Background: Despite quality improvement programs such as the American Heart Association/American Stroke Association Target_Stroke initiative, a substantial portion of acute ischemic stroke patients are still treated with alteplase later than 60 minutes, for unclear reasons. This study aims to describe the documented reasons for delays as well as the associations between reasons for delays and patient outcomes.
Methods: We analyzed 55,296 patients who received intravenous alteplase in 1,422 hospitals participating in Get With The Guidelines-Stroke from October 2012 to April 2015, excluding transferred patients and inpatient strokes. We assessed eligibility, medical, and hospital reasons for delays in door-to-needle time (DTN). Multivariable models were used to evaluate associations between reasons for delays, time lost, and hospital discharge outcomes, controlling for patient and hospital characteristics.
Results: There were 27,778 (50.2%) patients treated within 60 minutes, 10,086 (18.2%) treated in more than 60 minutes without documented delays, and 17,432 (31.5%) treated in more than 60 minutes with one or more documented reasons for delay. The longest DTN times were associated with inability to determine eligibility, delay in diagnosis, further diagnostic evaluation for hypoglycemia or seizure, management of emergent medical conditions and initial patient refusal (Table). One or more reason for delays was associated with in-hospital mortality (OR 1.2; 95CI 1.1-1.3), symptomatic intracranial hemorrhage (OR 1.2; 95CI 1.1-1.3), and lower odds of independent ambulation at discharge (OR 0.92; 95CI 0.9-1.0).
Conclusions: Hospital and eligibility delays such as delay in diagnosis and inability to determine eligibility are common and are associated with longer DTN and poorer outcomes. Improved stroke recognition and management of acute comorbidities may help to reduce DTN times and improve outcomes.