Impact of emergency department arrival time on door-to-needle time in patients with acute stroke

Abstract

BackgroundThis study aimed to identify which emergency department (ED) factors impact door-to-needle (DTN) time in acute stroke patients eligible for intravenous thrombolysis. The purpose of analyzing emergency department factors is to determine whether any modifiable factors could shorten the time to thrombolytics, thereby increasing the odds of improved clinical outcomes.MethodsThis was a prospective observational quality registry study that included all patients that received alteplase for stroke. These data are our hospital data from the national Get With The Guidelines Registry. The Get With The Guidelines® Stroke Registry is a hospital-based program focused on improving care for patients diagnosed with a stroke. The program has over five million patients, and hospitals can access their own program data. The registry promotes the use of and adherence to scientific treatment guidelines to improve patient outcomes. The time of patient arrival to the ED was captured via the timestamp in the electronic health record. Arriving between Friday 6 p.m. and Monday 6 a.m. was classified as “weekend,” regardless of the time of arrival. Time to CT, time-to-lab, and presence of a dedicated stroke team were also recorded. Emergency medical services (EMS) run sheets were used to verify arrival via ambulance.ResultsForty-nine percent of the cohort presented during the day shift, 24% during the night shift, and 27% on the weekend. A total of 85% were brought by EMS, and 15% of patients were walk-ins. The median DTN time during the day shift was 37 min (IQR 26–51, range 10–117). The median DTN time during the night shift was 59 min (IQR 39–89, range 34–195). When a dedicated stroke team was present, the median DTN time was 36 min, compared to 51 min when they were not present. The median door-to-CT time was 24 min (IQR 18–31 min). On univariate analyses, arriving during the night shift (P < 0.0001), arriving as a walk-in (P = 0.0080), and longer time-to-CT (P < 0.0001) were all associated with longer DTN time. Conversely, the presence of a dedicated stroke team was associated with a significantly shorter DTN time (P < 0.0001).ConclusionFactors that contribute most to a delay in DTN time include arrival during the night shift, lack of a dedicated stroke team, longer time-to-CT read, and arrival as a walk-in. All of these are addressable factors from an operational standpoint and should be considered when performing quality improvement of hospital protocols.

Emergency Department Time Targets for Interhospital Transfer of Patients with Acute Ischemic Stroke

“…Among the factors associated with not receiving rt-PA in our study, no statistically significant correlation was found between the two groups regarding the arrival mode type at the ED (p = 0.958), or the presence of risk factors for stroke. Referring to the data from the literature, there are different proportions of the arrival mode type or risk factors between groups, such as arriving during the night shift (p < 0.0001) and not arriving with the emergency medical system (p = 0.0080) [21], and about 18.1% reported arriving at the ED by ambulance, while the majority arrived by private car [22]; considering the fact that the proportion of risk factors and arrival mode are statistically insignificant between our study groups, we find these to be strengths in this study, because we can better analyze the impact of ED time targets on the received or absence of rt-PA treatments in patients with AIS.…”

Code Stroke Alert: Focus on Emergency Department Time Targets and Impact on Door-to-Needle Time across Day and Night Shifts

“…Univariate analyses revealed that arriving during the night shift ( p < 0.0001), arriving as a walk-in ( p = 0.0080), and experiencing a longer time to CT scan ( p < 0.0001) were all associated with a longer DTN time. Conversely, the presence of a dedicated stroke team was associated with a significantly shorter DTN time ( p < 0.0001) [ 15 ].…”