Door-to-imaging Time Research Articles

Abstract WMP38: Access to Acute Stroke Care: Global Perspective From Registry of Stroke Care Quality (RES-Q)

Introduction: Disparities in access to acute stroke care represents a major global challenge. Addressing such challenges requires a comprehensive understanding of the variations in stroke care quality between nations. Methods: We used data from the global Registry of Stroke Care Quality (RES-Q). RES-Q is web-based quality monitoring platform for the management of stroke care. Key quality metrics on patients with acute ischemic stroke admitted in 2022 were calculated: patients percentage arriving by Emergency Medical Services (EMS); patients percentage admitted to the Stroke Unit/Intensive Care Unit (ICU); Door-to-Imaging Time (DIT), Door-to-Needle Time (DNT) for intravenous thrombolysis. Results: Of 153 181 patients across 912 hospitals in 67 countries enrolled in the register, 125 390 had acute ischemic stroke. After excluding secondary transfers (n=26 648), missing or erroneous data (n=45 526), and countries with <200 cases (n=1 410), a total of 51,806 patients from 696 hospitals and in 30 countries were analyzed. The percentage of patients arriving at healthcare facilities by EMS varied from 3% to 98% (median 51%; IQR 26-87) and admitted to the Stroke Units/ICUs from 25% to 99% (median 78%; IQR 47-89). The median DIT was 32; IQR 21-39, with range 10-60 minutes. The median DNT was 44; IQR 31-52, with range 20-71 minutes. Median DNT of patients admitted directly to the CT scanner was 24 minutes (IQR 15-38), and, if admitted to the emergency department, DNT was 39 minutes (IQR 25-55). Data by quartiles (best is blue, worst is red) from each country are presented in a detailed Table below. Conclusion: Our study underscores the critical role of the global registry in enabling cross-national comparative analyses of acute stroke care quality. The findings highlight disparities and variations in critical aspects of acute stroke care, paving the way for targeted interventions, policy reforms, and enhanced collaboration among stakeholders to improve stroke care globally.

Early arrival did not ensure the early acquisition of intravenous thrombosis for acute ischemic stroke during the COVID-19 pandemic.

Intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) is a time-dependent treatment with a narrow therapeutic time window, in which the time delay could result from the deadline effect. One hospital-based cohort was recruited to detect the factors contributing to the deadline effect, where patients with the deadline effect were defined as those who were presented with the onset-to-door time (ODT) in the first 50%, while the door-to-needle time (DNT) was in the last quartile. DNT (in-hospital delay) was further subdivided into several time intervals [door-to-examination time (DET), door-to-imaging time (DIT), door-to-laboratory time (DLT), and decision-making time (DMT) of the patients or their proxies. A total of 186 IVT cases were enrolled, of which 17.2% (32/186) suffered a delay of the deadline effect. The median age was 66 years, and 35.5% were female. Baseline characteristics were similar between the two groups (all p>.05). For the comparisons of the time intervals, DIT (26 versus 15 min, p=.001) was significantly longer in the group with deadline effect, while the differences of DET, DLT, DMT, and ONT did not reach statistical significance (all p>.05). Upon multivariable adjustment in the binary logistic regression model, longer DIT [odds ratio (OR), 1.076; 95% confidence interval (CI), 1.036-1.118; p<.001], and history of coronary heart disease (OR, 3.898; 95%CI, 1.415-10.735; p=.008) were independently associated with deadline effect in the binary logistic regression model, while admitted in the working day (OR, 0.674; 95%CI, 0.096-0.907; p=.033), and having medical insurance (OR, 0.350; 95% CI, 0.132-0.931; p=.035) were negatively associated with the deadline effect. A speed-safety tradeoff phenomenon from the deadline effect was observed in 17.2% of IVT cases during the COVID-19 pandemic, where longer DIT contributed a lot to this time delay. Patients without medical insurance, or admitted in official holidays were more likely to experience a delay of the deadline effect.

