Door-to-Needle Times for Tissue Plasminogen Activator Administration
and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative
Gregg C. Fonarow, MD; Xin Zhao, MS; Eric E. Smith, MD, MPH; Jeffrey L. Saver, MD; Mathew J. Reeves, PhD; Deepak L. Bhatt, MD, MPH; Ying Xian, MD, PhD; Adrian F. Hernandez, MD, MHS; Eric D. Peterson, MD, MPH; Lee H. Schwamm, MD
- The clot-busting drug tPA (Intravenous tissue plasminogen activator) reduces long-term disability and complications if it is administered early to patients who suffer from ischemic stroke. Prior studies indicated less than one-third of stroke patients were treated within the guideline-recommended door-to-needle time of 60 minutes or less.
- Target: Stroke™ was launched in 2010 to reduce this shortfall, with the goal of participating hospitals to administer tPA to at least 50% of their patients with acute ischemic stroke within 60 minutes of hospital arrival. All Get With The Guidelines®-participating hospitals were encouraged to participate and given a detailed toolkit, including 10 key strategies, protocols and other tools to reduce door-to-needle times. The AHA/ASA Get With The Guidelines quality improvement field staff also provided expert assistance to hospitals in their efforts to make improvements in door-to-needle times. A network of stroke champions in every state was used to motivate and facilitate changes at the hospital and clinician level.
- The study included 71,169 stroke patients treated with tPA from 1,030 Get With The Guidelines hospitals.
- The percentage of patients with door-to-needle times of 60 minutes or less increased from 29.6 percent prior to Target: Stroke to 53.3 percent in 2013.
- Before Target: Stroke, the median (midpoint) door-to-needle times was 74 minutes and dropped to 59 minutes by 2013 – a 15 minute reduction.
- Other improvements included in-hospital deaths (9.9 percent to 8.3 percent); discharge to home (38 percent to 43 percent); independence with walking (42 percent to 45 percent); and symptomatic intracranial hemorrhage (bleeding in the brain) within 36 hours (5.7 percent to 4.7 percent).
- The reduction in time-to-treatment was also accompanied by lower in-hospital mortality, lower rates of intracranial brain hemorrhage (bleeding in the brain), and fewer complications.
Hospital participation in a national quality initiative was associated with improvement in the timeliness of tPA administration. This improvement was associated with lower in-hospital mortality, symptomatic intracranial hemorrhage and overall tPA complications with an increase in the percentage of patients able to be discharged to home.
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