Damn, when all you have is a hammer(tPA) everything looks like a nail. They are still making what I consider to be a failure in logic. They are assuming that faster reperfusion results in better recovery. That might be true but why aren't the results even better? They still have not identified that the neuronal cascade of death is a major problem. The damned goal is wrong, door-to-needle is not the goal, Saving neurons is the goal.
http://www.medpagetoday.com/MeetingCoverage/ISCCardioEdition/44338
An effort to shorten the time between when patients with acute ischemic stroke
arrive at the hospital and when they receive intravenous thrombolytic
therapy -- the door-to-needle time -- proved successful, researchers
found.
The percentage of patients with a door-to-needle time of
60 minutes or less was 29.6% just before the "Target: Stroke" initiative
was implemented at the beginning of 2010 and 53.3% in the third quarter
of 2013 (P<0.0001), a clinically relevant improvement, according to Gregg Fonarow, MD, of the University of California Los Angeles.
At
the same time, clinical outcomes improved and complications from the
use of tissue plasminogen activator (tPA) fell, he reported at the International Stroke Conference here.
"While
there have been concerns about potentially rushing the administration
of tPA that could lead to inappropriate patient selection, dosing
errors, and greater likelihood of complications, these findings actually
suggest the contrary," he said at a press briefing. "More rapid
reperfusion therapy is not only feasible, but can be achieved with
actual reduction in complications and improved outcomes."
The
benefits of tPA are highly dependent on treating patients as soon as
possible, Fonarow said, but prior research showed that only 30% of
patients receiving thrombolytic therapy were treated with a
door-to-needle time of 60 minutes or less, a standard recommended by the
American Heart Association/American Stroke Association.
The
Target: Stroke initiative was developed to address that problem. It was
offered to all hospitals that were already participating in the Get With the Guidelines-Stroke quality improvement initiative, and all accepted.
Target:
Stroke was launched at the beginning of 2010 with the initial goal of
having hospitals achieve door-to-needle times of 60 minutes or less in
at least half of their patients. The initiative pushed 10 key strategies
to speed treatment and provided hospitals with an implementation
manual, clinical decision support tools, education, best practices from
other centers, performance feedback, and opportunities for national
recognition.
Among the 10 strategies were hospital pre-notification by emergency medical services, a rapid triage protocol and stroke team notification, and use of a single call/paging system for the entire stroke team.
The
current analysis looking at the effect of the program included 27,319
patients treated before implementation, and 43,850 treated after, at
1,030 hospitals that were participating throughout the study period.
Characteristics of the patients and hospitals were not different between
the two time periods.
The median door-to-needle time dropped from 74 minutes at the end of 2009 to 59 minutes in the third quarter of 2013 (P<0.0001).
In addition, the percentage of hospitals with door-to-needle times of
60 minutes or less in at least half of their patients rose from 15.6% to
46.7% over that same interval (P<0.0001).
Although
the percentage of patients treated with the target door-to-needle time
was trending upward before implementation of Target: Stroke, the rate of
increase accelerated significantly when the program was put in place
(from 1.36% to 6.2% per year, P<0.0001).
There was no control group, but Fonarow said it is unlikely that such a dramatic shift occurred on its own.
The
improvements -- which were seen regardless of sex, race/ethnicity,
age, and stroke severity -- were accompanied by gains in clinical
outcomes, as well. In-hospital mortality dropped from 9.93% to 8.25%,
and the percentage of patients discharged home rose from 37.6% to 42.7%.
The
rate of symptomatic intracranial hemorrhage fell from 5.68% to 4.68%
and the rate of any tPA complications declined from 6.68% to 5.5%, which
Fonarow attributed to getting the drug to patients earlier when less
ischemic damage has occurred to the brain and blocked vessel.
All of those changes remained significant after adjustment for patient and hospital characteristics.
In
recognition of the fact that more work is needed to improve
door-to-needle times even further, Fonarow and his colleagues have
recently launched a second phase of the Target: Stroke initiative. The
new effort will aim to continue to work with hospitals that haven't yet
reached the goal of having at least half of their patients treated
within the recommended interval and to push the top performing centers
to even higher goals.
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