Transfer Delays for EVT Linked to Worse Functional Outcomes in AIS

 The FUCKINGLY OBVIOUS SOLUTION is 100% RECOVERY PROTOCOLS REGARDLESS OF TIME! And you're so blitheringly stupid you can't figure that out? You continue going down the wrong research path! That is the primary definition of incompetence! This is all excuses, excuses, excuses! In business excuses aren't allowed, firings would start immediately! Leaders would solve the problem of 100% recovery the correct way! EXACT 100% RECOVERY PROTOCOLS!

Transfer Delays for EVT Linked to Worse Functional Outcomes in AIS

 Longer door-in-door-out times for EVT for AIS are significantly associated with worse functional outcomes and lower odds of independent ambulation at discharge. Worse functional outcomes and higher complication rates in acute ischemic stroke (AIS) are strongly associated with longer endovascular therapy (EVT) transfer door-in-door-out (DIDO) time, according to results of a study published in The Lancet Neurology  The American Heart Association (AHA) and American Stroke Association (ASA) recommend that a DIDO time should not exceed 90 minutes. However, data from the Get With The Guidelines (GWTG)–Stroke registry indicate that the median DIDO time is 132 minutes. Investigators analyzed data from the GWTG-Stroke registry to assess the functional outcomes of longer DIDO times. Adults (N=22,410) with AIS who were transferred to an acute care hospital for EVT between 2019 and 2023 were evaluated for Modified Rankin Scale (mRS) at discharge on the basis of DIDO time. The patients had a median age of 70 (IQR, 60-80) years, 50.1% were women, 73.9% were White, the median DIDO time was 121 (IQR, 89-175) minutes, they had a median National Institutes of Health Stroke Severity (NIHSS) score of 14 (IQR, 7-21) at the EVT hospital arrival, and 75.8% underwent EVT. …delays in DIDO time at transferring hospitals were associated with lower odds of receiving endovascular therapy, greater odds of complications after reperfusion therapy, worse functional status, and lower odds of independent ambulation at discharge. The patients had a DIDO time within 90 minutes (26.3%), between 91 and 180 minutes (50.4%), between 181 and 270 minutes (13.4%), and longer than 270 minutes (9.8%). In the fully adjusted model, patients with DIDO times longer than 270 minutes (adjusted odds ratio [aOR], 1.70; 95% CI, 1.53-1.89), between 181 and 270 minutes (aOR, 1.49; 95% CI, 1.36-1.64), and between 91 and 180 minutes (aOR, 1.29; 95% CI, 1.20-1.37) were more likely to have an mRS ordinal shift compared with patients who had a DIDO time within 90 minutes. Similarly, the patients with a DIDO time of 91 minutes or longer were more likely to have an mRS score at discharge of at least 3 (aOR range, 1.33-1.63) or 4 (aOR range, 1.22-1.60) and were less likely to have the ability to ambulate independently (aOR range, 0.67-0.85) than patients with a DIDO time within 90 minutes. The patients with DIDO times longer than 90 minutes were also less likely to receive EVT (aOR range, 0.35-0.71) and to have no post-reperfusion complications (aOR range, 0.74-0.85) than patients with DIDO times within AHA/ASA recommendations. In a secondary analysis, the investigators observed that the association between longer DIDO times and worse mRS at discharge were stronger among the patients who received EVT than those who did not. The supplementary analysis that excluded patients who did not receive EVT replicated the association between longer DIDO times and worse functional outcomes. This study may have been limited by sourcing data from hospitals participating in the GWTG-Stroke quality improvement program, so results may not be generalizable to nonparticipating sites. The study investigators concluded, “In this national cohort study of patients with acute ischemic stroke transferred for consideration of endovascular therapy, delays in DIDO time at transferring hospitals were associated with lower odds of receiving endovascular therapy, greater odds of complications after reperfusion therapy, worse functional status, and lower odds of independent ambulation at discharge.” In an interview with Cardiology Advisor, Brian Stamm, MD, MSc, clinical assistant professor of Neurology at the University of Michigan, American Heart Association volunteer, and one of the authors of this study, also discussed the barriers that may make it difficult for hospitals and healthcare systems to implement strategies to minimize DIDO time. “While the current study did not specifically assess barriers to minimizing DIDO time, prior studies suggest the following factors may be important: failure to perform early stroke screens, delays in telestroke consultation, processes of arranging interhospital transfer, and communication issues between the sending and receiving hospital, among other factors,” said Dr Stamm, going on to explain that his team is currently studying ways for hospitals and healthcare systems to navigate these barriers. “Dr Prabhakaran’s NIH-funded HI-SPEED study seeks to implement a 7-component intervention to improve the accuracy and timeliness of acute stroke diagnosis and DIDO time for patients requiring transfer. The intervention includes stroke screening scales, brain imaging protocols, early assessment with telestroke, interhospital communication using app-based technologies, door-to-needle (thrombolysis) best practices, early ambulance activation, and a standardized hand-off tool for paramedics. This ongoing study will determine whether this intervention improves DIDO times for patients with stroke.” Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. References:Royan R, Stamm B, Giuracanu M, et al.

