Reducing intravenous thrombolysis delay in acute ischemic stroke through a quality improvement program in the emergency department

 So no one is even close to the needed time frame, 3 minutes after the stroke. 

But have you gotten tPA delivered in 3 minutes? Door-to-needle time is an invalid measurement.   You're going to have to deliver tPA in the ambulance. CAN YOU DO THAT?

In this research in mice the needed time frame for tPA delivery is 3 minutes. That's for full recovery NOT the intermediate step of reperfusion. If your hospital is touting reperfusion you don't have a functioning stroke hospital.

Electrical 'storms' and 'flash floods' drown the brain after a stroke

The latest here:

Reducing intravenous thrombolysis delay in acute ischemic stroke through a quality improvement program in the emergency department

Guangxiong Yuan^1†, Hong Xia^1†, Jun Xu¹, Chen Long¹, Lei Liu¹, Feng Huang¹, Jianping Zeng^2* and Lingqing Yuan^3*

• ¹Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
• ²Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
• ³National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China

Objective: This study aims to investigate the effectiveness of a quality improvement program for reducing intravenous thrombolysis (IVT) delay in acute ischemic stroke (AIS).

Materials and methods: We implement a quality improvement program consisting of 10 interventions for reducing IVT delay, including the establishment of an acute stroke team, standardized management of stroke teams, popularization of stroke and its treatment, emergency bypass route (BER), the achievement of computed tomography (CT) priority, no-delay CT interpretation, intravenous thrombolysis on the CT table, payment after treatment, whole recording, and incentive policy. We retrospectively analyzed the clinical time and outcome data of AIS patients treated with IVT in pre-intervention (108 patients) and post-intervention groups (598 patients), and further compared the differences between the non-emergency bypass route (NBER) and BER in the post-intervention group.

Results: The thrombolysis rate increased from ~29% in the pre-intervention group to 48% in the post-intervention group. Compared with the pre-intervention group, the median of door-to-needle time (DNT) was greatly shortened from 95 to 26 min (P < 0.001), door-to-CT time (DCT) was noticeably decreased from 20 to 18 min (P < 0.001), and onset-to-needle time (OTT) significantly declined from 206 to 133 min (P = 0.001). Under the new mode after the intervention, we further analyzed the IVT delay difference between the NBER (518 patients) and BER groups (80 patients) from the post-intervention group. The median values of DNT (18 vs. 27 min, P < 0.001), DCT (10 vs. 19 min, P < 0.001), and OTT (99 vs. 143 min, P < 0.001) showed significant reductions in the BER group. The quality improvement program under the emergency platform successfully controlled the median of DNT to within 26 min.

Conclusions: Collectively, the BER mode is a feasible scheme that greatly decreased DNT in AIS patients, and the secret to success was to accomplish as much as possible before the patient arrives at the emergency room.(If your patient arrives at the emergency room without tPA already being administered you are too late and have failed.)

Introduction

Stroke is one of the most important public health problems in the world (1). In China, it is the main cause of disability and death in urban and rural areas, constituting almost one-third of the total number of deaths from stroke worldwide (2). Ischemic stroke accounts for 70% of all strokes (3). Early intravenous thrombolysis significantly improves the chance of recovery in patients with acute ischemic stroke (AIS) in a time-dependent manner (4–7). Therefore, reducing the delay of treatment has become the focus of many studies in recent years (8, 9), and associated studies have shown that shortening the door-to-needle time (DNT) can effectively reduce the delay in the hospital and improve the thrombolysis rate of stroke patients (10–12). The American Heart Association/American Stroke Association (AHA/ASA) guideline recommends DNT ≤60 min (6), but research suggests that only 27% of patients received intravenous thrombolysis within 60 min from hospital arrival (13).

At present, the relatively fastest DNT in the world is 20 min in the Helsinki model and 25 min in the Melbourne model (6, 14).(Both are actually still failures in not being fast enough.) Compared with the developed countries, some measures reducing the delay of thrombolysis cannot be fully adapted to all regions in the developing countries. Therefore, published data for shortening DNT have shown some gaps, variations, and inconsistencies in the results achieved by many teams (15, 16). In China, the previous electronic medical records of patients in other medical institutions cannot be obtained in advance, as they are in the Helsinki model (14). Similarly, due to the problem of medical insurance, it is also impossible to pre-mix expensive drugs, such as alteplase (rt-PA). In addition, the doctor–patient relationship in our country is in a tense situation at this time, and the risk of thrombolysis treatment is high. Therefore, every link between doctor–patient communication and decision-making is particularly important. On this basis, we have been actively exploring a kind of thrombolysis model suitable for the national conditions of China.

In this study, we analyzed the association data of DNT between pre-intervention and post-intervention modes at Xiangtan in China, and introduced the experience of our center's thrombolysis model to improve the delay time of patients' treatment from three aspects: stroke education, team training, and simplification of the thrombolysis process. We expect to provide a medical therapeutic reference to more developing countries and regions with similar environments in health care systems.

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