Positive impact of the participation in the ENCHANTED trial in reducing Door-to-Needle Time.

Jie Yang,Hisatomi Arima,Jing Hang,Craig S Anderson,Richard I Lindley,Jian Ping Yu,Pablo Lavados,Thompson Robinson,John Chalmers,Xia Wang

doi:10.1038/s41598-017-14164-8

Abstract

Door-to-needle time (DNT) is a key performance indicator for efficient use of intravenous thrombolysis in acute ischemic stroke (AIS). We aimed to determine whether DNT improved over time in the Enhanced Control of Hypertension and Acute Stroke Study (ENCHANTED) and the clinical predictors of DNT. Temporal trends in DNT were assessed across fourths of time since activation of study centers using generalized linear model. Predictors of long DNT (>60 min) were determined in logistic regression models. Overall mean DNT (min) was 71.8 (95% confidence interval [CI] 70.4–73.2), but decreased significantly over time (fourths): 77.9 (74.9–80.9), 69.3 (66.7–72.0), 69.1 (66.5–71.8) and 71.4 (68.7–74.2) (P for trend, 0.003). The reduction in DNT was particularly marked in China (P for trend, 0.001), but was not significant across the other participating countries (P for trend, 0.065). Independent predictors of long DNT were recruitment from China, short onset-to-door time, lower numbers of patients treated per center, higher diastolic blood pressure, off-hour admission, and absence of proximal clot occlusion. DNT in ENCHANTED declined progressively during the trial, especially in China. However, DNT in China is still longer than the key performance parameter of ≤60 minutes recommended in guidelines. Effective national programs are needed to improve DNT in China.

Highlights

Intravenous recombinant tissue plasminogen activator is the only approved medical reperfusion therapy for patients with acute ischemic stroke (AIS)[1]
Multivariable analysis shows the independent predictors of longer Door-to-needle time (DNT) included recruitment from China, shorter onset-to-door time (ODT) (0.58, 0.53–0.65; P < 0.0001), fewer patients treated in the center (0.96, 0.95–0.97; P < 0.0001), higher diastolic blood pressure (BP) (1.07, 1.00–1.14; P = 0.037), off-hour admission (1.27, 1.07–1.50; P = 0.005), and CT or
There was a significant reduction of 33 minutes between the first and final fourth epocs in time across the trial in China (P for trend, 0.001), whilst there was little temporal difference in the other participating countries. These analyses of a large clinical trial dataset involving AIS patients treated in a wide range of hospitals in multiple countries shows that DNT, whilst longer than recommended in best practice guidelines, progressively decreased in centers over the course of the study

Summary

Introduction

Intravenous recombinant tissue plasminogen activator (rtPA) is the only approved medical reperfusion therapy for patients with acute ischemic stroke (AIS)[1]. Guidelines[1,2] recommend this treatment to be initiated as soon as possible within 4.5 hours of stroke onset, as shorter onset-to-treatment time (OTT) translates into a better functional outcome[3,4]. A focus on decreasing in-hospital DNT is feasible, valuable and arguably essential, for quality systems of stroke care[1,6]. We used the dataset from the Enhanced Control of Hypertension and Acute Stroke Study (ENCHANTED)[7,8] rtPA-dose comparison arm to determine (i) whether DNT improved over time among participants, (ii) the extent to which DNT in China differed from other regions, and (iii) the clinical predictors of DNT

Objectives

Methods

Results

Conclusion