Diurnal Variation of Intravenous Thrombolysis Rates for Acute Ischemic Stroke and Associated Quality Performance Parameters

Abstract

IntroductionBased on data from the Baden-Wuerttemberg stroke registry, we aimed to explore the diurnal variation of acute ischemic stroke (IS) care delivery.Materials and methods92,530 IS patients were included, of whom 37,471 (40%) presented within an onset-to-door time ≤4.5 h. Daytime was stratified in 3-h time intervals and working vs. non-working hours. Stroke onset and hospital admission time, rate of door-to-neurological examination time ≤30 min, onset-/door-to-imaging time IV thrombolysis (IVT) rates, and onset-/door-to-needle time were determined. Multivariable regression models were used stratified by stroke onset and hospital admission time to assess the relationship between IVT rates, quality performance parameters, and daytime. The time interval 0:00 h to 3:00 h and working hours, respectively, were taken as reference.ResultsThe IVT rate of the whole study population was strongly associated with the sleep–wake cycle. In patients presenting within the 4.5-h time window and potentially eligible for IVT stratification by hospital admission time identified two time intervals with lower IVT rates. First, between 3:01 h and 6:00 h (IVT rate 18%) and likely attributed to in-hospital delays with the lowest diurnal rate of door-to-neurological examination time ≤30 min and the longest door-to-needle time Second, between 6:01 h and 15:00 h (IVT rate 23–25%) compared to the late afternoon and evening hours (IVT rate 27–29%) due to a longer onset-to-imaging time and door-to-imaging time. No evidence for a compromised stroke service during non-working hours was observed.ConclusionThe analysis provides evidence that acute IS care is subject to diurnal variation which may affect stroke outcome. An optimization of IS care aiming at constantly high IVT rates over the course of the day therefore appears desirable.

Effect of admission time on provision of acute stroke treatment at stroke units and stroke centers—An analysis of the Swiss Stroke Registry

“…12 In line, Reuter et al found the longest DNT time and the lowest IVT rate between 03:01 and 06:00 am. 9 Furthermore, Kristiansen et al found in-hospital performance measures to be worse in patients admitted during NH. 20 Other studies, however, showed no association of DNT with time of hospital arrival 11 and no deterioration of acute reperfusion therapy rates in candidates for thrombolytic therapy.…”

Only a Minority of Thrombectomy Candidates Are Admitted During Night Shift: A Rationale for Diurnal Stroke Care Planning

“…This ongoing evolution of acute stroke recanalization strategies will make new concepts of pre-and in-hospital care delivery necessary (21)(22)(23). It seems reasonable to consider the diurnal variation of the stroke for future implementation strategies of MT (7,13).…”

“…Stroke admission rates have a strong morning peak, which was observed regardless of stroke severity ( Figure 1 , Supplementary Table 1 ) ( 7 ). Absolute admission numbers were highest between 09:01 and 12:00 and lowest between 03:01 and 06:00 for all subgroups.…”

“…Diurnal emergency calls and hospital admission rates for cerebrovascular and cardiovascular disease follow a distinct pattern with a strong morning peak and generally higher rates during daytime compared to nighttime hours ( 7 , 13 – 15 ). In our analysis of 91,864 patients with AIS, the average annual admission rate for patients with severe AIS ranged from N = 8 at hospitals without a SU to N = 178 at stroke centers.…”

“…As admission time of patients with AIS is not uniformly distributed throughout the day, e.g., admission rates are lower during nighttime, 24 h/7 d coverage by every provider of MT may not be optimal for both the individual hospital and healthcare system. In this study, we investigated the potential loss in coverage of MT for eligible patients if this therapy was not provided 24 h/7 d ( 7 ).…”