Background: The benefits of intravenous tPA in acute ischemic stroke are time-dependent with guidelines recommending a door-to-needle (DTN) time of ≤60 minutes. The implementation of Target: Stroke Phase I in 2010 was associated with an increase in the proportion of patients with DTN times ≤60 minutes in the US from 28.9% in 2009 to 51.0% in 2013. This study aims to assess whether these improvements in DTN times could be maintained or further improved since the launch of Target: Stroke Phase II in Q2 2014.
Methods: Target: Stroke Phase II identified and disseminated additional best practice strategies, provided updated clinical decision support tools, and set new hospital recognition goals. Rates of DTN times ≤60 minutes were compared during final 4 quarters of Phase I (Q4 2012-Q3 2013) vs. Phase II (Q2 2014-Q1 2015) and overall by linear weighted regression.
Results: There were 99,176 intravenous tPA treated patients from 1228 GWTG-Stroke hospitals. Patient characteristics were similar during Phase I and II. Median DTN time significantly declined from the last 4 quarters of Phase I to the first 4 quarters of Phase II: 61 minutes (IQR 47-81) to 57 minutes (IQR 43-74) (P<0.0001). The % of patients with DTN times ≤60 minutes increased from last 4 quarters of Phase I to Phase II: 49.7% to 58.5%, absolute difference +8.8%, (P<0.0001). The % of patients with DTN times ≤45 minutes also increased from Phase I to Phase II: 22.0% to 29.2%, absolute difference +7.2%, (P<0.0001). The estimated annual rate of increase in patients with DTN times ≤60 minutes was 0.6% per year pre-Target Stroke, 5.6% per year during Phase I, and 8.6% in the first year of Phase II (P<0.0001) (Figure).
Conclusions: The timeliness of tPA administration is continuing to improve in GWTG-Stroke hospitals participating in Target: Stroke Phase II. Nevertheless, ongoing quality improvement efforts will be required to meet the goals of ≥75% of patients with DTN times ≤60 minutes and ≥50% of patients with DTN times ≤ 45 minutes.