Delays in diagnosis and determination of eligibility for treatment with intravenous tissue plasminogen activator (IV tPA) persist, extending door-to-needle times and possibly affecting outcomes in patients with acute stroke, according to findings presented at the 2017 International Stroke Conference, February 22-24, 2017, in Houston, Texas, and simultaneously published in Stroke.1
Despite several initiatives to improve time to treatment for stroke, many patients continue to receive IV tPA outside the ideal 60-minute window from symptom onset.2 Knowing that “time is brain” when it comes to stroke treatment, researchers led by Noreen Kamal, PhD, from the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Alberta, Canada, analyzed reported reasons for delays and how they affect patient outcomes.
The large study included 55,296 patients from 1422 hospitals participating in the Get With The Guidelines-Stroke initiative from October 2012 to April 2015. All patients included in the study received IV tPA.
Among the cohort, 50.2% of patients were treated within 60 minutes, 18.2% were treated >60 minutes without recorded delays, and 31.5% were treated >60 minutes with at least 1 documented reason for delay in treatment. From 2012 to 2015, the proportion of patients treated with IV tPA within 60 minutes increased from 42.5% to 56.4%; however, no change was observed in patients with documented eligibility or medical reasons for delays who were treated >60 minutes. After adjusting for patient and hospital characteristics, there was no change in the proportion of patients with documented eligibility or medical reasons for delay who were treated with IV tPA (odds ratio [OR], 0.97; 95% CI, 0.93-1.01).
Common reasons for delay in treatment included the inability of the care team to determine patient eligibility (9.2%), hypertension needing aggressive treatment (6.9%), and in-hospital delay (6.4%). Overall, delays as a result of difficulties determining patient eligibility for treatment were more common than those generated by the assessment and treatment of acute symptoms. Notably, the more delays that were recorded, the longer door-to-needle times became, with a median of 52 minutes to treatment with no recorded delay and 95 minutes with more than 2 reasons for delay. The longest door-to-needle times were recorded in patients who required further evaluation for hypoglycemia or seizure (median, 95 minutes) or a delay in stroke diagnosis (median, 92 minutes).
In patients with documented reasons for delay, there was an increased risk for in-hospital mortality (OR, 1.19; 95% CI, 1.10-1.29) and symptomatic intracranial hemorrhage (OR, 1.17; 95% CI, 1.06-1.29), and lower odds of independent ambulation at discharge (OR, 0.92; 95% CI, 0.88-0.97) compared with patients who had no delay to treatment.
“These observations in a contemporary cohort suggest that there are significant opportunities to further reduce [door-to-needle] times by focusing on faster, more effective management of concurrent medical conditions in parallel with better hospital processes to avoid system delays,” the investigators concluded, noting that current quality performance measures exclude patients with reasons for delay in their analyses, therefore artificially inflating the number of patients treated for 60 minutes or less.
The investigators also pointed out that a significant amount of delays were tied to delays in diagnosis, which may be attributed to limited availability of stroke neurologists or delays in response time of the consulting service. These findings are in line with previous research that shows patients treated at smaller community hospitals are more likely to be treated for more than 60 minutes.3,4
Overall, the investigators recommend that hospital processes and medical treatment can be improved to ensure more timely treatment and management, especially in high-risk patients.
See the study in Stroke for a full list of disclosures.
- Kamal N, Sheng S, Xian Y, et al. Delays in door-to-needle times and their impact on treatment time and outcomes in Get With The Guidelines-Stroke [published online February 22, 2017]. Stroke. doi: 10.1161/STROKEAHA.116.015712
- Marler JR, Winters Jones P, Emr M. The National Institute of Neurological Disorders and Stroke: Proceedings of national symposium on rapid identification and treatment of acute stroke. Bethesda, MD: National Institute of Neurological Disorders and Stroke; 1997.
- Strbian D, Ahmed N, Wahlgren N, et al; for the SITS Investigators. Trends in door-to-thrombolysis time in the safe implementation of stroke thrombolysis registry: effect of center volume and duration of registry membership. Stroke. 2015;46:1275-1280. doi: 10.1161/STROKEAHA.114.007170
- Smith EE. Door-to-needle times: let’s not leave smaller hospitals behind. Stroke. 2015;46:1158-1159. doi: 10.1161/STROKEAHA.115.008974