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Good is not Good Enough: The Benchmark Stroke Door-to-Needle Time Should be 30 Minutes

Published online by Cambridge University Press:  20 October 2014

Noreen Kamal
Affiliation:
Department of Clinical Neurosciences, University of Calgary, Calgary
Oscar Benavente
Affiliation:
Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
Karl Boyle
Affiliation:
Department of Medicine, University of Toronto Inpatient Stroke Unit, University of Toronto
Brian Buck
Affiliation:
Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta
Ken Butcher
Affiliation:
Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta
Leanne K. Casaubon
Affiliation:
Stroke Program, Toronto TIA and Minor Stroke Unit, Toronto Western Hospital, Toronto
Robert Côté
Affiliation:
Department of Neurology, Neurosurgery and Medicine, McGill University
Andrew M Demchuk
Affiliation:
Department of Clinical Neurosciences, University of Calgary, Calgary
Yan Deschaintre
Affiliation:
Department of Neurosciences, Quebec
Dar Dowlatshahi
Affiliation:
Departments of Medicine, Epidemiology and Community Medicine, University of Ottawa, Ottawa
Gordon J Gubitz
Affiliation:
Faculty of Medicine (Neurology), Dalhousie University, Canada
Gary Hunter
Affiliation:
Department of Medicine – Neurology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan
Tom Jeerakathil
Affiliation:
Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta
Albert Jin
Affiliation:
Department of Medicine, Queen’s University, London
Eddy Lang
Affiliation:
Department of Emergency Medicine, Faculty of Medicine, University of Calgary, Calgary Alberta Health Services, Calgary Zone, Calgary
Sylvain Lanthier
Affiliation:
Department of Neurology, Université de Montréal, Montreal, Quebec
Patrice Lindsay
Affiliation:
Heart and Stroke Foundation of Canada, Ottawa
Nancy Newcommon
Affiliation:
Calgary Stroke Program, Foothills Hospital, Calgary
Jennifer Mandzia
Affiliation:
Kingston Department of Clinical Neurosciences, Western University, London
Colleen M. Norris
Affiliation:
Faculty of Nursing, University of Alberta, Edmonton, Alberta Cardiodiovascular & Stroke Strategic Clinical Network, University of Alberta, Edmonton, Alberta
Wes Oczkowski
Affiliation:
Division of Neurology, Department of Medicine, McMaster University, Hamilton, Ontario
Céline Odier
Affiliation:
Department of Neurosciences, Quebec
Stephen Phillips
Affiliation:
Faculty of Medicine (Neurology), Dalhousie University, Canada Capital District Health Authority, Halifax, Nova Scotia, Canada.
Alexandre Y Poppe
Affiliation:
Department of Neurosciences, Quebec
Gustavo Saposnik
Affiliation:
Stroke Research Unit, Toronto
Daniel Selchen
Affiliation:
Division of Neurology, Regional Stroke Program, St. Michael’s Hospital, Toronto
Ashfaq Shuaib
Affiliation:
Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta
Frank Silver
Affiliation:
Department of Neurology, University of Toronto
Eric E Smith
Affiliation:
Department of Clinical Neurosciences, University of Calgary, Calgary
Grant Stotts
Affiliation:
Department of Medicine, University of Toronto Neurology, University of Toronto, Ottawa
Michael Suddes
Affiliation:
Calgary Stroke Program, Foothills Hospital, Calgary
Richard H. Swartz
Affiliation:
Regional Stroke Program, Sunnybrook Health Sciences Centre, University of Toronto
Philip Teal
Affiliation:
Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
Tim Watson
Affiliation:
Department of Clinical Neurosciences, University of Calgary, Calgary
Michael D. Hill
Affiliation:
Department of Clinical Neurosciences, University of Calgary, Calgary
Corresponding
E-mail address:
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Abstract

Type
Commentary
Copyright
Copyright © The Canadian Journal of Neurological Sciences Inc. 2014 

The importance of treating ischemic stroke patients quickly has long been recognized, and the mantra “Time is brain”, is now ubiquitous.Reference Gomez 1 , Reference Saver 2 Unfortunately, the thinking “We still have time in the treatment window…” is occurring too often during the acute stroke code. The treatment window from time of onset is 4.5 hoursReference Hacke, Kaste, Bluhmki and Brozman 3 in most guidelines,Reference Bluhmki, Chamorro and Dávalos 4 , Reference Sandercock, Wardlaw and Lindley 5 yet there is declining benefit as time elapses. A 1997 National Institute of Neurological Disorders and Stroke (NINDS) Symposium and the subsequent Brain Attack CoalitionReference Alberts, Latchaw and Jagoda 6 set the standard of 60 minute door-to-needle time.Reference Marler, Winters Jones and Emr 7 This door-to-needle time was arbitrary but designed to provide a useful metric. It has now been incorporated into both national guidelines and accreditation standardsReference Schwamm 8 Reference Casaubon and Suddes 10 but has been treated more like a guide or a range rather than a hard target. Parkinson’s law - “The job expands to fit the time available” - is as true in stroke care as it is in economics.Reference Parkinson 11 We argue that to change this mentality we must revise our target downward to a 30-minute median door-to-needle time.