Transfer Delays Tied to Worse Acute Stroke Intervention Results

 With proper leadership creating 100% recovery protocols these delays would not be allowed as an excuse anymore. SO, SOLVE THE FUCKING 100% RECOVERY PROBLEM! 

Transfer Delays Tied to Worse Acute Stroke Intervention Results

The study underscores the importance of door-in-door-out time as a metric associated with patient outcomes, one expert says.(Wrong metric, you blithering idiots! 100% RECOVERY is the only goal in stroke. You measure that, nothing else matters to survivors!)

byTodd Neale

For patients with acute ischemic stroke who require transfer to another hospital for endovascular therapy, spending more time in the initial emergency department is associated poorer short-term outcomes, an analysis of the Get With The Guidelines-Stroke registry shows.

Patients who had door-in-door-out (DIDO) times that exceeded the guideline-recommended target of 90 minutes or less at the receiving hospital were less likely to undergo endovascular therapy at the thrombectomy-capable hospital, were more likely to have complications from the procedure, and had worse functional outcomes at discharge, researchers led by Regina Royan, MD, and Brian Stamm, MD (both from University of Michigan, Ann Arbor), report in a study published in the February 2026 issue of the Lancet Neurology.

“We know that ‘time is brain’ for acute stroke treatment, so we hypothesized that longer DIDO delays would be associated with worse outcomes. Yet, there were several prior, small studies with conflicting results regarding the association between DIDO time and stroke outcomes,” Stamm told TCTMD via email. “Our comprehensive, national study now provides compelling evidence that DIDO time is strongly associated with outcomes from stroke.”

Here is your business101 requirements. Not measuring 100% recovery is the height of incompetence!

“What's measured, improves.” So said management legend and author Peter F. Drucker  

More than 40% of patients with acute ischemic stroke will need to be transferred between hospitals to receive endovascular therapy, and a prior study by these investigators showed that DIDO time at the first center often exceeded the goal of 90 minutes or less recommended in guidelines from the American Heart Association/American Stroke Association (AHA/ASA).

Commenting for TCTMD, Michael Mullen, MD (Temple University Hospital, Philadelphia, PA), a member of the stroke systems of care advisory group of the AHA/ASA, said this new study, “by quantifying not just the overall benefits of moving faster, but the benefits of a shorter door-in-door-out time, really helps to underscore the importance of DIDO and provides a very actionable target for future quality-improvement initiatives.”

DIDO Has Greater Impact in Patients Treated With Thrombectomy

The study included data on 22,410 patients (median age 70 years; 50.1% women) from the Get With The Guidelines-Stroke registry who were transferred from an acute care hospital to one of 489 thrombectomy-capable centers for endovascular therapy evaluation between 2019 and 2023.

The median DIDO time at the initial emergency department was 121 minutes, with only 26.3% of patients having a time of 90 minutes or less. Roughly three-quarters of patients received endovascular thrombectomy after transfer.

The primary outcome was the ordinal modified Rankin Scale (mRS) score at hospital discharge. After adjustment for potential confounders, having a DIDO time longer than 90 minutes, across multiple thresholds, was associated with greater odds of having a 1-point increase in mRS score at discharge:

• 91-180 minutes (adjusted OR 1.29; 95% CI 1.20-1.37)
• 181-270 minutes (adjusted OR 1.49; 95% CI 1.36-1.64)
• > 270 minutes (OR 1.70; 95% CI 1.53-1.89)

Moreover, patients with a longer DIDO time were less likely to undergo endovascular therapy:

• 91-180 minutes (adjusted OR 0.71; 95% CI 0.65-0.79)
• 181-270 minutes (adjusted OR 0.50; 95% CI 0.44-0.57)
• > 270 minutes (adjusted OR 0.35; 95% CI 0.30-0.40)

The link between longer DIDO times and worse functional outcomes was stronger in patients who ultimately received endovascular therapy than in those who didn’t. DIDO times greater than 90 minutes also were associated with lower odds of independent ambulation at discharge and of complication-free reperfusion therapy.

Altogether, Stamm said, “these findings underscore the importance of optimizing DIDO times to improve stroke outcomes.”

Targeting Speedier Transfers

Although the study was not designed to identify what factors played into longer DIDO times, Stamm said that prior research has identified multiple variables that are important when thinking about shortening delays, including rapid identification of stroke symptoms at the initial center, use of workflows that bundle required brain imaging, and optimization of ambulance availability for patient transport.

The ongoing HI-SPEED trial, which is led by the senior author of the current study, Shyam Prabhakaran, MD (University of Chicago Medicine, IL), “seeks to further understand the major barriers and test interventions to improve DIDO times,” Stamm noted.

There are two major components to improving the speed at which patients are transferred from one center to another for endovascular therapy, Mullen said. First, “there’s going to need to be a push to move as efficiently as possible at the primary stroke centers, at the acute stroke ready hospitals, and that will include getting advanced imaging whenever possible,” he said.

Second, there will have to be a focus on transport, with considerations dictated by system- and region-specific variables, Mullen said, noting, for example, that some centers use their own transport companies and others use outside services. “Every health system or different region is going to probably have slightly different pressures or barriers to getting an appropriate transport at the initial hospital as quickly as possible.”

