Differences in Process Management and In-Hospital Delays in Treatment with iv Thrombolysis

Abstract

ObjectivesRapid initiation of intravenous thrombolysis improves patient’s outcome in acute stroke. We analyzed inter-center variability and factors that influence the door-to-needle time with a special focus on process measurements in all Austrian stroke units.MethodsCase level data of patients receiving intravenous thrombolysis in the Austrian Stroke Unit Registry were enriched with information of a structured questionnaire on center specific process measures of all Austrian stroke units. Influence of case and center specific variables was determined by LASSO procedure.ResultsCenter specific median door-to-needle time ranged between 30 and 78 minutes. Between April 2004 and November 2012, 6246 of 57991 patients treated in Austrian stroke units with acute ischemic stroke received intravenous thrombolysis. An onset-to-door time >120 minutes, patients with total anterior circulation stroke, recent year of admission, patient transportation with ambulance crew and emergency physician, the use of point of care tests reduced the door-to-needle time, whereas onset-to-door ≤60 minutes, unknown onset-to-door, patients with an NIHSS ≤4 or posterior circulation stroke, initial admission to a general emergency department, a distant radiology department, primary imaging modality other than plain CT and waiting for the lab results were associated with an increase in door-to-needle time. Case level and center specific factors could explain the inter center variability of door-to-needle times in 31 of 34 stroke units in Austria.ConclusionsIn light of our results it seems crucial that every single stroke center documents and critically reviews possibilities of optimizing practice strategies in acute stroke care.

Variations in Acute Hospital Stroke Care and Factors Influencing Adherence to Quality Indicators in 6 European Audits

“…Similar to our data, previous studies have shown that older patients receive less often anticoagulation if they experience atrial fibrillation 5,6 and more often a swallow screening. 7 This might be because of the fact that older age is associated with more severe strokes being associated with higher risk of complications.…”

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

“…Arrival by emergency medical services was associated with improved DAT and DIT, 7,8 and patient factors such as blood pressure, blood glucose, National Institutes of Health Stroke Scale score of >2, intubation/high oxygen requirement, and sex were found to be significant factors that predicted activation and imaging times. [8][9][10] Interestingly, time cycle factors were significant in our study, contrasting previous research showing no association between DIT and time of day or day of week. 19 The underlying mechanism is not clear, but time may be a surrogate for ED crowding, given the cyclic nature of ED patient arrivals and patient volumes.…”

“…5,6 Mode of patient arrival (emergency medical services versus private vehicle) is another care process known to affect DIT. 7,8 In addition, patient-specific factors, including sex, symptom severity, symptom duration, history of diabetes mellitus, and initial blood pressure, also are reported to affect DIT. [8][9][10] Although research related to DIT in stroke is extensive, it has focused primarily on process-specific and patient-specific factors.…”

“…7,8 In addition, patient-specific factors, including sex, symptom severity, symptom duration, history of diabetes mellitus, and initial blood pressure, also are reported to affect DIT. [8][9][10] Although research related to DIT in stroke is extensive, it has focused primarily on process-specific and patient-specific factors. There has been little focus on how operational environments of care-more specifically, ED crowding-may affect the management of acute stroke patients.…”

Imaging Modalities in Acute Ischemic Stroke

“…Due to its widespread immediate availability, CT remains the most common and the first line imaging modality used in acute ischemic stroke (18). It is used to rule out hemorrhagic strokes (e.g., intracerebral hemorrhage (ICH)).…”