Abstract T P287: Reasons for Delays in Door to Needle Time

Abstract

Background: The National Quality Forum recently endorsed a performance measure for door-to-needle (DTN) time less than 60 minutes, with exclusion criteria for acceptable reasons for delay. However, the reasons for delay in timely treatment with tPA, and their impact on DTN times, are largely unknown. At our center we initiated the Hurry Acute Stroke Treatment and Evaluation-2 (HASTE-2) project to identify reasons for longer DTN. Methods: From 06/2012 to 06/2013 we encouraged treating physicians to fill out a 1-page case report form on opportunities for improvements and reasons for delays in treatment times, categorized according to systems-related delays (e.g. in patient registration, or in recognition of stroke symptoms and activation of the stroke) vs. medical/eligibility delays (e.g. management of concomitant emergent conditions or initial patient refusal). DTN data were analyzed from 113 consecutive patients presenting directly to the ER, treated with IV tPA within 4.5 hours of symptom onset. Results: Mean age was 71, 60/113 (53%) were women, median NIHSS was 13.5 and DTN was 57 minutes. Prospective data were recorded on the presence of absence of potential delays in 48/113 (42.5%); patients with missing data were somewhat younger (mean age 68.5 vs. 75.3, p=0.04) but did not differ in DTN or NIHSS. 52 different systems delays were identified in 30/48 patients (63%), and 15 different medical/eligibility delays were identified in 13/48 patients (27%). Medical/eligibility delays had the greatest impact on DTN: median 67 min [interquartile range 54-120] in patients with medical/eligibility delays, 47.5 min [40-66] in patients with only systems delays and 51 min [34-65] in patients with no delays (p=0.01). Conclusions: DTN may be prolonged for a variety of reasons. Up to 27% of patients have delays due to medical or eligibility-related causes that may be legitimate reasons for providing tPA later than the benchmark time of 60 minutes. Our difficulty in obtaining complete prospective physician documentation of reasons for delays suggests a need for improved chart documentation regarding DTN times.