Exact solutions are beyond the scope of the paper, but the study is helpful for setting DIDO time goals that hospitals can work toward, Mullen said.

“If these data are used to create quality targets, I think we’ll be surprised at how well we’ll be able to drive that time down if it’s appropriately incentivized,” he said. “We see that all over the place, whether it’s door-to-needle times for IV thrombolysis for stroke or door-to-balloon times for the cardiac space.”

by Todd Neale Editor, AI Exchange

Todd Neale is the Associate News Editor for TCTMD and a Senior Medical Journalist. He got his start in journalism at …

 Read Full Bio

Longer door-in-door-out times may Worsen Stroke Outcomes and Reduce endovascular therapy Use: Lancet

 No excuses are allowed!  You are still required to get them to 100% recovery!

GET THERE!

Longer door-in-door-out times may Worsen Stroke Outcomes and Reduce endovascular therapy Use: Lancet

 

Optimizing Stroke Pathways: An Observational Audit of Door-to-CT Time, Thrombolysis, and Clinical Outcomes

 You didn't even measure the most important outcome! 100% RECOVERY! Is everyone there that BLITHERINGLY STUPID?

Optimizing Stroke Pathways: An Observational Audit of Door-to-CT Time, Thrombolysis, and Clinical Outcomes

Zobia Farrukh • Muhammad Umer Younas • Abdullah Yousaf • Sabih Nofal • Zarghoona Kamal • Burhan Anjum

Published: November 17, 2025

DOI: 10.7759/cureus.97118 

Open Access

Peer-Reviewed

Cite this article as: Farrukh Z, Younas M, Yousaf A, et al. (November 17, 2025) Optimizing Stroke Pathways: An Observational Audit of Door-to-CT Time, Thrombolysis, and Clinical Outcomes. Cureus 17(11): e97118. doi:10.7759/cureus.97118

Abstract

Background

Stroke is a leading cause of disability and mortality worldwide, where timely intervention is crucial for favorable outcomes. This study aimed to evaluate door-to-CT time performance, eligibility for intravenous thrombolysis, and associated clinical outcomes in patients with acute stroke.

Methodology

This prospective observational study was conducted at Shalamar Hospital, Lahore, Pakistan, from February 2023 to February 2025. A total of 310 consecutive patients presenting with acute stroke symptoms were enrolled. Door-to-CT time, thrombolysis eligibility, and treatment details were recorded. Clinical outcomes were assessed at discharge using the modified Rankin scale (mRS).

Results

A total of 310 patients with clinically suspected stroke were enrolled in the study. The mean age of the patients was 61.4 ± 12.6 years, with 182 (58.7%) being male. Hypertension (225, 72.6%) and diabetes mellitus (138, 44.5%) were the most frequent comorbidities. A total of 201 (64.8%) patients underwent CT scanning within 25 minutes of arrival (door-to-CT time). Thrombolysis eligibility was established in 118 (38.1%) patients, of whom 96 (31.0% of the cohort) received intravenous recombinant tissue plasminogen activator (rt-PA). The mean door-to-needle time was 52.7 ± 14.6 minutes, with 71 (74%) of the treated patients achieving the <60-minute benchmark. Favorable outcomes (mRS score = 0-2) were observed in 50 (52.1%) thrombolysed patients compared to 71 (33.2%) non-thrombolysed patients (p < 0.01). Symptomatic intracerebral hemorrhage occurred in 6 (6.2%) treated patients, while overall in-hospital mortality was 34 (11.0%).

Conclusions

Achieving timely door-to-CT imaging significantly increases the likelihood of thrombolysis eligibility, while intravenous rt-PA improves functional outcomes with acceptable safety.

 

Mobile Stroke Unit Reduces Door-to-Puncture Time in LVO-Related Ischemic Stroke

 

But do they get tPA delivered within 3 minutes for full recovery? The goal is 100% recovery; NOT YOUR FUCKING TYRANNY OF LOW EXPECTATIONS of improve outcomes!

In this research in mice the needed time frame for tPA delivery is 3 minutes for full recovery.

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

 Send me hate mail on this: oc1dean@gmail.com. I'll print your complete statement with your name and my response in my blog. Or are you afraid to engage with my stroke-addled mind? Your patients need an explanation of why you aren't working on survivor requirements of 100% recovery protocols. 

