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Short Door-to-Needle Times in Acute Ischemic Stroke and Prospective Identification of Its Delaying Factors

BACKGROUND: The clinical benefit of intravenous thrombolysis (IVT) in acute ischemic stroke is time dependent. Several studies report a short median door-to-needle time (DNT; 20 min), mainly in large tertiary referral hospitals equipped with a level 1 emergency department, a dedicated stroke team av...

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Autores principales: Van Schaik, Sander M., Scott, Saskia, de Lau, Lonneke M.L., Van den Berg-Vos, Renske M., Kruyt, Nyika D.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: S. Karger AG 2015
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4519604/
https://www.ncbi.nlm.nih.gov/pubmed/26265910
http://dx.doi.org/10.1159/000432405
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author Van Schaik, Sander M.
Scott, Saskia
de Lau, Lonneke M.L.
Van den Berg-Vos, Renske M.
Kruyt, Nyika D.
author_facet Van Schaik, Sander M.
Scott, Saskia
de Lau, Lonneke M.L.
Van den Berg-Vos, Renske M.
Kruyt, Nyika D.
author_sort Van Schaik, Sander M.
collection PubMed
description BACKGROUND: The clinical benefit of intravenous thrombolysis (IVT) in acute ischemic stroke is time dependent. Several studies report a short median door-to-needle time (DNT; 20 min), mainly in large tertiary referral hospitals equipped with a level 1 emergency department, a dedicated stroke team available 24/7, and on-site neuroimaging facilities. Meanwhile, in daily practice, the majority of stroke patients are admitted to secondary care hospitals, and in practice, even the generous benchmark of the American Heart Association (a DNT of 60 min in >80% of the cases) is met for a minority of patients treated with IVT. The first objective of our study was to investigate if, in a secondary care teaching hospital rather than a tertiary referral hospital, similar short DNTs can be accomplished with an optimized IVT protocol. Our second objective was to prospectively identify factors that delay the DNT in this setting. METHODS: A multicenter, consecutive cohort study of patients treated with IVT in one of two secondary care teaching hospitals. In both hospitals, data of consecutive stroke patients as well as median DNTs and factors delaying this were prospectively assessed for each patient. Multivariable logistic regression analysis was used to evaluate associations between patient-related and logistic factors with a delayed (i.e. exceeding 30 min) DNT. RESULTS: In total, 1,756 patients were admitted for ischemic stroke during the study period. Out of these, 334 (19.0%) patients were treated with IVT. The median DNT was 25 min (interquartile range: 20-35). A total of 71% (n = 238) had a DNT below 30 min. In 63% of the patients treated with IVT the DNT was delayed by at least one factor. Patients without any delaying factor had a 10 min shorter median DNT compared to patients with at least one delaying factor (p < 0.001). The following factors were independently associated with a delayed DNT: uncertainty about symptom onset, uncontrolled blood pressure, fluctuating neurological deficit, other treatment before IVT, uncertainty about (anti-)coagulation status, other patient-related factors, and incorrect triage. CONCLUSIONS: Short median DNTs can also be accomplished in secondary care. Despite the short DNTs, several delaying factors were identified that could direct future improvement measures. This study supports the view that as a performance measure, the current DNT targets are no longer ambitious enough and it adds to the knowledge of factors delaying the DNT.
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spelling pubmed-45196042015-08-11 Short Door-to-Needle Times in Acute Ischemic Stroke and Prospective Identification of Its Delaying Factors Van Schaik, Sander M. Scott, Saskia de Lau, Lonneke M.L. Van den Berg-Vos, Renske M. Kruyt, Nyika D. Cerebrovasc Dis Extra Original Paper BACKGROUND: The clinical benefit of intravenous thrombolysis (IVT) in acute ischemic stroke is time dependent. Several studies report a short median door-to-needle time (DNT; 20 min), mainly in large tertiary referral hospitals equipped with a level 1 emergency department, a dedicated stroke team available 24/7, and on-site neuroimaging facilities. Meanwhile, in daily practice, the majority of stroke patients are admitted to secondary care hospitals, and in practice, even the generous benchmark of the American Heart Association (a DNT of 60 min in >80% of the cases) is met for a minority of patients treated with IVT. The first objective of our study was to investigate if, in a secondary care teaching hospital rather than a tertiary referral hospital, similar short DNTs can be accomplished with an optimized IVT protocol. Our second objective was to prospectively identify factors that delay the DNT in this setting. METHODS: A multicenter, consecutive cohort study of patients treated with IVT in one of two secondary care teaching hospitals. In both hospitals, data of consecutive stroke patients as well as median DNTs and factors delaying this were prospectively assessed for each patient. Multivariable logistic regression analysis was used to evaluate associations between patient-related and logistic factors with a delayed (i.e. exceeding 30 min) DNT. RESULTS: In total, 1,756 patients were admitted for ischemic stroke during the study period. Out of these, 334 (19.0%) patients were treated with IVT. The median DNT was 25 min (interquartile range: 20-35). A total of 71% (n = 238) had a DNT below 30 min. In 63% of the patients treated with IVT the DNT was delayed by at least one factor. Patients without any delaying factor had a 10 min shorter median DNT compared to patients with at least one delaying factor (p < 0.001). The following factors were independently associated with a delayed DNT: uncertainty about symptom onset, uncontrolled blood pressure, fluctuating neurological deficit, other treatment before IVT, uncertainty about (anti-)coagulation status, other patient-related factors, and incorrect triage. CONCLUSIONS: Short median DNTs can also be accomplished in secondary care. Despite the short DNTs, several delaying factors were identified that could direct future improvement measures. This study supports the view that as a performance measure, the current DNT targets are no longer ambitious enough and it adds to the knowledge of factors delaying the DNT. S. Karger AG 2015-06-12 /pmc/articles/PMC4519604/ /pubmed/26265910 http://dx.doi.org/10.1159/000432405 Text en Copyright © 2015 by S. Karger AG, Basel http://creativecommons.org/licenses/by-nc/3.0/ This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribution permitted for non-commercial purposes only.
spellingShingle Original Paper
Van Schaik, Sander M.
Scott, Saskia
de Lau, Lonneke M.L.
Van den Berg-Vos, Renske M.
Kruyt, Nyika D.
Short Door-to-Needle Times in Acute Ischemic Stroke and Prospective Identification of Its Delaying Factors
title Short Door-to-Needle Times in Acute Ischemic Stroke and Prospective Identification of Its Delaying Factors
title_full Short Door-to-Needle Times in Acute Ischemic Stroke and Prospective Identification of Its Delaying Factors
title_fullStr Short Door-to-Needle Times in Acute Ischemic Stroke and Prospective Identification of Its Delaying Factors
title_full_unstemmed Short Door-to-Needle Times in Acute Ischemic Stroke and Prospective Identification of Its Delaying Factors
title_short Short Door-to-Needle Times in Acute Ischemic Stroke and Prospective Identification of Its Delaying Factors
title_sort short door-to-needle times in acute ischemic stroke and prospective identification of its delaying factors
topic Original Paper
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4519604/
https://www.ncbi.nlm.nih.gov/pubmed/26265910
http://dx.doi.org/10.1159/000432405
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