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Original Investigation |

Door-to-Needle Times for Tissue Plasminogen Activator Administration and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative

Gregg C. Fonarow, MD1; Xin Zhao, MS2; Eric E. Smith, MD, MPH3; Jeffrey L. Saver, MD4; Mathew J. Reeves, PhD5; Deepak L. Bhatt, MD, MPH6; Ying Xian, MD, PhD2; Adrian F. Hernandez, MD, MHS2; Eric D. Peterson, MD, MPH2; Lee H. Schwamm, MD7
[+] Author Affiliations
1Division of Cardiology, University of California, Los Angeles
2Duke Clinical Research Center, Durham, North Carolina
3Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
4Department of Neurology, University of California, Los Angeles
5Department of Epidemiology, Michigan State University, East Lansing
6Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
7Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
JAMA. 2014;311(16):1632-1640. doi:10.1001/jama.2014.3203.
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Importance  The benefits of intravenous tissue plasminogen activator (tPA) in patients with acute ischemic stroke (AIS) are time dependent and guidelines recommend a door-to-needle (DTN) time of 60 minutes or less. However, studies have found that less than 30% of US patients are treated within this time window. Target: Stroke was designed as a national quality improvement initiative to improve DTN times for tPA administration in patients with AIS.

Objectives  To evaluate DTN times for tPA administration and the proportion of patients with times of 60 minutes or less before and after initiation of a quality improvement initiative and to determine whether potential improvements in DTN times were associated with improvements in clinical outcomes.

Design, Setting, and Patients  The Target: Stroke initiative disseminated 10 care strategies to achieve faster DTN times for tPA administration, provided clinical decision support tools, facilitated hospital participation, and encouraged sharing of best practices. This study included 71 169 patients with AIS treated with tPA (27 319 during the preintervention period from April 2003-December 2009 and 43 850 during the postintervention period from January 2010-September 2013) from 1030 Get With The Guidelines—Stroke participating hospitals (52.8% of total).

Main Outcomes and Measures  The DTN times for tPA administration of 60 minutes or less and in-hospital risk-adjusted mortality, symptomatic intracranial hemorrhage, ambulatory status at discharge, and discharge destination.

Results  Median DTN time for tPA administration declined from 77 minutes (interquartile range [IQR], 60-98 minutes) during the preintervention period to 67 minutes (IQR, 51-87 minutes) during the postintervention period (P < .001). The DTN times for tPA administration of 60 minutes or less increased from 26.5% (95% CI, 26.0%-27.1%) of patients during the preintervention period to 41.3% (95% CI, 40.8%-41.7%) during the postintervention period (P < .001). The DTN times of 60 minutes or less increased from 29.6% (95% CI, 27.8%-31.5%) of patients in the quarter immediately before the intervention (fourth quarter of 2009) to 53.3% (95% CI, 51.5%-55.2%) in the final postintervention quarter (third quarter of 2013) (P < .001). The annual rate of improvement in DTN times of 60 minutes or less increased from 1.36% (95% CI, 1.04%-1.67%) per year preintervention to 6.20% (95% CI, 5.58%-6.78%) per year postintervention (P < .001). In-hospital all-cause mortality improved significantly from the preintervention to the postintervention period (9.93% vs 8.25%, respectively; adjusted odds ratio [OR], 0.89 [95% CI, 0.83-0.94], P < .001), symptomatic intracranial hemorrhage within 36 hours was less likely to occur (5.68% vs 4.68%; adjusted OR, 0.83 [95% CI, 0.76-0.91], P < .001), and discharge to home was more frequent (37.6% vs 42.7%; adjusted OR, 1.14 [95% CI, 1.09-1.19], P < .001).

Conclusions and Relevance  Implementation of a national quality improvement initiative was associated with improved timeliness of tPA administration following AIS on a national scale, and this improvement was associated with lower in-hospital mortality and intracranial hemorrhage, along with an increase in the percentage of patients discharged home.

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Figure 1.
Selection of the Study Population

IQR indicates interquartile range; tPA, tissue plasminogen activator.

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Figure 2.
Time Trend in the Proportion of Patients with Door-to-Needle Times for Tissue Plasminogen Activator (tPA) of 60 Minutes or Less During the Preintervention and Postintervention Periods of Target: Stroke

The total number of patients included was 71 169 (per-quarter mean of 1695 patients; median, 1705; interquartile range, 583-2703; and range, 65-3450). The slopes and intercepts of the regression lines were obtained from the unadjusted segmented regression model for trend rate on door-to-needle time of 60 minutes of less. The rate of increase in patients with door-to-needle times of 60 minutes or less was 6.20% (95% CI, 5.58%-6.78%) per each 4 quarters postintervention for Target: Stroke vs 1.36% (95% CI, 1.04%-1.67%) per each 4 quarters preintervention for Target: Stroke (P < .001 for comparison of the 2 slopes).

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