Introduction: Tissue plasminogen activator (tPA) reduces disability from ischemic stroke, but this benefit is time dependent. Guidelines recommend a door-to-tPA time of < 60 mins. We retrospectively evaluated the effect of eight interventions on door-to-tPA time at a large safety net public hospital.
Hypothesis: High-yield interventions would significantly reduce door-to-tPA times, especially a stroke code activation system.
Methods: From Jan 2008 to Dec 2014, all patients (n=537) presenting to our emergency department (ED) with possible stroke and for whom tPA was considered were entered into a database. Critical ischemic stroke times were recorded and compared annually (physician at bedside, labs resulted, CT scan read, tPA given). Interventions to reduce time to tPA were introduced intermittently (Figure). Mean time to tPA was compared for the six-month period before and after each intervention was implemented. Student’s t-test was used with significance at p<0.05.
Results: The mean time to tPA improved from 2008 (98.9 min) to 2014 (60.0 min; p<0.001). This was largely driven by reductions in mean times from ED physician evaluation to head CT read (-35.3 min; p<0.0001) and from ED physician to neurologist evaluation (-23.3 min; p<0.0001). The interventions associated with the greatest reductions in mean time to tPA were an ED stroke pharmacist/giving tPA in the CT scanner (-17.5 min) and conducting monthly multidisciplinary stroke peer reviews (-15.9 min).
Conclusions: A safety net public hospital significantly reduced its time to tPA for stroke through a combination of interventions, including multidisciplinary stroke peer reviews and infusing tPA in the CT scanner.