Introduction: The American Heart and American Stroke Associations released their new Target: Stroke goal of IV tPA administration in under 45 minutes from arrival for all eligible patients. While many hospitals have improved with prompt IV tPA initiation, further analysis is necessary to determine reasons for ongoing delays in order to continue to improve door- to-needle (DTN) times.
Hypothesis: We hypothesized that identifying trends in IV tPA initiation delays could guide development of process improvement (PI) geared toward decreasing DTN times.
Methods: A retrospective cohort of 2,417 patients presenting to a five hospital campus system from January 2013 to March 2015 were studied to identify trends in IV tPA delays. Inclusion criteria: all patients presenting to the emergency department (ED) for which a code stroke was activated and IV tPA was initiated with DTN times greater than 60 minutes from arrival. Exclusion criteria: patients presenting to the ED for which a code stroke was activated but IV tPA was not administered, or IV tPA was initiated within 60 minutes of arrival.
Results: Sixty-seven patients met the inclusion criteria, and the following trends were identified: seven patients (10%) required management for other life threatening conditions prior to IV tPA, such as intubation or cardioversion; IV tPA was delayed in 28 patients (42%) due to an inability to determine eligibility. This was based on waxing and waning symptoms and/or uncertainty of last time known well (LKWT). Twenty patients (30%) required IV medications for hypertension and twelve (18%) patients and/or family members initially refused the drug.
Conclusion: This study revealed that 90% of IV tPA initiation delays were due to potential modifiable factors. Indicating that through implementation of PI changes, hospital systems may be able to prevent similar delays from occurring. Examples include: collaboration with emergency medical services to transport witnesses to the ED for assistance with prompt identification of LKWT, earlier management of hypertension, and a streamlined approach for risk and benefit discussions between clinicians, patients and/or family to assist in a rapid informed consent process.