Evaluating Thrombolysis Rates and Emergency Department Time Targets in Acute Ischemic Stroke: Need for Personalized Medicine.

BACKGROUND AND OBJECTIVES: In the era of personalized medicine, standard protocols regarding the management of acute ischemic stroke (AIS) focus on time targets alone without tailoring the protocol to the specific patient and hospital characteristics to increase IV thrombolysis rates and improve outcomes for these patients by considering organizational differences and patient-related factors that influence adherence to target times at the emergency department level. With this in mind, we evaluate the effect of achieving ED time targets from standard protocol and patient-related risk factors on the intravenous (IV) thrombolysis rate in patients with AIS in the therapeutic window. MATERIALS AND METHODS: For our research, we enrolled people who arrived at the ED with signs of recent AIS with an onset of less than 4.5 h. Initially, 355 patients were included in the study, but through careful screening, only 258 were considered eligible to participate. Of the final group of 258 patients, only 46 received intravenous thrombolysis treatment. RESULTS: In our study, when we are analyzing ED times in patients admitted with stroke symptoms in the therapeutic window, we found statistically significantly decreased ED times for patients that performed IV thrombolysis compared to patients not performing as follows: a median of 100 min in onset-to-ED door time (p < 0.001), a door-to-physician time (ED doctor) of 4 min (p = 0.009), door-to-blood-samples of 5 min (p = 0.026), a door-to-CT time of 15.5 min (p = 0.009), and door-to-CT results of 37 min (p < 0.001). In addition, patients who received intravenous thrombolysis were found to be significantly older (p < 0.001), with lower height and weight (p < 0.001 for both) and lower Glasgow Coma Scale (GCS) scores (9 ± 4.94 vs. 13.85 ± 2.41, p < 0.001). The logistic regression analysis indicated that the onset-to-ED time (p < 0.001) and the door-to-physician time (p = 0.014) for emergency medicine physicians are significant predictors of the likelihood of administering thrombolysis. By analyzing the impact of comorbidities, we observed that dyslipidemia, chronic arterial hypertension, and diabetes mellitus are significant predictive factors for performing IV thrombolysis (the presence of dyslipidemia and diabetes mellitus are predictive factors for performing IV thrombolysis, while the presence of arterial hypertension is not). CONCLUSIONS: The ED time targets that significantly influenced IV thrombolysis in our study were the onset-to-ED door time and the time it takes for the ED doctor to assess the AIS patient (door-to-physician time). The IV thrombolysis rate for these patients was 17.83%, lower than expected despite achieving most ED time targets, with the presence of chronic arterial hypertension as a significant predictive patient-related factor for not performing it. Even though our reported hospital's thrombolysis rate is favorable compared to international reports, there is always room for improvement. Based on our study results, it is necessary that new protocols to customized standard protocols and ED time targets for increasing IV thrombolysis rate in patients with AIS in the therapeutic window, focusing more on patient-related factors and type of hospitals, granting personalized medicine its right. Based on our study results, it is necessary that new protocols customize standard protocols and ED time targets for increasing IV thrombolysis rate in patients with AIS in the therapeutic window, focusing more on patient-related factors and type of hospitals, granting personalized medicine its right.

Code Stroke Alert: Focus on Emergency Department Time Targets and Impact on Door-to-Needle Time across Day and Night Shifts.

