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- Title
Door-to-Needle Times for Tissue Plasminogen Activator Administration and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative.
- Authors
Fonarow, Gregg C.; Xin Zhao; Smith, Eric E.; Saver, Jeffrey L.; Reeves, Mathew J.; Bhatt, Deepak L.; Ying Xian; Hernandez, Adrian F.; Peterson, Eric D.; Schwamm, Lee H.
- Abstract
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 Measures of DTN time for tPA administration improved significantly during the postintervention period compared with the preintervention period as did clinical outcomes. Study Period Preintervention (n = 27 319) Postintervention (n = 43 850) Adjusted Odds Ratio (95% CI) P Value tPA DTN time, median (IQR), min 77 (60-98) 67 (51-87) < .001 tPA DTN time < 60 min, % (95% CI) 26.5 (26.0-27.1) 41.3 (40.8-41.7) < .001 End of each period 29.6 (27.8-31.5) 53.3 (51.5-55.2) < .001 Improvement in tPA DTN time ≤ 60 1.36 (1.04-1.67) 6.20 (5.58-6.78) < .001 min, % per year (95% Cl) In-hospital all-cause mortality, % 9.93 8.25 0.89 (0.83-0.94) < .001 Discharge to home, % 37.6 42.7 1.14 (1.09-1.19) < .001 Independent ambulatory status, % 42.2 45.4 1.03 (0.97-1.10) .31 Symptomatic intracranial 5.68 4.68 0.83 (0.76-0.91) < .001 hemorrhage within 36 h, % 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.
- Subjects
TISSUE plasminogen activator; PLASMINOGEN activators; CORONARY disease; STROKE; HEMORRHAGE
- Publication
JAMA: Journal of the American Medical Association, 2014, Vol 311, Issue 16, p1632
- ISSN
0098-7484
- Publication type
Article
- DOI
10.1001/jama.2014.3203