Highlights
- •We implemented the strategic changes including the Helsinki thrombolysis model.
- •Phased strategic changes could reduce delay of tPA thrombolysis to 15 min.
- •Mild symptoms and anticoagulation were independent predictors for delay.
- •Simplification of brain imaging was a key strategy.
Abstract
Objectives
The present study aimed to determine whether phased changes in strategies including
the Helsinki model affect the delay of intravenous thrombolysis (IVT) using tissue
plasminogen activator (tPA) to treat acute ischemic stroke.
Method
We retrospectively studied 516 consecutive patients treated with IVT in our department
between October 2005 and December 2018. We implemented a system of hospital pre-notification
in 2005, when IVT was initially implemented at our center. We then improved the IVT
strategy by simplifying brain imaging (July 2011), premixing tPA (April 2014), locating
a blood cell counter in the emergency room (June 2015), manually administering a tPA
bolus before preparing a continuous infusion (January 2016), awarding a prize to members
of the acute stroke team (November 2016), and completing registration before arrival
and sending patients directly to computed tomography (February 2017). We analyzed
the effects of these strategic changes on annual median door-to-needle times (DTN).
Results
The DTN was annually reduced, from a median of 90 [interquartile range, 55–98] minutes
in 2006 to 15 [12–24.25] minutes in 2017. By 2017, 94% of patients were treated within
60 min of arrival. Multivariate logistic regression analysis revealed that initial
NIHSS score ≤ 4 (OR 2.67, 95% CI 1.3–5.7) and anticoagulation before onset (OR 6.00,
95% CI 2.47–14.58) were independently associated with 20 min or more of DTN in 186
patients treated from 2016 to 2018.
Conclusions
Phased strategic change to reduce the delay in delivering IVT reduced median DTN to
15 min at a single Japanese stroke center.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of the Neurological SciencesAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials.Lancet. 2014; 384: 1929-1935
- Reducing in-hospital delay to 20 minutes in stroke thrombolysis.Neurology. 2012; 79: 306-313
- Helsinki model cut stroke thrombolysis delays to 25 minutes in Melbourne in only 4 months.Neurology. 2013; 81: 1071-1076
- Improved reliability of the NIH Stroke Scale using video training. NINDS TPA Stroke Study Group.Stroke. 1994; 25: 2220-2226
- Guidelines for the intravenous application of recombinant tissue-type plasminogen activator (alteplase), the second edition, October 2012: a guideline from the Japan Stroke Society.J. Stroke Cerebrovasc. Dis. 2013; 22: 571-600
- Point-of-care laboratory halves door-to-therapy-decision time in acute stroke.Ann. Neurol. 2011; 69: 581-586
- Feasibility of using magnetic resonance imaging as a screening tool for acute stroke thrombolysis.J. Neurol. Sci. 2016; 368: 168-172
- MRI-based and CT-based thrombolytic therapy in acute stroke within and beyond established time windows: an analysis of 1210 patients.Stroke. 2007; 38: 2640-2645
- Magnetic resonance imaging-based versus computed tomography-based thrombolysis in acute ischemic stroke: comparison of safety and efficacy within a cohort study.Cerebrovasc. Dis. 2013; 35: 250-256
- Effects of increasing IV tPA-treated stroke mimic rates at CT-based centers on clinical outcomes.Neurology. 2017; 89: 343-348
- Trends in door-to-thrombolysis time in the safe implementation of stroke thrombolysis registry: effect of center volume and duration of registry membership.Stroke. 2015; 46: 1275-1280
- Thrombolysis: improving door-to-needle times for ischemic stroke treatment - a narrative review.Int. J. Stroke. 2018; 132: 268-276
- Delays in door-to-needle times and their impact on treatment time and outcomes in Get With The Guidelines-Stroke.Stroke. 2017; 48: 946-954
- ANGELS Initiative Community.https://www.angels-initiative.com/Date: 2017
- Effects of extending the time window of thrombolysis to 4.5 hours: observations in the Swedish stroke register (Riks-Stroke).Stroke. 2011; 42: 2492-2497
- A computerized in-hospital alert system for thrombolysis in acute stroke.Stroke. 2010; 41: 1978-1983
- Door-to-Needle Initiative.
- Thrombolysis and thrombectomy in patients treated with dabigatran with acute ischemic stroke: expert opinion.Int. J. Stroke. 2017; 12: 9-12
- Door-to-needle delays in minor stroke: a causal inference approach.Stroke. 2017; 48: 1980-1982
- Epidemiology of stroke and coronary artery disease in Asia.Circ. J. 2013; 77: 1923-1932
- International survey of acute stroke imaging used to make revascularization treatment decisions.Int. J. Stroke. 2015; 10: 759-762
Article info
Publication history
Published online: June 13, 2019
Received in revised form:
June 10,
2019
Received:
December 4,
2018
Identification
Copyright
© 2019 Elsevier B.V. All rights reserved.