What is your plan to deliver tPA in 3 minutes post stroke? No plan? Then get the hell out of 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:
Advancement of door-to-needle times in acute stroke treatment after repetitive process analysis: never give up!
Abstract
Background:
In
acute ischemic stroke, timely treatment is of utmost relevance.
Identification of delaying factors and knowledge about challenges
concerning hospital structures are crucial for continuous improvement of
process times in stroke care.
Objective:
In
this study, we report on our experience in optimizing the
door-to-needle time (DNT) at our tertiary care center by continuous
quality improvement.
Methods:
Five
hundred forty patients with acute ischemic stroke receiving intravenous
thrombolysis (IVT) at Hannover Medical School were consecutively
analyzed in two phases. In study phase I, including 292 patients,
process times and delaying factors were collected prospectively from May
2015 until September 2017. In study phase II, process times of 248
patients were obtained from January 2019 until February 2021. In each
study phase, a new clinical standard operation procedure (SOP) was
implemented, considering previously identified delaying factors. Pre-
and post-SOP treatment times and delaying factors were analyzed to
evaluate the new protocols.
Results:
In
study phase I, SOP I reduced the median DNT by 15 min. The probability
to receive treatment within 30 min after admission increased by factor
5.35 [95% confidence interval (CI): 2.46–11.66]. Further development of
the SOP with implementation of a mobile thrombolysis kit led to a
further decrease of DNT by 5 min in median in study phase II. The median
DNT was 29 (25th–75th percentiles: 18–44) min, and the probability to
undergo IVT within 15 min after admission increased by factor 4.2 (95%
CI: 1.63–10.83) compared with study phase I.
Conclusion:
Continuous
process analysis and subsequent development of targeted workflow
adjustments led to a substantial improvement of DNT. These results
illustrate that with appropriate vigilance, there is constantly an
opportunity for improvement in stroke care.
Introduction
The
slogan ‘time is brain’ dominates acute stroke therapy. In patients
suffering acute stroke due to large vessel occlusion, a loss of
1.9 million neurons per untreated minute is estimated.1
Favorable clinical outcome after ischemic stroke significantly depends
on the timely administration of acute therapies, that is, intravenous
thrombolysis (IVT) by recombinant tissue-type plasminogen activator
(rt-PA) and mechanical thrombectomy.2,3
Thus, every effort should be made to keep the time interval between
hospital admission and administration of rt-PA (door-to-needle time
[DNT]) as short as possible.
The DNT may be
divided into two intervals: The interval from admission to primary
cerebral imaging (door-to-image time [DIT]) and the interval between
imaging and start of treatment with rt-PA (image-to-needle time [INT]).4
A
multitude of different reasons affect and may delay workflow, including
patient-related factors like uncontrolled hypertension, agitation or
vomiting, and also shortcomings in process organization, such as missing
pre-notification by emergency medical services (EMS) or delay in brain
imaging.5 Some factors only affect the DIT, for example, a crowded emergency room (ER) or the scanner localization.6,7 In particular, fluctuations in INT, which have a variety of causes, are responsible for the variability of DNT.4
Since the introduction of IVT, neurologists have attempted to reduce DNT to improve patients’ outcome.8–15
With CODE STROKE, first established in 1994, neurologists initiated new
structures in acute stroke treatment, for example, by introducing a
single-call activation as well as monitoring of treatment times.12
Further development of this protocol resulted in EMS pre-notification,
reservation of computed tomography (CT)–scanner and administering rt-PA
in the imaging area.14 In 2017, Kamal et al.13
showed that a rapid patient registration, direct referral to the CT
imaging and administration of rt-PA at the scanner area had significant
impact upon DNT. To summarize, a variety of different improvement
strategies have been proposed which on their own or in concert can
significantly reduce stroke treatment times.11
Aiming at an effective improvement of the DNT at our center, we decided
to prospectively analyze the workflow between arrival of patients with
acute ischemic stroke considered in need for IVT and start of rt-PA
application. Thereby, nine possibly delaying factors were identified,
which were addressed in a new standard operation procedure (SOP) I,
which was prospectively evaluated thereafter. In a second step, the
long-term effect of SOP I and the effect of an amendment to the SOP
(i.e. SOP II) were retrospectively assessed.
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