The latest here:

Mobile Stroke Unit Reduces Door-to-Puncture Time in LVO-Related Ischemic Stroke

There are more favorable time metrics for patients transported by mobile stroke unit compared with those transported by EMS. Patients transported by a mobile stroke unit have more favorable time metrics, but have similar outcomes as those transported by emergency medical services (EMS). These findings were published inStroke: Vascular and Interventional Neurology Investigators from Grady Memorial Hospital in the United States hypothesized that patients transported by mobile stroke unit afte occlusion (LVO)-related ischemic stroke(IS) would have faster time metrics when receiving mechanical thrombectomy than patients transported by EMS. This study was a cross-sectional retrospective review of prospectively collected data between 2018 and 2023. Patients (N=565) who received endovascular therapy for LVO-related IS were evaluated for the endpoints of time interval between door-to-imaging, door-to-puncture, and door-to-reperfusion on the basis of whether they arrived at the hospital by mobile stroke unit (n=66) or EMS (n=499). The mobile stroke unit and EMS cohorts comprised 55% and 56% men, they had median ages of 66 (IQR, 47-77) and 66 (IQR, 56-76) years, they had an Alberta Stroke Program Early Computed Tomography (ASPECTS) score of 9 (IQR, 8-10) and 8 (IQR, 7-10), and the most common occlusion locations were middle cerebral artery M1 (39% vs 42%) or M2 (38% vs 23%), respectively. Safety and clinical outcomes were comparable among MSU and EMS-transport groups, supporting the need for further investigation of the direct-to-angio approach for patients with LVO.

Patients who arrived by mobile stroke unit had shorter door-to-imaging (median, 9 vs 17 min;P<.001), -puncture (median, 58 vs 82 min;  P<.001), and -reperfusion (median, 96 vs 127 min; P<.001) than patients who arrived by EMS. In the linear regression analysis, door-to-puncture was significantly shorter with mobile stroke unit than with EMS (b, -23.3; 95% CI, -34.7 to -11.9;P<.001). The significant shortening of time from door-to-puncture with mobile stroke unit was significantly mediated by multimodal imaging (8%;P=.012), time to multimodal imaging completion (53% P<.001), and time to any imaging completion (48%;P<.001). Direct-to-angio was not a significant mediator (P=.132). The mobile stroke unit- and EMS-transported patients did not differ by modified Rankin Scale (mRS) score at discharge (median, 3 vs 3; P=.198), mRS score at 90 days (median, 3 vs 3;P=.455), or mortality at 90 days (23% vs 20%; P=.691).This study was not powered to detect significant differences in clinical outcomes. The study authors concluded, “MSU [mobile stroke unit transport was associated with improved workflow leading to shorter times to treatment. Safety and clinical outcomes were comparable among MSU and EMS-transport groups, supporting the need for further investigation of the direct-to-angio approach for patients with LVO.” This article originally appeared on The Cardiology Advisor

Improved functional outcomes and cost benefits of door-to-needle time under 30 min in acute ischemic stroke: an observational study

WAY TOO SLOW; in mice you have to deliver in 3 minutes for full recovery!

In this research in mice the needed time frame for tPA delivery is 3 minutes for full recovery. What is your plan to accomplish that? Or are you ignoring that need?

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

The latest here:

 Improved functional outcomes and cost benefits of door-to-needle time under 30 min in acute ischemic stroke: an observational study

Jia Dong James Wang1, Ying-Qiu Dong2, Joshua Y. P. Yeo3, Kevin Soon Hwee Teo3, Shiyang Ng3, Mingxue Jing3, Bernard P. L. Chan3, Leonard L. L. Yeo3, Magdalene L. J. Chia3, Louis Widjaja4, Lily Y. H. Wong3, Pamela Lim2, Shikha Kumari2, Diarmuid Murphy2, Hock-Luen Teoh3 and Benjamin Y. Q. Tan2*

1Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore

2Value Driven Outcomes Office, Academic Informatics Office, National University Health System, Singapore, Singapore

3Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore

4Department of Medical Affairs, National University Hospital, Singapore, Singapore

Edited by

Kersten Villringer, Charité University Medicine Berlin, Germany

Reviewed by

Alejandro Vargas, Rush University Medical Center, United States

Loïc Legris, Grenoble Institut Neurosciences, France

*Correspondence

Benjamin Y. Q. Tan, ben.tan@nus.edu.sg

Received 26 February 2025

Accepted 29 April 2025

Published 03 June 2025

Citation

Wang JDJ, Dong Y-Q, Yeo JYP, Teo KSH, Ng S, Jing M, Chan BPL, Yeo LLL, Chia MLJ, Widjaja L, Wong LYH, Lim P, Kumari S, Murphy D, Teoh H-L and Tan BYQ (2025) Improved functional outcomes and cost benefits of door-to-needle time under 30 min in acute ischemic stroke: an observational study. Front. Stroke 4:1583875. doi: 10.3389/fstro.2025.1583875

Introduction: Intravenous thrombolysis (IVT) is cornerstone of acute ischemic stroke(AIS) recanalization therapy. Clinical guidelines advocate achieving Door-to-Needle (DTN) time of 60 min or less, with recent evidence highlighting clinical advantages of even shorter DTN times. However, economic implications of reducing DTN time are less well-studied. This study aims to assess shorter DTN targets impact on clinical outcomes and healthcare costs.

Methods: This observational cohort study included consecutive patients with AIS treated with IVT in a comprehensive stroke center from January 2017 to December 2023. Patients were stratified by DTN time into 4 groups: ≤ 30, 31–45, 46–60, and >60 min. Multivariate linear and logistic regressions were performed to evaluate impact of DTN time on functional and financial outcomes, including modified Rankin's Score (mRS) at 3-months post-AIS, length-of-stay (LoS), total hospitalization cost, symptomatic intracerebral hemorrhage (SICH) and inpatient mortality.

