Reducing the Door-to-needle Interval, Experience from the Stroke Centre in Kladno


Authors: M. Šrámek 1,2;  T. Růžičková 2,3;  P. Kešnerová 2,3;  P. Kadlecová 4;  R. Mikulík 4,5
Authors‘ workplace: Neurologické oddělení, Nemocnice Hořovice 1;  Neurologická klinika 2. LF UK a FN v Motole, Praha 2;  Neurologické oddělení, Oblastní nemocnice Kladno, a. s. 3;  Neurologická klinika LF MU a FN u sv. Anny v Brně 4;  Mezinárodní centrum klinického výzkumu (ICRC), FN u sv. Anny v Brně v Brně 5
Published in: Cesk Slov Neurol N 2014; 77/110(6): 747-752
Category: Short Communication

R. Mikulík a P. Kadlecová jsou podporováni z Evropského fondu regionálního rozvoje – Projekt FNUSA-ICRC (No. CZ.1.05/1.1.00/02.0123).

Overview

Aim:
To analyze the effectiveness of interventions intended to reduce door-to-needle time (DNT) for patients treated with intravenous thrombolysis (IVT), considering that DNT is the only parameter we can influence to improve the efficacy of IVT.

Material and methods:
The data were collected from the Stroke Centre of the Kladno Regional Hospital over the period 07/ 2011 to 06/ 2013. Interventions intended to reduce the DNT have been implemented in 05/ 2012 and include: well-developed cooperation with the emergency medical service, improved coordination of care within the hospital, administration of IVT immediately after CT in selected patients. DNTs in the target group (patients treated after implementation of the interventions) were compared to the DNTs in a historical control group (patients treated with thrombolysis from 7/ 2011 to 4/ 2012). Multiple logistic regression analysis was used for adjusting the baseline characteristics of the patients.

Results:
The target group showed clinically crucial shortening of DNT from 65 min to 45 min (p = 0.001), a slight reduction of the median onset-to-treatment time (OTT) from 144 min to 130 min (p = 0.66) and a slight decrease in symptomatic intracranial hemorrhage (SICH) compared to the control group –  from 4.40% to 3.70% (OR 0.90, 95% CI: 0.11– 7.03). We did not detect any SICH in the group of patients who were treated even though the complete laboratory results were not known (n = 17). Patients treated during working hours had a 6.8– times higher chance of treatment initiation within 60 min compared to patients treated during “on call” hours (OR 6.78, 95% CI: 2.34– 19.64).

Conclusions:
The interventions implemented to reduce DNT were highly effective and safe. IVT administration without complete laboratory results in selected patients was safe and significantly contributed to reducing the median DNT of the entire group.

Key words:
stroke – reducing DTN – increasing efficacy of IVT

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.


Sources

1. Neumann J, Tomek A, Školoudík D, Škoda O, Mikulík R, Herzig R et al. Doporučený postup pro intravenózní trombolýzu v léčbě akutního mozkového infarktu –  verze 2014. Cesk Slov Neurol N 2014; 77/ 110(3): 381– 385.

2. Fassbender K, Balucani C, Walter S, Levine SR, Haass A, Grotta J. Streamlining of prehospital stroke management: the golden hour. Lancet Neurol 2013; 12(6): 585– 596. doi: 10.1016/ S1474-4422(13)70100-5.

3. Saver JL, Fonarow GC, Smith EE, Reeves MJ, Grau-Sepulveda MV, Pan W et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA 2013; 309(23): 2480– 2488. doi: 10.1001/ jama.2013.6959.

4. Meretoja A, Keshtkaran M, Saver JL, Tatlisumak T, Parsons MW, Kaste M et al. Stroke thrombolysis: save a minute, save a day. Stroke 2014; 45(4): 1053– 1058. doi: 10.1161/ STROKEAHA.113.002910.

5. The European Stroke Organisation (ESO). Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008; 25(5): 457– 507. doi: 10.1159/ 000131083.

6. SITS Annual Report 2012 –  Czech Republic. Available from URL: http:/ / app.emarketeer.com/ resources/ 4139/ My_Documents/ Annual_Reports_2012/ 2012_Update_CzechRepublic.pdf.

7. Mikulík R, Kadlecová P, Clonkowska A, Kobayashi A, Brozman M, Švigelj V et al. Factors influencing in-hospital delay in treatment with intravenous thrombolysis. Stroke 2012; 43(6): 1578– 1583. doi: 10.1161/ STROKEAHA.111.644120.

8. Cucchiara BL, Jackson B, Weiner M, Messe SR. Usefulness of checking platelet count before trombolysis in acute ischemic stroke. Stroke 2007; 38(5): 1639– 1640.

9. Rost NS, Masrur S, Pervez MA, Viswanathan A, Schwamm LH. Unsuspected coagulopathy rarely prevents IV thrombolysis in acute ischemic stroke. Neurology 2009; 73(23): 1957– 1962. doi: 10.1212/ WNL.0b013e3181c5b46d.

10. Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke 2013; 44(3): 870– 947. doi: 10.1161/ STR.0b013e318284056a.

11. Meretoje A, Strbian D, Mustanoja S, Tatlisumak T, Lindsberg P, Kaste M. Reducing inhospital to 20 minutes in stroke thrombolysis. Neurology 2012; 79(4): 306– 313. doi: 10.1212/ WNL.0b013e31825d6011.

12. Meretoja A, Weir J, Ugalde M, Yassi N, Yan B, Hadd P et al. Helsinki model cut stroke thrombolysis delays to 25 minutes in Melbourne in only 4 months. Neurology 2013; 81(12):1071– 1076. doi: 10.1212/ WNL.0b013e3182a4a4d2.

13. Lorenzano S, Ahmed N, Tatlisumak T, Gomis M, Dávalos A, Mikulik R et al. Within-day and weekly variations of thrombolysis in acute ischemic stroke: results from safe implementation of treatments in stroke-international stroke thrombolysis register. Stroke 2014; 45(1):176– 184. doi: 10.1161/ STROKEAHA.113.002133.

14. Fonarow G, Zhao X, Smith E, Saver J, Reeves M, Bhath D et al. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA 2014; 311(16): 1632– 1640. doi: 10.1001/ jama.2014.3203.

Labels
Paediatric neurology Neurosurgery Neurology

Article was published in

Czech and Slovak Neurology and Neurosurgery

Issue 6

2014 Issue 6

Most read in this issue

This topic is also in:


Login
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account