Today we know that: (1) “Time is brain” in the most urgent way; (2) with attention to systems change, median door-to-needle times of 30 minutes can be achieved; (3) we fail to meet a 60-minute door-to-needle time for most patients in most centres. The sooner blood flow is restored in ischemic stroke, the better the outcomes.Reference Christou, Alexandrov and Burgin 12 , Reference Saver, Fonarow and Smith 13 For each 15 minute reduction in delay, there is an estimated 4% improvement in good clinical outcomes.Reference Saver, Fonarow and Smith 13 The number of neurons that are lost in a middle cerebral artery stroke has been quantified to be 1.9 million per minute or 114 million neurons every hour, which translates to 3.6 years in accelerated aging.Reference Saver 2 While this is based upon an average rate of infarct progression and individual patients may vary substantially, the damage is staggering. Acute ischemic stroke is a medical emergency that is as, or more, time sensitive than myocardial infarctionReference Rawles 14 and trauma.Reference Lerner and Moscati 15 We need to treat it as such. Using conservative calculations of 800 000 strokes per year in North America, where 40 000 are treated with intravenous tissue plasminogen activator (tPA), and 16 000 (40%) of these have a good outcome, an additional 3 000 patients will have good outcomes based on a decrease of 30 minutes in time to treatment.Reference Lees, Bluhmki and Von Kummer 16 In addition, this calculation does not allow for a projected increase in the number of patients treated. The optimal door-to-needle time is the fastest possible time that preserves safety and appropriateness.

When hospitals and stroke teams use a systematic quality improvement approach to stroke thrombolysis, significantly lower door-to-needle times can be realized. In Helsinki, an initial median door-to-needle time of 1 hour 45 minutes in 1998, was reduced to 50 minutes by 2004,Reference Lindsberg, Häppölä, Kallela, Valanne, Kuisma and Kaste 17 and then further reduced to 20 minutes in 2011 (excluding basilar artery occlusion).Reference Meretoja, Strbian, Mustanoja, Tatlisumak, Lindsberg and Kaste 18 This model was replicated at the Royal Melbourne Hospital, where median door-to-needle times were reduced from 61 minutes to 25 minutes.Reference Meretoja, Weir and Ugalde 19 Improvements in the United States (US) have been reported by the Target-Stroke initiative.Reference Fonarow, Smith and Saver 20 , Reference Fonarow, Zhao and Smith 21 Importantly, these improvements in door-to-needle treatment time have not resulted in an increase in complications. A key concept in fast treatment is the paradigm of parallel (rather than serial) diagnostic evaluation, assessment and treatment. The Emergency literature discusses the concept of “swarming” for acute trauma and acute myocardial infarction. The same must apply to acute stroke.

In Canada, comprehensive stroke centres have been able to achieve similar reduction in door-to-needle time. In Calgary, as a result of a six-sigma quality improvement process, the stroke team’s median door-to-needle time was reduced to 32 minutes (range 11–121 min) from 52 minutes (range 6–193 min). Comparable magnitude improvements have been seen in Montreal (median 54 min reduced to 30 min), Ottawa (median 74 min reduced to 37 min) and at other Canadian stroke centres. However, both the US and Canada have globally failed to meet the 60-minute door-to-needle target. Results from the American Heart Association “Get With the Guidelines” data show that only 26.6% of patients received tPA within 60 minutes of arriving at a hospital.Reference Fonarow, Smith and Saver 22 In Canada, results from the 2011 national stroke audit on quality of stroke care showed that only 34% of patients had a door-to-needle time equal to or less than 60 minutes. 23

To improve we can learn from success. The process changes that were employed by the groups in Helsinki, Melbourne and our groups in Canada are not novel. [Table] These groups have simply recognized the urgency in hyper-acute stroke care of ischemic stroke. They developed processes to ensure this mindset permeates to Emergency Medical Services (EMS), Emergency Department, and stroke team. They have worked in parallel as a team. Based on results from these groups, we ask: How long does it take to administer tPA? Is a median 60-minute door-to-needle time acceptable? Internationally, other professional groups have recognized that, globally, we are not treating stroke fast enough. Reference Fonarow, Smith and Saver 22 , 24

Table 30 changes to get to 30 minutes A list of process changes, used at centres across Canada, that may expedite the treatment of acute ischemic stroke with intravenous alteplase

EMS=emergency medical services; IV=intravenous; PACS=picture archive and retrieval system; ED=Emergency department; CT=computed tomography; tPA=tissue plasminogen activator; STAT=“immediately” (used in medical contexts from latin “statim”); Code=requiring a team of providers to rush to the specific location and begin immediate treatment; MD=Medical Doctor; RN=Registered Nurse; DTN=Door-to-Needle

We are calling for an aggressive update of our targets as a necessary step to better patient care. Today we should set a door-to-needle benchmark at a 30-minute median (60-minute 95th percentile). To achieve a system where 95% of patients get treated within 60 minutes, where patients are treated with the fastest possible door-to-needle time, we need a median door-to-needle time of 30 minutes. Systems that aim for and achieve this target will have engineered their processes to allow for predictable and unavoidable variance due to patient factors that can necessarily delay treatment. Centres that can achieve these results will see more of their patients walking out of hospital and will have met an essential criterion for being named a top stroke centre.

This target is not easy but it is demanded by the immutable biology of the disease. These efforts will require ongoing efforts to maintain success. Key implications of such a change could include centralization of acute stroke care to specialized centers where this makes sense geographically, increased use of telemedicine,Reference Schwamm, Holloway and Amarenco 25 a strong emphasis on training to avoid treatment of stroke mimics, and more careful and discriminative use of diagnostic imaging. Success will be achieved in different ways at different centres. For our patients, let us commit to reducing delays in stroke thrombolysis and set a new standard for ischemic stroke treatment.

References

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