Onset-to-door Time Research Articles

Effects of emergency medical service on prognosis of ischemic stroke patients treated with intravenous thrombolysis

To investigate the effect of emergency medical service (EMS) on the prognosis of ischemic stroke patients treated with intravenous thrombolysis. Clinical data of 2123 ischemic stroke patients treated with intravenous thrombolysis in 70 hospitals in Zhejiang province were retrospectively analyzed. There were 808 patients sent to the hospital by ambulance (EMS group) and 1315 patients by other transportations (non-EMS group). Good outcome was defined as modified Rankin Scale (mRS) ≤ 2 at 3-month. The onset to needle time (ONT), onset to door time (ODT), door to needle time (DNT) and outcome were compared between EMS group and non-EMS group. Binary logistic regression was used to explore the influencing factors for the outcome at 3-month. Compared with the non-EMS group, patients in the EMS group were older, with higher baseline National Institute of Health Sroke Scale (NIHSS) score, and had a higher proportion of atrial fibrillation (all P<0.05), but there were no significant differences in ONT, ODT and DNT between two groups (all P>0.05). Binary logistic regression showed that EMS was not independently associated with good outcome (OR=0.856, 95%CI:0.664-1.103, P>0.05). EMS had not improve the outcome of patients receiving intravenous thrombolysis in Zhejiang province.

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.

In Hyperacute Recanalization Therapy, Early Hospital Arrival Improves Outcome in Patients with Large Artery Occlusion

Background: It is unknown whether the effect of onset-­­to-door (OTD) time on clinical outcomes differs between ­patients with and without large artery occlusion (LAO) who undergo hyperacute recanalization therapy. Methods: Hyperacute recanalization therapy includes intravenous thrombolysis tissue-plasminogen activator (tPA), and endovascular therapy (EVT). Favorable clinical outcome was defined as modified Rankin Scale of ≤2 at discharge. Results: Among 164 patients, 117 (71%) patients received tPA, 86 (52%) received EVT, and 39 (24%) received tPA and EVT. One hundred and fifteen patients (70%) were classified into the LAO group and 49 (30%) into the non-LAO group. In the total cohort, multivariate regression analysis showed OTD time (OR 0.809 [95% CI 0.693–0.944], p = 0.007) was an independent factor related to the favorable outcome. Similarly, among patients with LAO, OTD was an independent negative factor for the favorable outcome (0.779 [0.646–0.940], p = 0.009). On the contrary, OTD was not associated with the favorable outcome (1.5 [0.7–2.5] vs. 1.7 [1.1–3.2], p = 0.155) in patients without LAO. This was confirmed with multivariate regression analysis, which did not show OTD to be an independent factor for the favorable outcome (0.900 [0.656–1.236], p = 0.516). Conclusion: The effect of early hospital arrival on clinical outcome differed between patients with and without LAO.

Abstract TP32: Predictors of Endovascular Treatment Among Stroke Codes Activated Within 6 Hours From Symptom Onset

Introduction: Prehospital stroke code activations help reducing wokflow times during in-hospital triage. We aim to identify predictors of endovascular treatment among activated stroke codes (ASC) within 6 hours from symptom onset. Methods: CICAT is a prospective official mandatory registry of all ASC in Catalunya. We studied all CICAT entries from 5 comprehensive stroke centers during 18 months. We recorded demographic, historic, clinical and imaging variables on admission. We explored the relationship between these variables and endovascular treatment (EVT) Results: From 3944 ASC, 2818 (71.5%) were admitted &lt; 6 hours from symptom onset. Mean age was 72±15.3 years, median RACE scale 4 (IQR 2-6), median onset-to-door time (OTDT) was 87 minutes (IQR 54-158), median NIHSS score 9 (IQR 4-18), median ASPECTS 10 (IQR 8-10. Final diagnosis was ischemic stroke in 1767 patients (62.7%), hemorrhagic stroke in 364 (12.9%), TIA in 167 (5.9%), stroke-mimic in 500 (17.7%). After admision a large vessel occlusion (LVO) was confirmed in 916 (23.2%) patients. While the rate of ASPECTS ≥ 9 among ischemic strokes progressively decreased over time (0-3h: 73.2% vs 3-6h: 57.1%: p&lt;0.01), the rate of ASPECTS ≥6 (0-3h: 95.1% vs 3-6h: 91.6%: p=0.13) and presence of LVO (0-3h: 22.4% vs 3-6h: 22.8%: p=0.82) did not decrease over time. Of all ACS, 16% (n=453) received EVT, with a median door to groin time of 77 minutes (IQR 55-102). Baseline variables independently associated with EVT were premorbid mRS&gt;2 (p&lt;0.001), prehospital RACE score &gt;4 (p=0.003) and NIHSSon admission &gt;8 (p&lt;0.001). The chances to receive EVT were similar in patients admitted 0-3 (16.4%) Vs. 3-6 hours (14.6; p=0.3). ASC with a RACE score&gt;4 had 26.0% probability to receive EVT Conclusion: Among ACS within 6 hours from symptom onset, time from onset to arrival is not associated with the probability of receiving EVT. Only 5% of these patients show an ASPECTS &lt;6 and this rate does not significantly increase during the first 6 hours. These data may be useful to generate direct transfer to angio-suite protocols.