Real-time feedback on mobile application use for emergency management affects the door-to-needle time and functional outcomes in acute ischemic stroke

ObjectivesTime from onset to reperfusion affects mortality and favorable outcomes in patients with acute ischemic stroke (AIS). To evaluate effects of a real-time feedback mobile application on critical time intervals and functional outcomes in stroke emergency management. MethodsWe recruited patients with clinically suspected acute stroke from December 1st, 2020 until July 30st, 2022. All Patients had a non-contrast computed tomography (CT) and were included only if they had AIS. We divided the patients into two groups based on the date of availability on mobile application: pre-APP group and post-APP group. Onset to Door time (ODT), Door to Imaging Time (DIT), Door to Needle Time (DNT), Door to Puncture Time (DPT), Door to Recanalization Time (DRT), National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) were compared between two groups. ResultsWe retrospectively enrolled 312 AIS patients who were assigned into the pre-APP group (n = 159) and post-APP group (n = 153). The median ODT time and median admission NIHSS score were not significantly different between the two groups at baseline assessment. The median (IQR) DIT [44 (30-60) min vs 28 (20-36) min, P < 0.01] and DNT [44 (36.25-52) min vs 39 (29-45) min, P = 0.02] both decreased significantly in two groups. However, median DPT and DRT time showed no significant differences. The proportion of mRS score of 0 to 2 at day 90 was significantly higher in the post-App group than in the pre-App group, at 82.4% and 71.7%, respectively (dominance ratio OR=1.84, 95% CI: 1.07 to 3.16, P = 0.03). ConclusionThe present findings indicate that the real-time feedback of stroke emergency management used by a mobile application have potential for shortening the DIT and DNT time and improve the prognosis of stroke patients.

Stroke Thrombolysis: Beating the Clock.

Recombinant tissue plasminogen activator (rtPA) has revolutionized the management of acute ischemic stroke. Shorter door-to-imaging and door-to-needle (DTN) times are crucial for improving the outcomes in thrombolysed patients. Our observational study evaluated the door-to-imaging time (DIT) and DTN times for all thrombolysed patients. The study was a cross-sectional observational study over a period of 18 months at a tertiary care teaching hospital and included 252 acute ischemic stroke patients of which 52 underwent thrombolysis with rtPA. The time intervals between arrival to neuroimaging and initiation of thrombolysis were noted. Of the total patients thrombolysed, only 10 patients underwent neuroimaging [non-contrast computed tomography (NCCT) head with MRI brain screen] within 30 minutes of their arrival in the hospital, 38 patients within 30-60 minutes and 2 each within the 61-90 and 91-120 minute time frames. The DTN time was 30-60 minutes for 3 patients, while 31 patients were thrombolysed within 61-90 minutes, 7 patients within 91-120 minutes, while 5 each took 121-150 and 151-180 minutes for the same. One patient had a DTN between 181 and 210 minutes. Most patients included in the study underwent neuroimaging within 60 minutes and subsequent thrombolysis within 60-90 minutes of their arrival in the hospital. But the time frames did not meet the recommended ideal intervals, and further streamlining of stroke management is needed even at tertiary care centers in India. Shah A, Diwan A. Stroke Thrombolysis: Beating the Clock. Indian J Crit Care Med 2023;27(2):107-110.

Impact of improved stroke green channel process on the delay of intravenous thrombolysis in patients with acute cerebral infarction during the COVID-19 pandemic: An observational study.

