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.
A total number of 185,501 patients were treated with intravenous tPA within 4.5 hours of symptom onset from Get-with-the-guidelines stroke hospitals. The duration of the study was from April 2003 to September 2018. Of those, 154,221 were included in the primary analysis, based on having stroke symptom onset to treatment time within 3 hours. The interventions were shown to be successful. Three years after implementation, the median DTN times decreased from 74 minutes in 2009 to 59 minutes by 2013, and the percentage of patients with DTN times ≤60 minutes increased from 30% to 53%. The proportion of patients with DTN times ≤60 minutes increased from 26.4% during the preintervention period, to 42.7% during Target: Stroke Phase I, and 68.6% during Phase II. For Phase II, DTN times ≤45 minutes increased from 10.1% in the preintervention period, to 17.7% in Target: Stroke Phase I, and 41.4% in Target: Stroke Phase II. Shorter DTN times were associated with better outcomes in terms of lower in-hospital mortality, fewer symptomatic intracranial hemorrhage, more frequent discharge to home, more frequent independent ambulation, and more frequent disability free patients at discharge. Those who were not treated with tPA, the in-hospital mortality rates were 4.5% during the preintervention period, 3.6% during Target: Stroke Phase I, and 3.1% during Target: Stroke Phase II. The degree of mortality benefit for patients treated with tPA (Target: Stroke Phase I: 0.84 [0.79–0.89]; Phase II: 0.69 [0.64–0.74]) was greater than that found for patients with acute ischemic stroke not treated with tPA. This suggests that this benefit in tPA treated patients was not due to overall improvements in stroke care alone.
This article shows that active concurrent multi-factorial interventions to reduce DTN times are effective and overall lead to improved clinical outcomes for our stroke patients. These intervention tools provided by the AHA/ASA need to be further utilized and adapted by institutions to shorten DTN times and overall improve clinical outcomes. An interesting thing to note in terms of study findings is that female and non-Hispanic Black patients were more likely to experience delay in terms of DTN times. This indicates that more interventions regarding social determinants of health need to be undertaken to provide equitable care amongst all population subgroups.
Study limitations include voluntary program enrollment and this may not adequately capture the full spectrum of practice. Second, this was not a randomized controlled trial and therefore causal relationships can’t be established. Third, Target: Stroke Phase II started a year before the publication of the major endovascular thrombectomy trials which could have influenced workflow including for tPA as well.
- Lees, Kennedy R., et al. “Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials.” The Lancet 375.9727 (2010): 1695-1703.