Background: The benefits of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke are time dependent, and national guidelines recommend door-to-needle (DTN) time within 60 minutes. Several strategies have been reported to be associated with reducing DTN times. However, effectiveness of such strategies has not been fully evaluated.
Methods: In 2014, we assembled a multidisciplinary team called ‘Acute Stroke Team (AST)’ aiming for improving outcomes of patients with acute ischemic stroke, especially by reducing onset-to-treatment time. A new protocol was implemented to minimize delays: AST staff prenotification, parallel process workflow, and rapid acquisition of laboratory testing and brain imaging. AST reviewed all intravenous tPA cases and discussed the points of improvement. AST also organized both public and in-hospital lectures, and simulation training course. We compared patients received intravenous tPA within 4.5 hours from the symptom onset at our institute in the pre AST (April 2011 - August 2014) and post AST (September 2014 - July 2016) period. Using univariate methods and multivariable logistic regression, we assessed the associated factors with favorable outcomes.
Results: In the pre and post AST period, 46 and 36 patients were treated with intravenous tPA, respectively. Compared with pre AST period, the median (interquartile range) DTN times was reduced from 71 (63-95) minutes to 55 (49-71) minutes (p<0.01), and the percentage of patients with DTN times within 60 minutes were improved from 22% to 64% (P<0.001) in the post AST period. By multivariable analysis, shorter DTN times (OR 0.98, 95% CI 0.95-0.99, p=0.025), lower age (OR 0.90, 95% CI 0.85-0.96, p=0.001) and lower NIHSS on admission (OR 0.88, 95% CI 0.82-0.95, p=0.001) were independently associated with independent ambulation at hospital discharge.
Conclusions: Multidisciplinary team-based approach reduced DTN times. Reducing DTN times was associated with improving patient outcomes. Future efforts should focus on sustainability and safety of this approach.