ObjectiveThis study analyzed the impact of the improved stroke green channel process on the delay of intravenous thrombolysis in patients with acute cerebral infarction under coronavirus disease 2019 (COVID-19) prevention and control measures.MethodsWe included 57 patients from the stroke center of the Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine before the improvement of the stroke green channel process (March–July 2019), as well as 94 patients during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak (March–July 2020) and 68 patients during the Omicron variant outbreak (March–July 2022) after the improvement of stroke green channel process. The door-to-needle time (DNT), door-to-imaging time (DIT), and door-to-test completion time were compared among the three groups. We analyzed the impact of this process improvement in the emergency green channel during the pandemic on the delay of intravenous thrombolysis.ResultsThis study included a total of 229 patients with acute cerebral infarction who went through the green channel for intravenous thrombolysis (57 in the pre-pandemic group, 94 in the SARS-CoV-2 outbreak group, and 68 in the Omicron outbreak group). The percentages of patients undergoing intravenous thrombolysis in the pre-pandemic, SARS-CoV-2 outbreak, and Omicron outbreak groups differed significantly (19.32%, 22.27%, and 28.94%, respectively, P = 0.029). Compared to the pre-pandemic group, the National Institutes of Health Stroke Scale (NIHSS) score at admission was significantly higher in the Omicron outbreak group (7.71 ± 7.36 in the Omicron outbreak group vs. 5.00 ± 4.52 in the pre-pandemic group) (P = 0.026) but not in the SARS-CoV-2 outbreak group (4.79 ± 5.94 in the SARS-CoV-2 outbreak group vs. 5.00 ± 4.52 in the pre-pandemic group, P = 0.970). Significantly higher proportions of patients undergoing emergency intravenous thrombolysis came to the hospital by ambulance in the SARS-CoV-2 and Omicron outbreak groups compared to the pre-pandemic group (38.6% in the pre-pandemic group, 51.1% in the SARS-CoV-2 outbreak group, and 82.4% in the Omicron outbreak group, P < 0.001). Compared to the pre-pandemic group, the DIT was significantly higher in the SARS-CoV-2 outbreak group (22.42 ± 7.62 min in the SARS-CoV-2 outbreak group vs. 18.91 ± 8.23 min in the pre-pandemic group, P =0.031) but not the Omicron outbreak group (20.35 ± 10.38 min in the Omicron outbreak group vs. 18.91 ± 8.23 min in the pre-pandemic group, P = 0.543). The door-to-test completion time was significantly longer in the SARS-CoV-2 and Omicron outbreak groups compared to that in the pre-pandemic group (78.37 ± 25.17 min in the SARS-CoV-2 outbreak group, 92.60 ± 25.82 min in the Omicron outbreak group vs. 65.11 ± 22.35 min in the pre-pandemic group, P < 0.001); however, the DNT in the SARS-CoV-2 and Omicron outbreak groups did not differ significantly from those in the pre-pandemic group (both P > 0.05).ConclusionDuring the two periods of the COVID-19 outbreak (SARS-CoV-2 and Omicron), after the improvement of the green channel for intravenous thrombolysis, there might be some delay in in-hospital DIT during the SARS-CoV-2 outbreak, however, the in-hospital delay indicator DNT for intravenous thrombolysis were not affected.

Language preference does not influence stroke patients' symptom recognition or emergency care time metrics

Our objective was to determine whether acute ischemic stroke (AIS) patients' language preference is associated with differences in time from symptom discovery to hospital arrival, activation of emergency medical services, door-to-imaging time (DTI), and door-to-needle (DTN) time. We identified consecutive AIS patients presenting to a single urban, tertiary, academic center between 01/2003-05/2014 for whom language preference was available. Data were abstracted from the institution's Research Patient Data Registry and Get with the Guidelines-Stroke Registry. Bivariate and regression models evaluated the relationship between language preference and: 1) time from symptom onset to hospital arrival, 2) use of EMS, 3) DTI, and 4) DTN time. Of 3190 AIS patients, 300 (9.4%) were non-English preferring (NEP). Comparing NEP to English preferring (EP) patients in unadjusted or adjusted analyses, time from symptom discovery to arrival and rate of EMS utilization were not significantly different (overall median time 157min, IQR 55-420; EMS utilization: 65% vs. 61.3% p=0.21). There was also no significant differences in DTI or in likelihood of guideline-recommended DTI≤25min (overall median 59min, IQR 29-127; DTI≤25min 24.3% vs. 21.3% p=0.29) or DTN time or in likelihood of guideline-recommended DTN≤60min (overall median 53min, IQR 36-73; DTN≤60min 62.5% vs. 58.2% p=0.60). Consistent with prior reports examining disparities in care, a systems-based approach to acute stroke prevents differences in hospital-based metrics. Reassuringly, NEP and EP patients also had similar speed of symptom recognition and EMS utilization.

Impact of Emergency Department Crowding on Delays in Acute Stroke Care.