Results: 1,146 patients (62.0% male) with mean age of 68.6 years were included. Overall, 47.6% of patients achieved a mRS of 0–2 at 3 months after AIS. Patients with DTN time of ≤ 30 min demonstrated higher odds of achieving mRS 0–2 at 3 months (OR 2.35, 95% CI 1.26–4.39) compared to DTN time of ≥60 min. They also experienced 4-day shorter length of stay (LoS) until rehabilitation (p = 0.005) and 22.7% reduction in total hospitalization costs (p = 0.004).

Conclusions: This study suggests that DTN time of ≤ 30 min is associated with improved functional outcomes and significant cost benefits, supporting consideration of this more aggressive target for acute stroke units. Further research is needed to assess feasibility and broader impact of implementing a 30-min DTN goal in routine clinical practice.

Keywords

stroke, ischemic stroke, thrombolysis, functional status, outcome

Quality Improvement Intervention for Reducing Acute Treatment Times in Ischemic Stroke: A Cluster Randomized Clinical Trial

 

Do you really think you can get your stroke patient treated in 3 minutes to get to full recovery?  NO? So, you fully expect your stroke medical 'professionals' to have EXACT 100% RECOVERY PROTOCOLS regardless of the time you present to the hospital? But they don't have that now and aren't working on it, ARE THEY?

Door to needle time is way to slow! It has to be as soon as the patient is identified with a stroke. Like maybe these fast diagnosis options?

Hats off to Helmet of Hope - stroke diagnosis in 30 seconds; February 2017 

Smart Brain-Wave Cap Recognises Stroke Before the Patient Reaches the Hospital

 October 2023

And then this to rule out a bleeder.

New Device Quickly Assesses Brain Bleeding in Head Injuries - 5-10 minutes April 2017

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

 In this research in mice the needed time frame for tPA delivery is 3 minutes for full recovery.

Saving lives is great but survivors want full recovery, or don't you ever talk to survivors?

The latest here:

Quality Improvement Intervention for Reducing Acute Treatment Times in Ischemic Stroke: A Cluster Randomized Clinical Trial

• December 2024
• JAMA Neurology

DOI:10.1001/jamaneurol.2024.4304

Authors:

Sanne J. den Hartog Nikki van Leeuwen

Show all 83 authors

To read the full-text of this research, you can request a copy directly from the authors.

Download citation References (34)

Abstract

Importance Efficient care processes are crucial to minimize treatment delays and improve outcome after endovascular thrombectomy (EVT) in patients with ischemic stroke. A potential means to improve care processes is performance feedback. Objective To evaluate the effect of performance feedback to hospitals on treatment times for EVT. Design, Setting, and Participants This cluster randomized clinical trial was conducted from January 1, 2020, to June 30, 2022. Participants were consecutive adult patients with ischemic stroke who underwent EVT in 13 Dutch hospitals. No patients were excluded. Data analysis took place from March to May 2023. Intervention The intervention consisted of feedback on hospital performance using structure, process, and outcome indicators. Indicator scores were based on data from a national quality registry and compared with a benchmark. Performance feedback was provided through a dashboard for local quality improvement teams who developed and implemented improvement plans based on the feedback. Every 6 months, 3 to 4 randomly selected hospitals switched to the intervention condition. Main Outcome and Measures The

primary outcome was time from door to groin puncture for all patients treated with EVT.(WRONG OUTCOME! The outcome to measure is 100% recovery! NOTHING LESS YOU BLITHERING IDIOTS!) Secondary outcomes included door-to-needle time, National Institutes of Health Stroke Scale (NIHSS) score at day 2, expanded Treatment in Cerebral Infarction (eTICI) score, and modified Rankin Scale (mRS) score at 3 months. The effect of the intervention was estimated with multivariable linear mixed models. Results A total of 4747 patients were included (intervention: 2431; control: 2316). Their mean (SD) age was 72 (13) years; 2337 (49.2%) were female and 2410 (50.8%) were male. The median (IQR) baseline NIHSS score was 14 (8-19). Median (IQR) door-to–groin puncture time under the intervention condition was 47 (25-71) minutes, compared with 52 (29-75) minutes under the control condition. The adjusted absolute reduction was 5 minutes (β = −4.8; 95% CI, −9.5 to −0.1; P = .04), corresponding to a relative reduction of 9.2% (95% CI, −18.3% to −0.2%). Conclusion and Relevance This study found that performance feedback provided through a dashboard used by local quality improvement teams reduced door-to–groin puncture time for EVT. Implementation of performance feedback in hospitals providing EVT can improve the quality of care for ischemic stroke. Trial Registration The Netherlands Trial Register: NL9090

Improving Knowledge About Stroke Using Simulation Training

 Door to needle time is way too slow! How EXACTLY are you going to get tPA delivered in 3 minutes post stroke?

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

 In this research in mice the needed time frame for tPA delivery is 3 minutes for full recovery.