Prehospital Notification Procedure Improves Stroke Outcome by Shortening Onset to Needle Time in Chinese Urban Area.

Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) can improve clinical outcome in eligible patients with acute ischemic stroke (AIS). However, its efficacy is strongly time-dependent. This study was aimed to examine whether prehospital notification by emergency medical service (EMS) providers could reduce onset to needle time (ONT) and improve neurological outcome in AIS patients who received IVT. We prospectively collected the consecutive clinical and time data of AIS patients who received IVT during one year after the initiation of prehospital notification procedure (PNP). Patients were divided into three groups, including patients that transferred by EMS with and without PNP and other means of transportation (non-EMS). We then compared the effect of EMS with PNP and EMS use only on ONT, and the subsequent neurological outcome. Good outcome was defined as modified Rankin Scale score of 0-2 at 3-months. In 182 patients included in this study, 77 (42.3%) patients were transferred by EMS, of whom 41 (53.2%) patients entered PNP. Compared with non-EMS group, EMS without PNP group greatly shortened the onset to door time (ODT), but EMS with PNP group showed both a significantly shorter DNT (41.3 ± 10.7 min vs 51.9±23.8 min, t=2.583, p=0.012) and ODT (133.2 ± 90.2 min vs 174.8 ± 105.1 min, t=2.228, p=0.027) than non-EMS group. Multivariate analysis showed that the use of EMS with PNP (OR=2.613, p=0.036), but not EMS (OR=1.865, p=0.103), was independently associated with good outcome after adjusting for age and baseline NIHSS score. When adding ONT into the regression model, ONT (OR=0.994, p=0.001), but not EMS with PNP (OR=1.785, p=0.236), was independently associated with good outcome. EMS with PNP, rather than EMS only, improved stroke outcome by shortening ONT. PNP could be a feasible strategy for better stroke care in Chinese urban area.

Differences in Clinical Characteristics between Patients with Transient Ischemic Attack Whose Symptoms Do and Do Not Persist on Arrival

Symptoms of transient ischemic attack (TIA) persist on arrival and subsequently resolve in some patients admitted to hospitals early after onset. Differences in clinical characteristics between patients with acute TIA whose symptoms do and do not persist on arrival remain unclear. We retrospectively extracted data of consecutive TIA patients with an onset-to-door time (ODT) of 24 hours or less and without a history of stroke from a multicenter TIA database. Clinical characteristics were compared between patients with and without persisting symptoms on arrival. Two hundred sixty-six patients (158 men, 68.0 ± 12.9 years) were included. Of the total number of patients, 105 (39.5%) had persisting symptoms with a mean National Institutes of Health Stroke Scale score of 2.4 (median, 1.0). Patients with persisting symptoms were more likely to have sensory disorder, ambulance-transported admission, long-duration TIA (≥60 minutes), and shorter ODT than those without. Multivariate analysis showed that sensory disorder (odds ratio [OR] 2.52, 95% confidence interval [CI] 1.35-4.77), ambulance-transported admission (OR 1.80, 95% CI 1.00-3.28), and long-duration TIA (OR 3.96, 95% CI 2.12-7.71) were positively associated and that an ODT of more than 12 hours (OR .18, 95% CI .04-.63) was inversely associated with the presence ofpersisting symptoms. Patients with persisting symptoms were more likely to be examined by a stroke physician at first (69% versus 57%, P = .049) and then hospitalized in a stroke unit (59% versus 43%, P = .010). Clinical manifestations and management after admission might differ between patients with acute TIA whose symptoms do and do not persist on arrival.