IntroductionDelays in identification and treatment of acute stroke contribute to significant morbidity and mortality. Multiple clinical factors have been associated with delays in acute stroke care. We aimed to determine the relationship between emergency department (ED) crowding and the delivery of timely emergency stroke care.MethodsWe used prospectively collected data from our institutional Get with the Guidelines-Stroke registry to identify consecutive acute ischemic stroke patients presenting to our urban academic ED from July 2016–August 2018. We used capacity logs to determine the degree of ED crowding at the time of patients’ presentation and classified them as ordinal variables (normal, high, and severe capacity constraints). Outcomes of interest were door-to-imaging time (DIT) among patients potentially eligible for alteplase or endovascular therapy on presentation, door-to-needle time (DTN) for alteplase delivery, and door-to-groin puncture (DTP) times for endovascular therapy. Bivariate comparisons were made using t-tests, chi-square, and Wilcoxon rank-sum tests as appropriate. We used regression models to examine the relationship after accounting for patient demographics, transfer status, arrival mode, and initial stroke severity by the National Institutes of Health Stroke Scale.ResultsOf the 1379 patients with ischemic stroke presenting during the study period, 1081 (78%) presented at times of normal capacity, 203 (15%) during high ED crowding, and 94 (7%) during severe crowding. Median DIT was 26 minutes (interquartile range [IQR] 17–52); DTN time was 43 minutes (IQR 31–59); and median DTP was 58.5 minutes (IQR 56.5–100). Treatment times were not significantly different during periods of higher ED utilization in bivariate or in multivariable testing.ConclusionIn our single institution analysis, we found no significant delays in stroke care delivery associated with increased ED crowding. This finding suggests that robust processes of care may enable continued high-quality acute care delivery, even during times with an increased capacity burden.

118 Emergency Department Crowding is Not Associated With Delays in Acute Stroke Care

Delays in identification and treatment of acute stroke contribute to significant morbidity and mortality. Multiple clinical factors have been associated with delays in acute stroke care. We aimed to determine the relationship between emergency department (ED) crowding and the delivery of timely emergency stroke care. We used prospectively collected data from our institutional Get with the Guidelines-Stroke registry to identify consecutive acute ischemic stroke patients presenting to our large, urban academic ED from July 2016 to August 2018. Patients included in analysis were those who presented within six hours of last known well time. We used ED capacity logs to determine the degree of ED crowding at the time of patients’ presentation (normal, high, and severe capacity constraints). Outcomes of interest were door-to-imaging time (DIT), door-to-needle time (DTN), and door-to-groin puncture times (DGPT). Bivariate comparisons were made using t-tests, chi-square, and non-parametric testing as appropriate. We used wilcoxon rank sum testing to examine the bivariate relationship between ED capacity and our outcomes of interest, and regression models to examine the relationship after accounting for patient demographics, arrival mode, whether the patient was transferred from another hospital, and stroke severity. Of the 1,378 patients who presented with ischemic strokes during the study period, 1,080 (78%) presented during times of normal ED utilization, 203 (15%) during high ED utilization, and 94 (6.8%) during severe capacity constraints. Among patients presenting acutely, median DIT was 51.5 minutes (interquartile range [IQR] 23-130), median DTN time was 43 minutes (IQR 31-59), and median DGPT was 72 mins (IQR 57-117.5). Overall DIT for patients who received alteplase was 18 mins (IQR 14-26). Treatment times were not significantly different during periods of higher ED utilization in bivariate or in multivariable testing. In our single institution analysis, we found no significant delays in stroke care delivery associated with increased ED crowding. This finding suggests that robust processes of care may enable continued high-quality acute care delivery, even during times with an increased capacity burden.

Analysis of intravenous thrombolysis time and prognosis in patients with in-hospital stroke

To compare the time delay between in-hospital stroke and out-of-hospital stroke patients, and to explore the influence factors for the prognosis of in-hospital stroke patients treated by intravenous thrombolysis. Clinical data of 3050 patients with ischemic stroke who received intravenous thrombolysis in 71 hospitals in Zhejiang province from June 2017 to September 2018 were analyzed. Differences of time delay including door to imaging time (DIT), imaging to needle time (INT) and door to needle time (DNT) between in-hospital stroke (n=101) and out-of-hospital stroke (n=2949) were observed. The influencing factors for the outcome at 3 month after intravenous thrombolysis in patients with in-hospital stroke were analyzed using binary logistic regression analysis. Patients with in-hospital stroke had longer DIT[53.5 (32.0-79.8) min vs. 20.0 (14.0-28.0) min, P<0.01], longer IDT[47.5(27.3-64.0)min vs. 36.0(24.0-53.0)min, P<0.01], and longer DNT[99.0 (70.5-140.5) min vs. 55.0 (41.0-74.0) min, P<0.01], compared with patients with out-of-hospital stroke; patients in comprehensive stroke center had longer DIT[59.5(44.5-83.3) min vs. 37.5(16.5-63.5) min, P<0.01], longer DNT[110.0(77.0-145.0) min vs. 88.0 (53.8-124.3) min, P<0.05], but shorter INT[36.5(23.8-60.3)min vs. 53.5 (34.3-64.8) min, P<0.05], compared with patients in primary stroke center. Age (OR=0.934, 95%CI: 0.882-0.989, P<0.05) and baseline National Institute of Health Stroke Scale score (OR=0.912, 95%CI: 0.855-0.973, P<0.01) were independent risk factors for prognosis of in-hospital stroke patients. In-hospital stroke had longer DIT and DNT than out-of-hospital stroke, which suggests that a more smooth thrombolysis process of in-hospital stroke should be established.