BACKGROUND AND OBJECTIVES: To minimize stroke-related deaths and maximize the likelihood of cerebral reperfusion, medical professionals developed the "code stroke" emergency protocol, which allows for the prompt evaluation of patients with acute ischemic stroke symptoms in pre-hospital care and the emergency department (ED). This research will outline our experience in implementing the stroke code protocol for acute ischemic stroke patients and its impact on door-to-needle time (DTN) in the ED. METHODS: Our study included patients with a "code stroke alert" upon arrival at the emergency department. The final sample of this study consisted of 258 patients eligible for intravenous (IV) thrombolysis with an onset-to-door time < 4.5 h. ED admissions were categorized into two distinct groups: "day shift" (from 8 a.m. to 8 p.m.) (n = 178) and "night shift" (from 8 p.m. to 8 a.m.) (n = 80) groups. RESULTS: An analysis of ED time targets showed an increased median during the day shift for onset-to-ED door time of 310 min (IQR, 190-340 min), for door-to-physician (emergency medicine doctor) time of 5 min (IQR, 3-9 min), for door-to-physician (emergency medicine doctor) time of 5 min (IQR, 3-9 min), and for door-to-physician (neurologist) time of 7 min (IQR, 5-10 min), also during the day shift. During the night shift, an increased median was found for door-to-CT time of 21 min (IQR, 16.75-23 min), for door-to-CT results of 40 min (IQR, 38-43 min), and for door-to-needle time of 57.5 min (IQR, 46.25-60 min). Astonishingly, only 17.83% (n = 46) of these patients received intravenous thrombolysis, and the proportion of patients with thrombolysis was significantly higher during the night shift (p = 0.044). A logistic regression analysis considering the door-to-needle time (minutes) as the dependent variable demonstrated that onset-to-ED time (p < 0.001) and door-to-physician (emergency medicine physicians) time (p = 0.021) are predictors for performing thrombolysis in our study. CONCLUSIONS: This study identified higher door-to-CT and door-to-emergency medicine physician times associated with an increased DTN, highlighting further opportunities to improve acute stroke care in the emergency department. Further, door-to-CT and door-to-CT results showed statistically significant increases during the night shift.

Emergency Department Time Targets for Interhospital Transfer of Patients with Acute Ischemic Stroke.

Background and objectives: Although the intravenous tissue plasminogen activator (rt-PA) has been shown to be effective in the treatment of acute ischemic stroke (AIS), only a small proportion of stroke patients receive this drug. The low administration rate is mainly due to the delayed presentation of patients to the emergency department (ED) or the lack of a stroke team/unit in most of the hospitals. Thus, the aim of this study is to analyze ED time targets and the rate of rt-PA intravenous administration after the initial admission of patients with AIS in an ED from a traditional healthcare center (without a neurologist or stroke team/unit). Methods: To analyze which factors influence the administration of rt-PA, we split the general sample (n = 202) into two groups: group No rt-PA (n = 137) and group rt-PA (n = 65). This is based on the performing or no intravenous thrombolysis. Results: Analyzing ED time targets for all samples, we found that the median onset-to-ED door time was 180 min (IQR, 120-217.5 min), door-to-physician time was 4 min (IQR, 3-7 min), door-to-CT time was 52 min (IQR, 48-55 min), and door-in-door-out time was 61 min (IQR, 59-65 min). ED time targets such as door-to-physician time (p = 0.245), door-to-CT time (p = 0.219), door-in-door-out time (p = 0.24), NIHSS at admission to the Neurology department (p = 0.405), or NIHSS after 24 h (p = 0.9) did not have a statistically significant effect on the administration or no rt-PA treatment in patients included in our study. Only the highest door-to-CT time was statistically significantly correlated with the death outcome. Conclusion: In our study, the iv rt-PA administration rate was 32.18%. A statistically significant correlation between the highest door-to-CT time and death outcome was found.

Improving access to services for psychotic patients: does implementing a waiting time target make a difference.

OBJECTIVE: In April 2015, the English National Health Service started implementing the first waiting time targets in mental health care. This study aims to investigate the effect of the 14-day waiting time target for early intervention in psychosis (EIP) services after the first six months of its implementation. STUDY DESIGN: We analyse a cohort of first-episode psychosis patients from the English administrative Mental Health and Learning Disabilities Dataset 2011 to 2015. We compare patients being treated by EIP services (treatment) with those receiving care from standard community mental health services (control). We combine non-parametric matching with a difference-in-difference approach to account for observed and unobserved group differences. We analyse the probability of waiting below target and look at different percentiles of the waiting time distribution. RESULTS: EIP patients had an 11.6-18.4 percentage point higher chance of waiting below target post-policy compared to standard care patients. However, post-policy trends at different percentiles of the waiting time distribution were not different between groups. CONCLUSIONS: Mental health providers seem to respond to waiting time targets in a similar way as physical health providers. The increased proportion waiting below target did not, however, result in an overall improvement across the waiting time distribution.