The latest here:

Improving Knowledge About Stroke Using Simulation Training

Tanvi Ambulkar • Prachi Ambulkar • Anamika Saha • Jasmesh Sandhu • Alisha Gurung • Chris Jacobs

Published: December 05, 2024

DOI: 10.7759/cureus.75143

Peer-Reviewed

Cite this article as: Ambulkar T, Ambulkar P, Saha A, et al. (December 05, 2024) Improving Knowledge About Stroke Using Simulation Training. Cureus 16(12): e75143. doi:10.7759/cureus.75143

Abstract

Background

Stroke is a medical emergency that is risk-stratified using a national scoring system called the National Institute of Health Stroke Scale (NIHSS). The management of an acute stroke necessitates prompt management and swift decision-making. Human factors were identified in the literature as the main rate-limiting step to improving door-to-needle (DTN) time. We felt it would be prudent to design a local stroke course implemented at Great Western Hospital Swindon that incorporates both traditional and simulation-based elements to improve theoretical knowledge and emulate real-life scenarios. The objective of this course was to improve practical application in the efficient assessment and management of stroke patients, as this is critical to delivering timely treatment with thrombolysis or thrombectomy. 

Methods

Twenty-four medical professionals (medical students and resident doctors) participated in our course between November 2022 and July 2023. The domains assessed included understanding thrombolysis, understanding thrombectomy, confidence in performing NIHSS, and confidence in the assessment of stroke patients. The effectiveness of the stroke simulation course was assessed both quantitatively and qualitatively with pre- and post-course questionnaires.

Results

There was a significant improvement (p<0.05) in all four assessed domains. There was a significant increase (p=0.0003) in the mean difference of score 3.75 (95% CI: 2.43-5.07) in understanding thrombolysis. Similarly, understanding of thrombectomy was significantly improved (p=0.0002) with a mean difference in score of 3.4 (95% CI: 2.28-4.46). There was also a significant increase (p<0.0001) in confidence in completing NIHSS scoring by a mean of 4.33 (95% CI: 3.55-5.12). Lastly, there was a significant increase (p=0.0012) in the mean by 2.75 (95% CI: 1.51-3.99) in confidence in the assessment of stroke. Overall, 95.8% of the participants found the course at least good, if not very good or excellent, and 91.7% would recommend this course to others.

Conclusion

We found traditional and simulation-based training to be effective in improving understanding of thrombolysis, understanding of thrombectomy, confidence in NIHSS scoring, and confidence in the assessment of stroke patients. This study validates the effectiveness of our course in improving assessment and management in acute stroke patients. We infer that improvements in these domains coupled with simulation training focused on human factors (e.g., fatigue affecting decision-making or logistical issues such as delays in neuroimaging due to scanner availability) would achieve better DTN time in the participants of our course.

Introduction

Stroke is the second-leading cause of mortality after ischaemic heart disease (IHD) worldwide [1] and the fourth highest in England and Wales, causing 5.1% of all deaths in 2022 (0.8% increase compared to 2021) [2]. Stroke is also known to be a risk factor in the development of dementia [3,4] and Alzheimer's [5], which was the number one cause of mortality, accounting for 11.5% of registered deaths in England and Wales in 2022 [2]. In the United Kingdom, approximately 1.3 million are living with a stroke at an estimated cost of £26 billion per year, including £8.6 billion for the National Health Service (NHS) and social care [6]. Although reperfusion therapy (intravenous thrombolysis and mechanical thrombectomy) has shown promise in managing ischaemic stroke [7,8], the mainstay of clinical outcomes ultimately relies on a narrow time window to intervene [9,10]. This suggests that effective clinical assessment and swift decision-making are essential to reduce mortality, improve quality of life after a stroke, and reduce financial burden.

The National Stroke Service Model 2021 recommends an ideal door-to-needle (DTN) time of 20 minutes [11]. Level one evidence suggests simulation training reduces DTN time by approximately 15 minutes [12]. This is critical as every minute in cerebral ischaemia can cause a loss of up to 1.9 million neurons, which can result in irreversible neurological damage [13]. Since the human factor is the main rate-limiting step [14], we have designed a course incorporating both traditional and simulation-based training to improve participant confidence. The primary outcomes are to aid medical professionals in making an efficient assessment of patients with a suspected stroke, improving confidence in the National Institute of Health Stroke Scale (NIHSS) scoring, improving understanding of thrombolysis and thrombectomy, and hence reducing DTN time.(Needle time has to be before the hospital) 

Reducing Door-to-Puncture Times for Mechanical Thrombectomy in a Large Tertiary Hospital

 You blithering idiots, door to puncture time means NOTHING to survivors; 100% recovery is the only requirement for survivors!