Factors affecting in-hospital delay of intravenous thrombolysis for acute ischemic stroke: A retrospective cohort study.

This study was designed to investigate the factors affecting the in-hospital delay of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS).Two hundred and forty-eight consecutive AIS patients treated with intravenous administration of alteplase in Gansu Provincial Hospital from December 2014 to August 2018 were enrolled retrospectively in this study. According to door-to-needle (DTN) time, the patients were divided into either a delay group (DTN time > 60 minutes; n = 184) or a non-delay group (DTN time ≤60 minutes; n = 64). The baseline data, laboratory tests, onset-to-door (OTD) time, door-to-accepting time (DTA), door-to-imaging time (DTI), and decision-making time in both groups were recorded. Multivariate logistic analysis was performed to analyze the data.There were significant differences in previous history of cerebral ischemic attack, emergency system admission, education degree of decision makers, annual income, admission National Institutes of Health Stroke Scale (NIHSS), OTD time, DTA time, decision-making time between the 2 groups (all P < .05). Other baseline data and clinical features showed no significant difference between 2 groups (P > .05). Multivariate logistic regression analysis revealed that the risk of in-hospital delay was lower for the higher NIHSS score (OR = 0.775, 95% CI: 0.644-0.933, P = .007), the longer OTD time (OR = 0.963, 95% CI: 0.937-0.991, P = .010), the shorter decision-making time (OR = 1.224, 95% CI: 1.004-1.492, P = .045).This study suggested that NIHSS score, OTD time and decision-making time are the independent factors affecting the in-hospital delay of IVT for AIS.

Stroke-related education to emergency department staff: An acute stroke care quality improvement initiative.

Acute ischemic stroke therapy is time sensitive, and optimum treatment is missed due to pre-hospital and/or in-hospital delay. A prospective observational (before and after) study was conducted for 1 year.The study period was defined as phase-I or pre-education phase, phase-II or immediate post-education phase, and phase-III or delayed post-education phase, with each phase lasting for 4months. All consecutive stroke patients presenting within 12 hours of stroke onset were enrolled. Baseline and outcome data including acute stroke care quality matrices and functional outcomes were collected. A total of 264 patients were enrolled. All acute stroke care quality matrices improved significantly (P ≤ 0.01) with a median door to imaging time (DTI) of 114, 35, and 47 minutes in the three phases consecutively. In phase-II, proportions of patients imaged within 25 minutes of arrival increased by 35%. Mean door to needle (DTN) time were 142 ± 49.7,63.7 ± 25.1, and 83.9 ± 38.1 minutes in the three consecutive phases. Patients with DTN < 60 minutes of arrival increased by 63%. Modified Rankin score (mRS) at 3 months improved significantly in all ischemic stroke patients (P = 0.04) and patients with mRS of 0-2 increased by 22%. Stroke education to emergency department (ED) staff is an effective method to improve acute stroke care.

Abstract WP261: Non-English-preferring Patients Have No Differences in Stroke Symptom Recognition or Emergency Care Time Metrics