Impact of transport pathways on the time from symptom onset of ST-segment elevation myocardial infarction to door of coronary intervention facility

BackgroundReducing total ischemic time is important in achieving better outcome in ST-segment elevation myocardial infarction (STEMI). Although the onset-to-door (OTD) time accounts for a large portion of the total ischemic time, factors affecting prolongation of the OTD time are not established. PurposeThe purpose of this study was to determine the impact of transport pathways on OTD time in patients with STEMI. Methods and subjectsWe retrospectively studied 416 STEMI patients who were divided into 4 groups according to their transport pathways; Group 1 (n=41): self-transportation to percutaneous coronary intervention (PCI) facility; Group 2 (n=215): emergency medical service (EMS) transportation to PCI facility; Group 3 (n=103): self-transportation to non-PCI facility; and Group 4 (n=57): EMS transportation to non-PCI facility. OTD time was compared among the 4 groups. Essential resultsMedian OTD time for all groups combined was 113 (63–228.8)min [Group 1, 145 (70–256.5); Group 2, 71 (49–108); Group 3, 260 (142–433); and Group 4, 184 (130–256)min]. OTD time for EMS users (Groups 2 and 4) was 138min shorter than non-EMS users (Groups 1 and 3). Inter-hospital transportation (Groups 3 and 4) prolonged OTD by a median of 132min compared with direct transportation to PCI facility (Groups 1 and 2). Older age, history of myocardial infarction, prior PCI, shock at onset, high Killip classification, and high GRACE Risk Score were significantly more frequent in EMS users. Principal conclusionsSelf-transportation without EMS and inter-hospital transportation were significant factors causing prolongation of the OTD time. Approximately 35% of STEMI patients did not use EMS and 21% of patients were transported to non-PCI facilities even though they called EMS. Awareness in the community as well as among medical professionals to reduce total ischemic time of STEMI is necessary; this involves educating the general public and EMS crews.

Relationship Between Onset-to-Door Time and Door-to-Thrombolysis Time

Inverse relationship between onset-to-door time (ODT) and door-to-needle time (DNT) in stroke thrombolysis was reported from various registries. We analyzed this relationship and other determinants of DNT in dedicated stroke centers. Prospectively collected data of consecutive ischemic stroke patients from 10 centers who received IV thrombolysis within 4.5 hours from symptom onset were merged (n=7106). DNT was analyzed as a function of demographic and prehospital variables using regression analyses, and change over time was considered. In 6348 eligible patients with known treatment delays, median DNT was 42 minutes and kept decreasing steeply every year (P<0.001). Median DNT of 55 minutes was observed in patients with ODT ≤30 minutes, whereas it declined for patients presenting within the last 30 minutes of the 3-hour time window (median, 33 minutes) and of the 4.5-hour time window (20 minutes). For ODT within the first 30 minutes of the extended time window (181-210 minutes), DNT increased to 42 minutes. DNT was stable for ODT for 30 to 150 minutes (40-45 minutes). We found a weak inverse overall correlation between ODT and DNT (R(2)=-0.12; P<0.001), but it was strong in patients treated between 3 and 4.5 hours (R(2)=-0.75; P<0.001). ODT was independently inversely associated with DNT (P<0.001) in regression analysis. Octogenarians and women tended to have longer DNT. DNT was decreasing steeply over the last years in dedicated stroke centers; however, significant oscillations of in-hospital treatment delays occurred at both ends of the time window. This suggests that further improvements can be achieved, particularly in the elderly.

