‘Work during patient transport’ key to cutting stroke treatment delays
MedWire News: Finnish researchers report that they have cut their door-to-needle time for stroke patients to a median of just 20 minutes.
This reduction, from a starting point of 105 minutes, was achieved through a series of adjustments to their thrombolysis protocol, Atte Meretoja (Helsinki University Central Hospital) reported at the European Stroke Conference in Lisbon, Portugal.
In particular, he highlighted the effect of keeping computed tomography (CT) to the bare minimum. Patients who required CT angiography or perfusion CT before a treatment decision could be made had double the door-to-needle time of those who needed only standard CT.
This was one of the final adjustments made to the protocol, in 2005, along with implementation of point-of-care international normalized ratio (INR) testing. Also from 2005, the neurologist interviewed patients or relatives/eye-witnesses by telephone while the patient was still in transit to hospital and accessed the patient's electronic medical records before their arrival.
These final changes caused the median door-to-needle time to fall from about 55 minutes, in 2004, to a little over 30 minutes, in 2005. There were no further protocol changes after that, but as the team continued "learning by doing" the median time fell further, to 20 minutes in 2011, not including patients with basilar artery occlusion. Thrombolysis rates were high by this point, at 31%, noted Meretoja.
Another change that had previously had a large impact was the relocation of the CT to the emergency department, which reduced the median door-to-needle time by at least 20 minutes.
The protocol begins when the ambulance crew suspects a stroke, and contacts the neurologist by mobile phone. The neurologist speaks to the patient or eye-witness, accesses medical records, alerts the stroke team, and pre-orders the laboratory and CT (which is cleared if needed) - all while the patient is in transit.
On arrival at hospital, the patient is taken straight to the CT table, where imaging is performed and analyzed while simultaneously the patient's INR and National Institutes of Health Stroke Scale score are calculated. Thrombolysis is performed while the patient is still on the CT table.
In 2011, the researchers treated 94% of their patients within 60 minutes of arrival. Meretoja compared this with data from the US Get With The Guidelines-Stroke project, which reported a rate of 27% for the 2003-2009 period.
He stressed that the rapid time to treatment was not associated with increased rates of intracranial hemorrhage or treatment of stroke mimics. The team's mortality and good outcome rates were as good as, if not slightly better than, rates reported in randomized trials and in the Safe Implementation of Treatments in Stroke (SITS) registry.
The findings of this study are also published in Neurology.
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By Eleanor McDermid