Introduction: The influence of patients’ language preference on the delivery of acute ischemic stroke (AIS) care in the pre-hospital and in-hospital emergency care settings is scarcely known. We hypothesize that stroke knowledge differences may be associated with non-English preferring (NEP) patients having slower time from symptom discovery to hospital presentation and less engagement of emergency medical services (EMS) than English preferring (EP) patients. Language barriers may also interfere with the delivery of time-sensitive emergency department care. Objectives: To identify whether language preference is associated with differences in patients’ time from stroke symptom discovery to hospital arrival, activation of emergency medical services, door-to-imaging time (DIT), and door-to-needle (DTN) time. Methods: We identified consecutive AIS patients presenting to a single urban, tertiary, academic center between 01/2003-04/2014. Data was abstracted from the institution’s Research Patient Data Registry and Get with the Guidelines-Stroke Registry. Bivariate and regression models evaluated the relationship between language preference and: 1) time from symptom onset to hospital arrival, 2) use of EMS, 3) DIT, and 4) DTN time. Results: Of 3,190 AIS patients who met inclusion/exclusion criteria, 9.4% were NEP (n=300). Time from symptom discovery to arrival, and EMS utilization were not significantly different between NEP and EP patients in unadjusted or adjusted analyses (overall median time 157 minutes, IQR 55-420; EMS utilization: 65% vs. 61.3% p=0.21). There was no significant difference between NEP and EP patients in DIT or in likelihood of DIT ≤ 25 minutes in unadjusted or adjusted analyses (overall median 59 minutes, IQR 29-127; DIT ≤ 25 minutes 24.3% vs. 21.3% p=0.29). There was also no significant different in DTN time or in likelihood of DTN ≤ 60 minutes in unadjusted or adjusted analyses (overall median 53 minutes, IQR 36-73; DTN ≤ 60 minutes 62.5% vs. 58.2% p=0.60). Conclusion: Non-English-preferring patients have similar response to stroke symptoms as reflected by EMS utilization and time from symptom discovery to hospital arrival. Similarly, NEP patients have no differences in in-hospital AIS care metrics of DIT and DTN time.

Door-to-Imaging Time for Acute Stroke Patients Is Adversely Affected by Emergency Department Crowding.

National guidelines call for door-to-imaging time (DIT) within 25 minutes for suspected acute stroke patients. Studies examining factors that affect DIT have focused primarily on stroke-specific care processes and patient-specific factors. We hypothesized that emergency department (ED) crowding is associated with longer DIT. We conducted a retrospective investigation of 1 year of consecutive patients in our prospective Code Stroke registry, which included all ED stroke team activations. The registry and electronic health records were abstracted for 27 potential predictors of DIT, including patient, stroke care process, and ED operational factors. We fit a multivariate logistic regression model and calculated odds ratios and 95% confidence intervals. Second, we constructed a random forest recursive partitioning model to cross-validate our findings and explore the proportional importance of each category of predictor. Our primary outcome was the binary variable of DIT within the 25-minute goal. A total of 463 patients met inclusion criteria. In the regression model, ED occupancy rate emerged as a predictor of DIT, with odds ratio of 0.83 (95% confidence interval, 0.75-0.91) of DIT within 25 minutes per 10% absolute increase in ED occupancy rate. The secondary analysis estimated that ED operational factors accounted for nearly 14% of the algorithm's prediction of DIT. ED crowding is associated with reduced odds of meeting DIT goals for acute stroke. In addition to improving stroke-specific processes of care, efforts to reduce ED overcrowding should be considered central to optimizing the timeliness of acute stroke care.

Abstract WP235: A Novel Pre-notification System Using a Smartphone Application Improves Quality Indicator for Thrombolysis Therapy in Acute Ischemic Stroke

Background and Purpose: Prehospital notification of patients with suspected acute stroke by emergency medical services (EMS) personnel is recommended to reduce delays in time-dependent management such as thrombolytic therapy. We developed ” the Brain Saver”, which is a smartphone-assisted prenotification system using mobile application platform, and evaluated preliminarily the effects of this system on improving quality indicator for thrombolysis therapy in acute ischemic stroke. Methods: Through the Brain Saver, the EMS personnel sent the clinical information, such as age, sex, time of symptom onset, expected arrival time, neurological symptom of the patient with suspected acute stroke in the field, so that the stroke team prepared to prioritize the hospital resources such as computerized tomography (CT) and various laboratory test for suspected stroke patients. On arrival at emergency room, patients were transferred directly from triage onto the CT room on the ambulance stretcher, and the stroke team meet patient. Between September 2014 and July 2015, we compared quality indicators including door-to-needle time (DNT), door-to-imaging time (DIT) of patients with intravenous tissue plasminogen activator (tPA) with prenotification to those without prenotification. Results: During study period, time of onset to arrival in patients with prenotification using the Brain Saver was similar in those without. However, compared with tPA patients who arrived without prenotification, the median (interquartile range) DNT decreased from 55 (42-92) to 36 (32-42) minutes (p=0.003) and DIT was reduced from 11 (7-15) to 3 (2-6) minutes (p&lt;0.0001). Conclusions: The Brain Saver was the efficient tool to communicate between EMS personnel and the stroke team for the prenotification of patients with acute stroke. The prenotification improved quality indicator of in-hospital stroke management by reducing time delay in thrombolytic therapy.

