Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention.

Abstract

BACKGROUND:

The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines.

METHODS:

We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010-2013) and Target: Stroke Phase II (2014-2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018.

RESULTS:

Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60-98) preintervention, to 66 minutes (51-87) during Phase I, and 50 minutes (37-66) during Phase II (P<0.001). Proportions of patients with DTN ≤60 minutes increased from 26.4% to 42.7% to 68.6% (P<0.001). Proportions of patients with DTN ≤45 minutes increased from 10.1% to 17.7% to 41.4% (P<0.001). By the end of the second intervention, 75.4% and 51.7% patients achieved 60-minute and 45-minute DTN goals. Compared with the preintervention period, hospitals during the second intervention period (2014-2018) achieved higher rates of tPA use (11.7% versus 5.6%; adjusted odds ratio, 2.43 [95% CI, 2.31-2.56]), lower in-hospital mortality (6.0% versus 10.0%; adjusted odds ratio, 0.69 [0.64-0.73]), fewer bleeding complication (3.4% versus 5.5%; adjusted odds ratio, 0.68 [0.62-0.74]), and higher rates of discharge to home (49.6% versus 35.7%; adjusted odds ratio, 1.43 [1.38-1.50]). Similar findings were found in sensitivity analyses of 185 501 patients receiving tPA within 4.5 hours of symptom onset.

CONCLUSIONS:

A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.

• Authors: Ying Xian, Haolin Xu, Eric E Smith, Jeffrey L Saver, Mathew J Reeves, Deepak L Bhatt, Adrian F Hernandez, Eric D Peterson, Lee H Schwamm, Gregg C Fonarow
• Journal: Stroke (Stroke) Vol. 53 Issue 4 Pg. 1328-1338 (04 2022) ISSN: 1524-4628 [Electronic] United States
• PMID: 34802250 (Publication Type: Journal Article, Research Support, Non-U.S. Gov't)

Chemical References

• Tissue Plasminogen Activator

Topics

• Aged
• Female
• Humans
• Ischemic Stroke (drug therapy)
• Male
• Quality Improvement
• Thrombolytic Therapy
• Time Factors
• Time-to-Treatment
• Tissue Plasminogen Activator (therapeutic use)
• Treatment Outcome
• United States (epidemiology)