Reducing Door-to-Puncture Times for Mechanical Thrombectomy in a Large Tertiary Hospital

Zhenghong Liu, MBBS, MRCEM https://orcid.org/0000-0003-3361-3818, Man Qing Leong, BSc https://orcid.org/0000-0002-6299-1685, Nanlan Li, BA, MPP https://orcid.org/0009-0009-3886-2400, Miqi Mavis Teo, MBBS, MMEd (Anaes) https://orcid.org/0000-0003-2759-2563, Wei- Li Rachel Leong, MBBS, MMEd (Anae) https://orcid.org/0000-0003-2329-4235, Steve Chen Pong Wong, MBBS, MMed (Diag Rad), FRCR (UK) https://orcid.org/0000-0003-2936-4054, Jing Si Chew, BN, MN https://orcid.org/0009-0000-6871-0496, Seyed Ehsan Saffari, PhD https://orcid.org/0000-0002-6473-4375, Yee Hau Pang, MBBS, MRCP(UK) https://orcid.org/0000-0002-3957-471X, and Ghim Song Chia, MD, FRCR, MMed (Diag Rad) https://orcid.org/0000-0002-1305-2753Authors Info & Affiliations

October 2024 issue

14 (5)

https://doi.org/10.1212/CPJ.0000000000200325

• 
  

• Abstract
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Abstract

Background and Objectives

Endovascular therapy (EVT) for stroke has emerged as an important therapy for selected stroke patients, and shorter times to clot removal improve functional outcomes(NOT GOOD ENOUGH! 100% recovery is the goal of survivors.) . EVT requires the close coordination of multiple departments and poses unique challenges to care coordination in large hospitals. We present the results of our quality improvement project that aimed to improve our door-to-groin puncture (DTP) times for patients who undergo EVT after direct presentation to our emergency department.

Methods

We conducted time-motion studies to understand the full process of an EVT activation and conducted Gemba walks in multiple hospitals. We also reviewed the literature and interviewed stakeholders to create interventions that were implemented over 4 Plan-Do-Study-Act (PDSA) cycles. We retrospectively collected data starting from baseline and during every PDSA cycle. During each cycle, we studied the impact of the interventions, adjusted the interventions, and generated further interventions. A variety of interventions were introduced targeting all aspects of the EVT process. This included parallel processing to reduce waiting time, standardization of protocols and training of staff, behavioral prompts in the form of a stroke clock, and push systems to empower staff to facilitate the forward movement of the patient. A novel role-based communication app to facilitate group communications was also used.

Results

Eighty-eight patients spanning across 22 months were analyzed. After the final PDSA cycle, the median DTP time was reduced by 36.5% compared with baseline (130 minutes (interquartile range [IQR] 111–140) to 82.5 minutes (IQR 74.8–100)). There were improvements in all phases of the EVT process with the largest time savings occurring in EVT decision to patient arrival at the angiosuite. Interventions that were most impactful are described.

Discussion

EVT is a complex process involving multiple processes and local factors. Analysis of the process from all angles and intervening on multiple small aspects can add up to significant improvements in DTP times.

 

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Stroke Patient Transfer Times Longer Than Recommended

 You have massively failed at delivering tPA in 3 minutes. What is your followup to still meet the goal of 100% recovery for all? NONE? Then you don't belong in stroke, get the hell out and let better people actually solve stroke!

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

 In this research in mice the needed time frame for tPA delivery is 3 minutes for full recovery.

The latest here:

Stroke Patient Transfer Times Longer Than Recommended

The median interhospital transfer time for stroke patients needing targeted therapy is 174 minutes, which is longer than the recommended 120 minutes, results of a new US registry-based study show.

The study also uncovered age, racial, and gender disparities in transfer times.

Dr Shyam Prabhakaran

The study exposed transfer delays in US stroke systems that "dramatically" affect patients, study author Shyam Prabhakaran, MD, professor and chair of neurology, University of Chicago, told Medscape Medical News. "There are effective treatments for stroke, and many, many patients are getting them too late or not at all because of delays."

To reduce such lags, "we need to really be proactive like we have been in other processes," for example, improving "door to needle" time(door to needle is totally the incorrect measure, it's time from stroke onset), he added, referring to time to administer thrombolytic therapy.

The findings were published online August 15 in JAMA.

Stroke patients who present at hospital emergency departments (EDs) often need to be transferred to another institution to access time-dependent therapies, including intravenous (IV) thrombolysis and endovascular therapy, as well as neurosurgical or neurocritical care services. The recommended time from initial check-in at the ED to such a transfer ― the door-in, door-out time ― is less than 120 minutes.

Understanding disparities and modifiable factors associated with door-in, door-out times could help reduce delays in interhospital transfer times, the researchers write.

The study included US hospitals participating in the Get With the Guidelines–Stroke registry, a national database for voluntary quality improvement maintained by the American Heart Association/American Stroke Association. About a third of the move than 6000 hospitals in the US are part of this registry.

The analysis included 108,913 patients (mean age, 66.7 years; 71.7% White; 50.6% men) who had a stroke between January 2019 and December 2021 and were transferred from 1925 hospitals to another acute care hospital. Most patients had initially presented to teaching hospitals (62.9%), in urban areas (68.5%), and during the COVID-19 pandemic (59.6%).

 

Of the total patients who were transferred, 67,235 had acute ischemic stroke, and 41,678 had hemorrhagic stroke. The most common reasons for transfer were advanced stroke care (70.7%), evaluation for endovascular therapy (20.3%), and IV thrombolysis management (10.8%).

