Door-to-Needle Time in Acute Stroke Treatment and the “July Effect”

Abstract

Intravenous thrombolysis improves outcomes in acute ischemic stroke in a time-dependent fashion. As in teaching hospitals, clinical outcomes may worsen due to the arrival of new inexperienced house staff early in the academic year (July effect, JE), we evaluated the impact of the "JE" on the door-to-needle time for intravenous thrombolysis and other stroke outcomes. In this retrospective cohort study, we assessed all acute ischemic strokes treated with intravenous thrombolysis between July 2003 and June 2016. Among 101 patients, there was no detrimental July effect on the door-to-needle time, rate of thrombolysis within 60 minutes of arrival, thrombolysis of stroke mimics, post-thrombolysis intracranial hemorrhages, National Institutes of Health Stroke Scale, and modified Rankin Scale outcomes.

Thrombolysis and Mechanical Thrombectomy as Leading Treatments for Acute Ischemic Stroke

“…A quick diagnosis, adequate logistics and rapid response of the stroke team are key determinants of this variable. Due to the demonstrated improvement in clinical results, current guidelines recommend performing at least 80% of rt-Pa treatments within 60 minutes of DTN [13]. DNT provides valuable insight into the course of work in treating stroke and is an indicator of the efficiency of the stroke department.…”

The “July effect”: Outcomes in microvascular reconstruction during resident transitions

“…4,5 Other fields that have begun to investigate the possibility of a July effect include gastroenterology, transplant surgery, neurosurgery, cardiothoracic surgery, gynecology, and neurology. [6][7][8][9][10][11] Specifically, within the field of otolaryngology, in patients undergoing head and neck oncologic ablative surgery there was no significant increase in mortality, surgical, or medical complications secondary to the July effect. 12 Similarly, for patients undergoing pituitary skull base surgery, there was no difference in postoperative complications between July and non-July months.…”

“…For example, within orthopedic hip fractures, Anderson et al observed a 12% greater relative risk of mortality during July/August, whereas Englesbe et al observed no changes in mortality during resident changeover . Other fields that have begun to investigate the possibility of a July effect include gastroenterology, transplant surgery, neurosurgery, cardiothoracic surgery, gynecology, and neurology …”

The Rookie Goes to Bat: Is there a “July Effect” on Stroke Treatment at Teaching Hospitals?

“…Hence, we read with interest the article “Door-to-needle time in acute stroke treatment and the ‘July Effect’” by Dr Hawkes and colleagues from Argentina in this month’s Neurohospitalist . 2 In a span of over 13 years, they retrospectively studied 101 acute ischemic stroke cases, divided into 3-month intervals, to assess differences between DTNT, thrombolytic-related intracranial hemorrhage, and 3-month outcomes using modified Rankin Scale and National Institute of Health Stroke Scale.…”

“…This may lead to longer DTNT in July than in other months. Authors cite a 5% reduction in in-hospital mortality for every 15-minute reduction in DTNT 2 but utilized a 1-hour cutoff; perhaps significance would have been achieved with ordinal minutes instead. Worse than DTNT delays, however, would be a missed stroke, untreated with thrombolytic that should have been (ie, due to misread neuroimaging, inaccurately timed onset, misunderstood symptoms, or alternate diagnosis, and so forth).…”