Ideal telestroke time targets: Telestroke-based treatment times in the United States stroke belt.

Background: Studying critical time interval requirements can enhance thrombolytic treatment for stroke patients in telestroke networks. We retrospectively examined 12 concurrent months of targeted time interval information in the South Central US telemedicine programme, Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES).Hypothesis: We hypothesised that consult data analysis would highlight areas for improvement to shorten overall door to Intra venous (IV) tissue plasminogen activator (tPA) administration time. Methods: We analysed critical time targets for 238 consecutive telestroke neurology consults obtained over 12 months from AR SAVES spoke sites when tPA was administered. The following time intervals were analysed: emergency department (ED) door to Computed Tomography (D-CT); ED door to call centre (D-CC) for initiation of consult; ED door to neurology call (D-NC); neurology call to camera (NC-Cam); tele consult time (Con); ED door to tissue plasminogen activator (tPA)/needle (DTN). Results: The median times of D-CT (13 min, inter quartile range (IQR) 6­22 min), D-CC (34 min, IQR 20­45 min), D-NC (40 min, IQR 21­71 min), NC-Cam (4 min, IQR 2­8 min), and Con (25 min, IQR 17­37 min) all contributed to a DTN median time of 71 min (IQR 50­104 min). A total of 238 patients received tPA with a 29.4% treatment rate and a DTN time of ≤60 min was achieved in 25.2% of patients. Conclusions: Focusing on reducing D-CC and Con times may help to achieve the DTN time of < 60 min for the majority of patients. Having ideal time targets for telestroke patients akin to traditional patients will help identify and improve the overall goal of a DTN time < 60 min.

Factors associated with failure of emergency wait-time targets for high acuity discharges and intensive care unit admissions.

OBJECTIVE: Ontario established emergency department length-of-stay (EDLOS) targets but has difficulty achieving them. We sought to determine predictors of target time failure for discharged high acuity patients and intensive care unit (ICU) admissions. METHODS: This was a retrospective, observational study of 2012 Sunnybrook Hospital emergency department data. The main outcome measure was failing to meet government EDLOS targets for high acuity discharges and ICU emergency admissions. The secondary outcome measures examined factors for low acuity discharges and all admissions, as well as a run chart for 2015 - 2016 ICU admissions. Multiple logistic regression models were created for admissions, ICU admissions, and low and high acuity discharges. Predictor variables were at the patient level from emergency department registries. RESULTS: For discharged high acuity patients, factors predicting EDLOS target failure were having physician initial assessment duration (PIAD)>2 hours (OR 5.63 [5.22-6.06]), consultation request (OR 10.23 [9.38-11.14]), magnetic resonance imaging (MRI) (OR 19.33 [12.94-28.87]), computed tomography (CT) (OR 4.24 [3.92-4.59]), and ultrasound (US) (OR 3.47 [3.13-3.83]). For ICU admissions, factors predicting EDLOS target failure were bed request duration (BRD)>6 hours (OR 364.27 [43.20-3071.30]) and access block (AB)>1 hour (OR 217.27 [30.62-1541.63]). For discharged low acuity patients, factors predicting failure for the 4-hour target were PIAD>2 hours (OR 15.80 [13.35-18.71]), consultation (OR 20.98 [14.10-31.22]), MRI (OR 31.68 [6.03-166.54]), CT (OR 16.48 [10.07-26.98]), and troponin I (OR 13.37 [6.30-28.37]). CONCLUSION: Sunnybrook factors predicting failure of targets for high acuity discharges and ICU admissions were hospital-controlled. Hospitals should individualize their approach to shortening EDLOS by analysing its patient population and resource demands.