In Stroke, a Major Reduction in Door-to-Needle Time

Mark J. Alberts, MD


May 04, 2017

Hello, and welcome to this Medscape stroke update. My name is Dr Mark Alberts, chief of neurology at Hartford Hospital and head of the Ayer Neurosciences Institute for Hartford HealthCare System. It is my pleasure to report to you today from the 2017 American Academy of Neurology (AAN) Annual Meeting in Boston, Massachusetts.

I would like to briefly update you on two important stroke studies that were presented at this meeting.

Starting Stroke Management in the Ambulance

Dr Topakian and colleagues from Austria[1] reported on their ability to give intravenous (IV) tissue plasminogen activator (tPA) with a door-to-needle time of only 10 minutes in a significant percentage of patients [with stroke]. How did they achieve this? Let's look at some of the data.

Overall, 27% of patients [in the analysis] received tPA; they looked at 361 of these patients. Some patients had a door-to needle-time of up to 50 minutes, but the average time was 25 minutes. Door-to-needle time was reduced to 10 minutes or less in about 17% of patients.

How were they able to do that? They took several steps, some of which may be translatable and transferable to our care paradigms in the United States. They obtained history of stroke onset and other conditions during transportation in the ambulance. They were able to determine the patient's weight and to pre-mix tPA before the patient even got to the emergency department (ED). What else? They had physicians in the ambulance—this is a common thing to do in Austria. They were able to get a lot of medical information before the patient even arrived in the ED.

What does this mean for our patients in the United States? We can learn several lessons. Number one: Obtaining a more complete history during transportation seems to be an excellent idea. Number two: Obtaining patient weight during transportation would allow the ED personnel to mix up tPA and have it ready to go. The only things that would need to be done when the patient arrives are a cursory exam and CT scan.

A door-to-needle time of 10 minutes would be fantastic. We know that "time is brain." By reducing this time delay from an average of 40 or 50 minutes down to 10 minutes, we anticipate that patients would have a better outcome, and that is what we are all looking for.

Stroke Codes: 24/7 Neurology Response

The other study was done by Dr Schneider and colleagues[2] at a hospital in Asheville, North Carolina. They changed their staffing paradigm so that neurologists and/or neuro-hospitalists were in the hospital 24 hours a day, 7 days a week. They responded to stroke codes in the emergency department and throughout the hospital, and tracked their use of IV tPA. During this epoch of improved neuro-hospitalists and neurologist staffing, they collected data on 535 stroke patients with an average National Institutes of Health stroke scale score of 11.6.

They found that a neuro-hospitalist could be at the bedside within 2.5 minutes of a stroke code being called. The average door-to-needle time fell from 48 minutes, which is average, to 37 minutes, which is very good. They did note less of a fall during nighttime calls compared with daytime calls, but that is expected. In 90% of cases seen in the ED, emergency medical service personnel pre-notified ED personnel and the neuro-hospitalist that the patient was coming in.

Most important, they found that hospital mortality fell by 3% with 24/7 in-hospital, neuro-hospitalist staffing. That is a very hard endpoint. That has a lot of meaning for our patients as well as for the entire healthcare delivery paradigm. However, they did not collect data on functional outcomes, which would have been nice to have. Overall, they found that this enhanced staffing model of having neuro-hospitalists available 24/7 reduced door-to-needle time and mortality—two very good outcomes from this unique staffing model.

That's it for this Medscape stroke update from the AAN meeting. Thank you for tuning in.


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