Identification of Rate-Limiting Steps in the Provision of Thrombolytics for Acute Ischemic Stroke

Abstract

Background: Tissue plasminogen activator (tPA) is the only pharmacotherapy shown to improve outcomes in acute ischemic stroke. The American Heart Association (AHA) recommends a door-to-needle (DTN) time of <60 minutes in at least 50% of patients presenting with acute ischemic stroke. Objective: The purpose of this study was to analyze the possible barriers that may delay tPA administration within the emergency department (ED) of an academic medical center. Methods: A retrospective chart review was conducted from February 2011 to October 2013. Patients were included if they were admitted through the ED with a diagnosis of acute ischemic stroke and received tPA. Results: Of the 130 patients who met inclusion criteria, 43.1% received tPA in ≤60 minutes. Several factors were identified to be significantly different in those with a DTN time of >60 minutes—time to ED physician consultation, neurologist arrival, blood sample acquisition, and result time ( P < .05 for all comparisons). Correlation analysis demonstrated several independent variables associated with DTN time of ≤60 minutes—time from admission to ED physician consultation, receipt of computed tomography (CT) scan, blood sample acquisition, laboratory results, and neurology service arrival ( P < .05 for all comparisons). Conclusion: The findings from this study highlight the importance of prompt physician evaluation, direct transfer to the CT scanner, and a quick turnaround time on laboratory values. The development of protocols to ensure the rapid receipt of tPA therapy should focus on limiting any potential delay these steps may cause.