IV
tPA-treated patients who achieve guidelinerecommended door-to-needle within 60 mins
• We surveyed 350 hospitals joining Target:
Stroke regarding their baseline use of
strategies to reduce door-to-needle time
prior to the initiation of Target Stroke
• The survey was developed based on
literature review and expert consensus for
strategies identified as being associated with
shorter door-to-needle times
• After excluding 46 hospitals that did not give
tPA or reported invalid treatment timelines,
the final study population consisted of 5,460
patients from 304 hospitals between 1/20082/2010
Results
Hospital Characteristics
Level
Hospital type, academic
Annual ischemic stroke volume, median
(IQR)
tPA treated patients per year, median
(IQR)
Door-to-needle time, median (IQR)
Initiating or revising strategies to reduce
door-to-needle time in the prior 2 years
Planned to have a dedicated team
focused on reducing door-to-needle time
Strategies Reported by Hospitals to Improve Acute Ischemic Stroke Evaluation and Treatment Times
N=304 (% or value)
50%
163 (106-247)
10 (6-17)
79 (71-89) min
70%
92%
Distribution of Door-to-Needle Times among 5,460 Patients
from 304 Hospitals in Target: Stroke
Strategies
All of the time Some of the time None of the time Unable to determine
EMS Prenotification
Rapid Triage and Stroke Team
Notification
Single Call Activation System
In-House Stroke Expertise 24X7
52.3%
42.4%
3.6%
1.6%
68.8%
23.4%
6.6%
1.3%
62.5%
79.0%
9.5%
14.8%
25.0%
5.3%
3.0%
1.0%
Strategies
Rapid Brain Imaging Protocol
CT Scanner Located in
Emergency Department
Rapid Laboratory Testing Protocol
Ischemic Stroke Critical Pathway
tPA Administration Protocol
tPA Stored in Emergency
Department
Pre-Mixing of tPA
Interdisciplinary Stroke Team for
Performance Improvement
Regular Feedback on DTN Times
Provided
Yes
91.8%
No
8.2%
42.1%
57.9%
93.1%
56.6%
89.8%
6.9%
43.4%
10.2%
62.2%
37.8%
83.9%
16.2%
93.8%
6.3%
72.4%
27.6%
Conclusions
• While most US hospitals participating in this survey report use of the strategies to improve the timeliness of tPA
administration for acute ischemic stroke, significant variation exists
• Further research is needed to understand which of these strategies are most effective in improving acute
ischemic stroke care
DISCLOSURE INFORMATION: Target: Stroke is an initiative provided by the American Heart Association/American Stroke Association. The University of California, Regents receive funding for Dr Saver’s services as a scientific consultant regarding trial design and conduct to Covidien, CoAxia, BrainsGate, Genervon, and
Grifols. Dr Saver is an investigator in the NIH FAST-MAG, MR RESCUE, CLEARER, and IMS 3 multicenter clinical trials for which the UC Regents receive payments on the basis of clinical trial performance; has served as an unpaid site investigator in multicenter trials run by Lundbeck and Covidien for which the UC Regents
received payments on the basis of clinical trial contracts for the number of subjects enrolled; and is an employee of the University of California, which holds patent rights in coil retrievers. Dr. Deepak L. Bhatt discloses the following relationships - Advisory Board: Medscape Cardiology; Board of Directors: Boston VA Research
Institute, Society of Chest Pain Centers; Chair: American Heart Association Get With The Guidelines Science Subcommittee; Honoraria: American College of Cardiology (Editor, Clinical Trials, Cardiosource), Duke Clinical Research Institute (clinical trial steering committees), Slack Publications (Chief Medical Editor,
Cardiology Today Intervention), WebMD (CME steering committees); Other: Senior Associate Editor, Journal of Invasive Cardiology; Research Grants: Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, Sanofi Aventis, The Medicines Company; Unfunded Research: FlowCo, PLx Pharma, Takeda.