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      Impact of “Stroke Code”-Rapid Response Team: An Attempt to Improve Intravenous Thrombolysis Rate and to Shorten Door-to-Needle Time in Acute Ischemic Stroke

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          Abstract

          Objective:

          “Stroke code” (SC) implementation in hospitals can improve the rate of thrombolysis and the timeline in care of stroke patient.

          Materials and Methods:

          A prospective data of patients treated for acute ischemic stroke (AIS) after implementation of “SC” (post-SC era) were analyzed (2015–2016) and compared with the retrospective data of patients treated in the “pre-SC era.” Parameters such as symptom-to-door, door-to-physician, door-to-imaging, door-to-needle (DTN), and symptom-to-needle time were calculated. The severity of stroke was calculated using the National Institutes of Health Stroke Score (NIHSS) before and after treatment.

          Results:

          Patients presented with stroke symptoms in pre- and post-SC era (695 vs. 610) and, out of these, patients who came in window period constituted 148 (21%) and 210 (34%), respectively. Patients thrombolyzed in pre- and post-SC era were 44 (29.7%) and 65 (44.52%), respectively. Average DTN time was 104.95 min in pre-SC era and reduced to 67.28 min ( P < 0.001) post-SC implementation. Percentage of patients thrombolyzed within DTN time ≤60 min in pre-SC era and SC era was 15.90% and 55.38%, respectively.

          Conclusion:

          Implementation of SC helped us to increase thrombolysis rate in AIS and decrease DTN time.

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          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, Xin Zhao, Eric E. Smith … (2016)
          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. Stroke was designed as a national quality improvement initiative to improve DTN times for tPA administration in patients with AIS. 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. The 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). 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. 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). 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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            Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes.

            Nathan Olson, Jeffrey L Saver, Lee H. Schwamm … (2011)
            The benefits of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke are time dependent, and guidelines recommend an arrival to treatment initiation (door-to-needle) time of ≤60 minutes. Data from acute ischemic stroke patients treated with tPA within 3 hours of symptom onset in 1082 hospitals participating in the Get With the Guidelines-Stroke Program from April 1, 2003, to September 30, 2009 were studied to determine frequency, patient and hospital characteristics, and temporal trends in patients treated with door-to-needle times ≤60 minutes. Among 25 504 ischemic stroke patients treated with tPA, door-to-needle time was ≤60 minutes in only 6790 (26.6%). Patient factors most strongly associated with door-to-needle time ≤60 minutes were younger age, male gender, white race, or no prior stroke. Hospital factors associated with ≤60 minute door-to-needle time included greater annual volumes of tPA-treated stroke patients. The proportion of patients with door-to-needle times ≤60 minutes varied widely by hospital (0% to 79.2%) and increased from 19.5% in 2003 to 29.1% in 2009 (P 60 minutes. Fewer than one-third of patients treated with intravenous tPA had door-to-needle times ≤60 minutes, with only modest improvement over the past 6.5 years. These findings support the need for a targeted initiative to improve the timeliness of reperfusion in acute ischemic stroke.
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              Stroke Epidemiology and Stroke Care Services in India

              Jeyaraj Pandian, Paulin Sudhan (2013)
              Developing countries like India are facing a double burden of communicable and non-communicable diseases. Stroke is one of the leading causes of death and disability in India. The estimated adjusted prevalence rate of stroke range, 84-262/100,000 in rural and 334-424/100,000 in urban areas. The incidence rate is 119-145/100,000 based on the recent population based studies. There is also a wide variation in case fatality rates with the highest being 42% in Kolkata. Stroke units are predominantly available in urban areas that too in private hospitals. Intravenous (IV) and intra-arterial thrombolysis (IA) are commonly used in India. In the on-going Indo USA National stroke registry the rate of IV thrombolysis is 11%. Stroke rehabilitation is not well developed in India due to lack of personnel. Organised rehabilitation services are available in the country but they are mainly in private hospitals of the cities. Even though India is a leading generic drugs producer still many people can't afford the commonly used secondary prevention drugs. As a first step the Government of India has started the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS). The government is focusing on early diagnosis, management, infrastructure, public awareness and capacity building at different levels of health care for all the non-communicable diseases including stroke. An organised effort from both the government and the private sector is needed to tackle the stroke epidemic in India.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Indian J Crit Care Med
                Journal ID (iso-abbrev): Indian J Crit Care Med
                Journal ID (publisher-id): IJCCM
                Title: Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine
                Publisher: Medknow Publications & Media Pvt Ltd (India )
                ISSN (Print): 0972-5229
                ISSN (Electronic): 1998-359X
                Publication date (Print): April 2018
                Volume: 22
                Issue: 4
                Pages: 243-248
                Affiliations
                [1]Neuro Trauma Unit, Ruby Hall Clinic, Pune, Maharashtra, India
                [1 ]Department of Neurology, Ruby Hall Clinic, Pune, Maharashtra, India
                [2 ]Deapartment of Medicine, BJMC, Pune, Maharashtra, India
                [3 ]Department of Radiology, Ruby Hall Clinic, Pune, Maharashtra, India
                [4 ]Resident General Medicine, Ruby Hall Clinic, Pune, Maharashtra, India
                [5 ]Department of Accident and Emergency, Ruby Hall Clinic, Pune, Maharashtra, India
                Author notes
                Address for correspondence: Dr. Sushma K. Gurav, Neuro Trauma Unit, Ruby Hall Clinic, Pune, Maharashtra, India. E-mail: kirtisush_gurav@ 123456yahoo.co.in
                Article
                Publisher ID: IJCCM-22-243
                DOI: 10.4103/ijccm.IJCCM_504_17
                PMC ID: 5930528
                PubMed ID: 29743763
                SO-VID: d09ab7e4-3b82-4755-979b-780f3967e3f7
                Copyright © Copyright: © 2018 Indian Journal of Critical Care Medicine
                License:

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                Categories
                Subject: Research Article

                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: acute ischemic stroke,door to needle time,stroke code
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: acute ischemic stroke, door to needle time, stroke code

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