Mona Al Banna, MB BCh, Msc(Res)
Xian Y, Xu H, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Hernandez AF, Peterson ED, Schwamm LH, Fonarow GC. Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention. Stroke. 2021.
Thrombolysis trials have shown that the benefits of tPA are time dependent, with the number needed to treat increasing from 4.5 when treated in the first 90 minutes to 14.9 when treated in the 3 to 4.5 hour window.1 National guidelines have established target goals for door-to-needle (DTN) times. However, rapid delivery thrombolytic therapy occurs infrequently in hospitals in the United States, and often these target goals are not met.
The authors of this study set out to evaluate DTN times and clinical outcomes in patients pre- and post- two successive nationwide quality improvement intervention initiatives between April 2003 and September 2018. The intervention was Target: Stroke, which is a QI initiative sponsored by the American Heart Association/American Stroke Association (AHA/ASA) to assist hospitals in improving DTN times. Target Stroke I provided participating hospitals with best practice strategies, supporting tools, and educational resources. An expert working group performed a systematic review and identified 10 best practice strategies that could be rapidly, feasibly, and cost-effectively adopted. These strategies included things such as EMS pre-notification, rapid acquisition of brain imaging and premixing tPA. In addition, an annual honor roll recognition program for hospitals achieving the DTN goal was also implemented to incentivize institutions. For Target: Stroke phase II, best practice strategies of direct EMS transfer of patients to imaging, updated comprehensive educational materials, customizable clinical decision support tools and performance feedback were made available to the participating institutions. The goal of Target: Stroke Phase I was to achieve DTN times within 60 minutes in at least 50% of ischemic stroke patients treated with tPA. Target: Stroke Phase II set the goal of achieving DTN times ≤60 minutes in 75% and ≤45 minutes in 50% of patients treated with tPA. The authors also evaluated clinical outcomes, including mortality, symptomatic ICH, discharge destination and functional outcomes at discharge and analyzed these trends before and after the initiation of Target: Stroke Phase I and Phase II programs.