Improving Door-to-Needle Times in Acute Ischemic Stroke: Principal Results

Updated:Feb 20,2014
Improving Door-to-Needle Times in Acute Ischemic Stroke: Principal Results from the Target: Stroke Initiative [epub 2/14/2014 STROKE]
Authors: Gregg C Fonarow, UCLA Medical Ctr, Los Angeles, CA; Xin Zhao, Duke Clinical Res Inst, Durham, NC; Eric E. Smith, Univ of Calgary, Calgary, AB, Canada; Jeffrey L. Saver, UCLA Neurology, Los Angeles, CA; Mathew J. Reeves, Michigan State Univ, East Lansing, MI; Deepak L. Bhatt, Brigham and Women's Hosp, Boston, MA; Ying Xian, Adrian Hernandez, Eric D. Peterson, Duke Clinical Res Inst, Durham, NC; Lee H. Schwamm, Massachusetts General Hospital, Boston, MA

Summary:
  • Stroke treatment times improved substantially in hospitals using The American Heart Association/American Stroke Association’s quality improvement initiative -- Target: Stroke.
  • Between 2010 and 2013, the time between hospital arrival and use of clot-busters dropped by 15 minutes in hospitals that follow the Target: Stroke guidelines.
  • Faster treatment was associated with significantly fewer complications, including death.
  • These findings reinforce the importance and clinical benefits of faster administration of intravenous tPA for ischemic stroke.
Key Points:
  • The percentage of patients treated within the recommended timeframe increased from less than one-third before Target: Stroke to more than half afterwards. The Target: Stroke program goal of 50 percent or more of patients having door-to-needle times within 60 minutes was successfully achieved. In addition, the average time to treatment dropped by 15 minutes, from 74 to 59 minutes.
  • Faster treatment was associated with lower rates of complications, including death. Before Target: Stroke, almost 10 percent of stroke patients died in the hospital, compared to about 8 percent of patients treated after the initiative started. In addition, patients treated by Target: Stroke strategies were less likely to develop the complication of bleeding within the skull.
  • Investigators analyzed data from 71,169 tPA-treated stroke patients at 1,029 hospitals participating in Target: Stroke. They compared the time to treatment and incidence of complications before implementation, from 2003 to 2009, to the post-implementation years, from 2010 to 2013. 
  • Patients’ average age was 72 years, and 50 percent were female. Almost three-quarters of patients were white, 14 percent were black and 6 percent were Hispanic. Follow-up was three years. 
  • The improvement in treatment times was seen in older and younger patients; men and women; and white, black and Hispanic patients.
Conclusion:
The timeliness of tPA administration improved substantially in Get With The Guidelines-Stroke hospitals after initiation of the Target: Stroke initiative. This improvement was accompanied by lower in-hospital mortality and lower tPA complications. This study has the potential to greatly impact future stroke care and treatment. Previous studies have shown that a small percentage of eligible stroke patients receive the recommended tPA at hospital arrival within the recommended timeframe. Most Americans have access to acute stroke care, but treatment rates remain low. This study shows that substantial improvement in those rates can be achieved.

Other Resources:
Target: Stroke Time Lost Is Brain Lost.
Focus on Quality The more healthcare quality improves, the more patient outcomes do too.