Abstract
The aim of this study was to reduce the door-to-needle (DTN) time of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) through a comprehensive, hospital-based implementation strategy. The intervention involved a systemic literature review, identifying barriers to rapid IVT treatment at our hospital, setting target DTN time intervals, and building an evolving model for IVT candidate selection. The rate of non-in-hospital delay (DTN time ≤ 60 min) was set as the primary endpoint. A total of 348 IVT cases were enrolled in the study (202 and 146 in the pre- and post-intervention group, respectively). The median age was 61 years in both groups; 25.2% and 26.7% of patients in the pre- and post-intervention groups, respectively, were female. The post-intervention group had higher rates of dyslipidemia and minor stroke [defined as National Institutes of Health Stroke Scale (NIHSS) ≤ 3]; less frequent atrial fibrillation; higher numbers of current smokers, heavy drinkers, referrals, and multi-model head imaging cases; and lower NIHSS scores and blood sugar level (all P < 0.05). All parameters including DTN, door-to-examination, door-to-imaging, door-to-laboratory, and final-test-to-needle times were improved post-intervention (all P < 0.05), with net reductions of 63, 2, 4, 28, and 23 min, respectively. The rates of DTN time ≤ 60 min and onset-to-needle time ≤ 180 min were significantly improved by the intervention (pre: 9.9% vs. post: 60.3%; P < 0.001 and pre: 23.3% vs. post: 53.4%; P < 0.001, respectively), which was accompanied by an increase in the rate of neurological improvement (pre: 45.5% vs. post: 59.6%; P = 0.010), while there was no change in incidence of mortality or systemic intracranial hemorrhage at discharge (both P > 0.05). These findings indicate that it is possible to achieve a DTN time ≤ 60 min for up to 60% of hospitals in the current Chinese system, and that this logistical change can yield a notable improvement in the outcome of IVT patients.
Highlights
Intravenous thrombolysis (IVT) is one of the most efficacious treatments for acute ischemic stroke (AIS), for which therapeutic intervention is highly time-sensitive [1,2,3]
Less than half of American [4] and even fewer Chinese [5,6] patients with AIS are treated with recombinant tissue plasminogen activator within the time frame recommended by the American Heart Association and American Stroke Association [door-to-needle (DTN) time 60 min] [7], which has been validated by the Get With The Guidelines—Stroke program [8]
Strategies for reducing in-hospital delays of IVT administration have been implemented in many Western institutions [4,9,10,11,12] and the median DTN time has been reduced to < 20 min in at least one stroke center [10], this has not been the case in most Chinese hospitals [5,6], which may be attributed to differences between the Chinese healthcare system and those of Western countries [13]
Summary
Intravenous thrombolysis (IVT) is one of the most efficacious treatments for acute ischemic stroke (AIS), for which therapeutic intervention is highly time-sensitive [1,2,3]. Strategies for reducing in-hospital delays of IVT administration have been implemented in many Western institutions [4,9,10,11,12] and the median DTN time has been reduced to < 20 min in at least one stroke center [10], this has not been the case in most Chinese hospitals [5,6], which may be attributed to differences between the Chinese healthcare system and those of Western countries [13]. In the present historical controlled study, we investigated the efficacy and safety of various strategies for reducing DTN time at a tertiary hospital in China
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