Impact of first contact on symptom onset–to-door time in patients presenting for primary percutaneous coronary intervention

ObjectivesTo determine effect of first medical contact type on symptom onset–to-door time (SODT). BackgroundShorter total ischemic time is associated with improved outcomes in ST-elevation myocardial infarction. MethodsFrom 2005 to 2009, we reviewed records of all consecutive patients treated with primary percutaneous coronary intervention for ST-elevation myocardial infarction at our tertiary care teaching hospital (median follow-up 3.85 years). We compared SODT in patients whose first medical contact was a private physician (in person or via telephone) vs patients who presented to the emergency department (ED) directly (in person or via Emergency Medical Services). ResultsOf 366 patients, 84 (23%) contacted a physician (group A) while 282 (77.6%) did not (group B). Group A had higher median SODT (239.5 vs 130 minutes, P = .0043) and significantly higher mortality (log rank P = .0392, Cox Proportional Hazard Model risk factors: physician contact first [P < .013], age [P < .0001] and peripheral vascular disease [P < .035]). Two factors associated with prolonged SODT: (1) contacting a physician first P = .002 and (2) personal mode of transportation, P = .002. Patients presenting during “on-hours” (weekdays) were more likely to first contact a physician compared with those presenting during “off-hours” (weeknights and weekends) (66.67% in group A vs 45.04% in group B, P < .001). ConclusionsPatients whose first medical contact was a physician had greater pre-hospital delays and worse survival compared to those who sought emergent medical care directly. This pattern occurred more often during “on-hours.” Educational efforts aimed at both patient and physician office practices are warranted.

Effect of Onset-to-Door Time and Door-to-Balloon Time on Mortality in Patients Undergoing Percutaneous Coronary Interventions for ST-Segment Elevation Myocardial Infarction

It is important to identify the factors related to survival of patients undergoing primary percutaneous coronary intervention for ST-segment elevation acute myocardial infarction. Our objective was to determine the interactive effect of the door-to-balloon (DTB) time and onset-to-door (OTD) time on longer term mortality for patients with ST-segment elevation acute myocardial infarction. The present study was a retrospective cohort analysis of the effect of the DTB time and OTD time on longer term (median follow-up 413 days) mortality for patients undergoing primary percutaneous coronary intervention in New York from January 1, 2004 to December 31, 2006, adjusting for the effect of other important risk factors. The patients with ST-segment elevation acute myocardial infarction with a DTB time of <90 minutes and OTD time of <4 hours had the lowest longer term mortality (3.51%). Patients with a DTB time <90 minutes and OTD time of >or =4 hours had significantly greater mortality than patients with an OTD time of <4 hours and DTB time of <90 minutes (adjusted hazard ratio 1.54, 95% confidence interval 1.04 to 2.30), as did patients with a DTB time of > or =90 minutes and OTD time of > or =4 hours (adjusted hazard ratio 1.48, 95% confidence interval 1.05 to 2.09). For an OTD time of <4 hours and DTB time of > or =90 minutes, mortality showed a trend toward being greater compared to shorter OTD and DTB times (adjusted hazard ratio 1.29, 95% confidence interval 0.95 to 1.77). In conclusion, the combination of short (<90 minutes) DTB time and short (<4 hours) OTD time was associated with the lowest longer term mortality rate.

Patient Education to Reduce Prehospital Delay Time in Acute Coronary Syndrome

Reducing time from symptom onset to reperfusion therapy decreases infarct size and improves survival in patients with ST-elevation myocardial infarction (STEMI). National quality improvement initiatives, including the Door-to-Balloon (D2B) Quality Alliance, have successfully disseminated evidence-based strategies to reduce door-to-balloon time.1,2 Many hospital systems have achieved the targeted door-to-balloon time <90 minutes for 75% of patients with STEMI presenting directly to a hospital with percutaneous coronary intervention capability.3 However, prehospital delay from time of symptom onset to hospital arrival remains the largest portion of the total delay time and has been refractory to interventions aimed at improving patient responsiveness. Article see p 524 For patients with STEMI, longer prehospital delay is associated with higher in-hospital mortality even after adjusting for patient-, hospital-, and system-level variables including door-to-balloon or door-to-needle time.4,5 In the past 15 years, 2 randomized controlled trials have tested whether educational interventions to improve patient knowledge about acute coronary syndrome (ACS) symptoms and to promote patient action to call 9-1-1 would reduce prehospital delay time. Luepker and colleagues randomized 20 US cities to serve as controls or to receive 18 months of education targeting mass media, community and professional organizations, and patients and clinicians in the Rapid Early Action for Coronary Treatment (REACT) trial.6 The median prehospital delay time was 2.3 hours at baseline and decreased slightly (4.7% per year) during the 18 months in the intervention group; however, this trend was not significantly different to that observed in the control group ( P =0.54). The use of emergency medical services (EMS) increased modestly in the …