Priming the ED

Emergency Medical Services (EMS) prenotification, by which ambulance staff alert the receiving hospital that a patient suspected of having had a stroke is en route, was used in 43.9% of patients overall. Although not performed uniformly, this protocol is recommended, because it "primes the emergency room to get their teams ready and move their patient more efficiently," said Prabhakaran.

The median door-in, door-out time, the primary outcome, was 174 minutes overall: 178 minutes for patients with hemorrhagic stroke; 201 minutes for those with ischemic stroke (and other); and 132 minutes for those with ischemic stroke who were eligible for endovascular therapy.

Prabhakaran noted that patients eligible for endovascular therapy are "very identifiable" through imaging, which can pick up large-vessel occlusions. This helps explain their relatively short transfer time.

On the other hand, ischemic stroke patients who are not candidates for endovascular therapy may need additional workup and treatment, including CT angiogram and IV thrombolysis, so the decision-making is "not as straightforward," and this may affect transfer time, he said.

Patients with hemorrhagic stroke have relatively fast door-in, door-out times, possibly because imaging shows immediately whether the patient has a hemorrhage, and guidelines recommend emergency transfer of such patients to centers with dedicated stroke expertise, which significantly streamlines the transfer algorithm for such patients.

Lagging Behind Target

For only 27.3% of patients was the door-in, door-out time within 120 minutes. "This shows the degree to which current hospital performance lags behind the recommended time and gives us a motivation and rationale to pursue a large-scale initiative to get hospitals to try to reduce these times," commented Prabhakaran.

Characteristics that were significantly associated with longer door-in, door-out times included the followng: age 80 years or older vs those aged 18–59 years (14.90 minutes longer; 95% CI, 12.32 – 17.47 minutes), female vs male (5.21 minutes; 95% CI, 3.55 – 6.86 minutes), Black non-Hispanic vs White non-Hispanic (8.21 minutes; 95% CI, 5.67 – 10.75 minutes), and Hispanic vs White non-Hispanic (5.37 minutes; 95% CI, 1.77 – 8.97 minutes).

Urban hospital location was also significantly associated with prolonged door-in, door-out times. This might be because city hospitals have more resources to use for patients, which could delay the transfer, said Prabhakaran.

The study took place during part of the COVID-19 pandemic, when many hospitals were unable to accommodate transfers. This likely contributed to some delays picked up by the study, said Prabhakaran.

Aside from being White and being eligible for endovascular therapy, having a National Institutes of Health Stroke Scale (NIHSS) score greater than 12 was also linked to having a door-in, door-out time of 120 minutes or less, as was having EMS prenotification.

Aiming to Tackle Barriers

The research team will be investigating ways to reduce transfer delays, aiming to "protocolize this in a standardized way that tackles many of the barriers we think affect this door-in-door-out process," said Prabhakaran.

This should start with EMS prenotification and should include standardized screening for stroke upon ED arrival, protocols for moving patients to imaging, and rapid communication with the receiving center, he said.

While the current door-in, door-out target is a maximum of 120 minutes, that could be reduced to 90 minutes and perhaps even 60 minutes, he added. "The door to needle time used to be 60 minutes as a goal; now it's 30 minutes."

Missing or incomplete data were a limitation of the study; for example, the NIHSS score wasn't available for 21.4% of the study sample, and for nearly half of patients, variables related to vascular imaging were missing. Other limitations included the fact that hospitals participating in the Get With the Guidelines–Stroke registry have an interest in improving stroke care; some potential determinants of door-in, door-out time, such as distance to a comprehensive stroke center and bed availability, were not considered in the analysis; and an association between door-in, door-out times and clinical outcomes was not evaluated.

Extremely Important Data

Commenting on the study, Michael Mullen, MD, associate professor of neurology, Lewis Katz School of Medicine, Temple University, and director of the stroke program at Temple University Hospital, said the data "are extremely important," as they highlight important disparities in stroke care.(Notice the appalling word 'care', NOT RESULTS OR RECOVERY! This is why we need survivors in charge we wouldn't allow such tyranny of low expectations)

"Get With the Guidelines has a track record of success as a tool to quantify, trend, and improve stroke care," said Mullen. "Hopefully these data can be leveraged for future quality improvement programs to reduce door-in, door-out time overall and to reduce or eliminate the observed disparities."

Mullen noted that the study doesn't provide the level of detail needed to understand why stroke transfer delays occur. The reasons are likely multifactorial and may vary by region and hospital.

Because race and gender disparities exist in other areas of stroke care ― and medical care in general ― "it's certainly possible that implicit and explicit bias and structural racism are contributing factors," he added.

And although the authors attempted to account for factors such as geographic region and hospital characteristics, "systematic differences in where people live and the hospitals and healthcare systems that care for them may be driving some of these disparities," said Mullen.

He agreed it's difficult to know how much the COVID-19 pandemic influenced the results, given the strain placed on the entire healthcare system during that time.

Prabhakaran has received grants from National Institute of Neurological Disorders and Stroke and the Agency for Healthcare Research and Quality and personal fees from UpToDate. Mullen is an American Heart Association volunteer.

JAMA. Published online August 15, 2023. Full text