Factors Associated with In-Hospital Delay in Intravenous Thrombolysis for Acute Ischemic Stroke: Lessons from China

In-hospital delay reduces the benefit of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS), while factors affecting in-hospital delay are less well known in Chinese. We are aiming at determining the specific factors associated with in-hospital delay through a hospital based cohort. In-hospital delay was defined as door-to-needle time (DTN) ≥60min (standard delay criteria) or ≥75% percentile of all DTNs (severe delay criteria). Demographic data, time intervals [onset-to-door time (OTD), DTN, door-to-examination time (DTE), door-to-imaging time (DTI), door-to-laboratory time (DTL) and final-test-to-needle time (FTN, the time interval between the time obtaining the result of the last screening test and the needle time)], medical history and additional variables were calculated using Mann-Whitney U or Pearson Chi-Square tests for group comparison, and multivariate linear regression analysis was performed to identify independent variables of in-hospital delay. A total of 202 IVT cases were enrolled. The median age was 61 years and 25.2% were female. The cutoff points for the upper quartile of DTN (severe delay criteria) was 135min.When compared with the reference group without in-hospital delay, older age, shorter OTD and less referral were found in the standard delay group and male sex, presence with transient ischemic attacks or rapidly improving symptom, and with multi-model CT imaging were more frequent in the severe delay group. In the multivariate linear regression analysis, FTN (P<0.001) and DTL (P = 0.002) were significantly associated with standard delay; while DTE (P = 0.005), DTI (P = 0.033), DTL (P<0.001), and FTN (P<0.001) were positively associated with severe delay. There was not a significant change in the trend of DTNs during the study period (P = 0.054). In-hospital delay was due to multifactors in China, in which time delays of decision-making process and laboratory tests contributed the most. Efforts aiming at reducing the delay should be focused on the optimization for the items of screening tests and improvement of the pathway organization.

Hospital variation in thrombolysis times among patients with acute ischemic stroke: the contributions of door-to-imaging time and imaging-to-needle time.

Given the limited time window available for treatment with tissue plasminogen activator (tPA) in patients with acute ischemic stroke, guidelines recommend door-to-imaging time (DIT) within 25 minutes of hospital arrival and door-to-needle (DTN) time within 60 minutes for patients with acute ischemic stroke. Despite improvements in DITs, DTN times for tPA treatment in patients with acute ischemic stroke remain suboptimal. To examine the contributions of DIT and imaging-to-needle (ITN) time to delays in timely delivery of tPA to patients with acute ischemic stroke and to assess between-hospital variation in DTN times. A cohort analysis of 1193 patients having acute ischemic stroke treated with intravenous tPA between January 2009 and December 2012. Multilevel linear regression models included random effects for 25 Michigan hospitals participating in the Paul Coverdell National Acute Stroke Registry. The primary outcome was a continuous measure of DTN time, in minutes, from emergency department arrival to thrombolytic delivery. The mean age was 68.1 years, the median National Institutes of Health Stroke Scale score was 11.0 (interquartile range, 6-17), 51.4% were female, and 37.5% were of nonwhite race/ethnicity.The mean (SD) DTN time was 82.9 (35.4) minutes, the mean (SD) DIT was 22.8 (15.9) minutes, and the mean (SD) ITN time was 60.1 (32.3) minutes. Most patients (68.4%) had DIT within 25 minutes, while 28.7% had DTN time within 60 minutes. Hospital variation accounted for 12.7% of variability in DTN times. Neither annual stroke volume nor primary stroke center designation was a significant predictor of shorter DTN time. Patient factors (age, sex, race/ethnicity, arrival mode, onset-to-arrival time, and stroke severity) explained 15.4% of the between-hospital variation in DTN times. After adjustment for patient-level factors, DIT explained 10.8% of the variation in hospital risk-adjusted DTN times, while ITN time explained 64.6%. Compared with DIT, ITN time is a much greater source of variability in hospital DTN times and is a more common contributor to delays in timely tPA therapy for acute ischemic stroke. More attention is needed to determine systems changes that can decrease ITN time for patients with acute ischemic stroke.

Factors Influencing Door-to-Imaging Time: Analysis of the Safe Implementation of Treatments in Stroke–EAST Registry

Brain imaging is logistically the most difficult step before thrombolysis. To improve door-to-needle time (DNT), it is important to understand if (1) longer door-to-imaging time (DIT) results in longer DNT, (2) hospitals have different DIT performances, and (3) patient and hospital characteristics predict DIT. Prospectively collected data in the Safe Implementation of Treatments in Stroke-EAST (SITS-EAST) registry from Central/Eastern European countries between 2008 and 2011 were analyzed. Hospital characteristics were obtained by questionnaire from each center. Patient- and hospital-level predictors of DIT of 25 minutes or less were identified by the method of generalized estimating equations. Altogether 6 of 9 SITS-EAST countries participated with 4212 patients entered into the database of which 3631 (86%) had all required variables. DIT of 25 minutes or less was achieved in 2464 (68%) patients (range, 3%-93%; median, 65%; and interquartile range, 50%-80% between centers). Patients with DIT of 25 minutes or less had shorter DNT (median, 60 minutes) than patients with DIT of more than 25 minutes (median, 86 minutes; P < .001). Four variables independently predicted DIT of 25 minutes or less: longer time from stroke onset to admission (91-180 versus 0-90 minutes; odds ratio [OR], 1.6; 95% confidence interval [CI], 1.3-1.8), transport time of 5 minutes or less (OR, 2.9; 95% CI, 1.7-4.7) between the place of admission and a computed tomography (CT) scanner, no or minimal neurologic deficit before stroke (OR, 1.3; 95% CI, 1.02-1.5), and diabetes mellitus (OR, .8; 95% CI, .7-.97). DIT should be improved in patients arriving early and late. Place of admission should allow transport time to a CT scanner under 5 minutes.

Time to Brain Imaging in Acute Stroke Is Improving

Patients with acute ischemic stroke benefit from rapid evaluation and treatment, and timely brain imaging is a necessary component. We determined the effect of a targeted behavioral intervention on door-to-imaging time (DIT) among patients with ischemic stroke treated with tissue-type plasminogen activator. Second, we examined the variation in DIT accounted for by patient-level and hospital-level factors. The Increasing Stroke Treatment through Interventional behavioral Change Tactics (INSTINCT) trial was a cluster-randomized, controlled trial involving 24 Michigan hospitals. The intervention aimed to increase tissue-type plasminogen activator utilization. Detailed chart abstractions collected data for 557 patients with ischemic stroke. We used a series of hierarchical linear mixed-effects models to evaluate the effect of the intervention on DIT (difference-in-differences analysis) and used patient-level and hospital-level explanatory variables to decompose variation in DIT. DIT improved over time, without a difference between intervention and control hospitals (intervention: 23.7-19.3 minutes, control: 28.9-19.2 minutes; P=0.56). Adjusted DIT was faster in patients who arrived by ambulance (7.2 minutes; 95% confidence interval, 4.1-10.2), had severe strokes (1.0 minute per +5-point National Institutes of Health Stroke Scale; 95% confidence interval, 0.1-2.0), and presented in the postintervention period (4.9 minutes; 95% confidence interval, 2.3-7.4). After accounting for these factors, 13.8% of variation in DIT was attributable to hospital. Neither hospital stroke volume nor stroke center status was associated with DIT. Performance on DIT improved similarly in intervention and control hospitals, suggesting that nonintervention factors explain the improvement. Hospital-level factors explain a modest proportion of variation in DIT, but further research is needed to identify the hospital-level factors responsible.

Improving Time to Brain Imaging in Acute Stroke: Analysis of the Increasing Stroke Treatment through Interventional Behavioral Change Tactics (INSTINCT) Trial

Acute ischemic stroke (IS) patients benefit from rapid evaluation and treatment. Timely brain imaging is a necessary component of evaluation and focus of national guideline and quality measurement standards. This study determined the effect of a targeted behavioral intervention on door-to-imaging-time (DIT) among acute IS patients treated with tissue plasminogen activator (t-PA) and explored patient- and hospital-level predictors of DIT.