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Delays in Door-to-Needle Times and Impact on Stroke Outcomes
Study Questions:
What are the reasons for delays in stroke treatment and the associations between reasons for delays and patient outcomes?
Methods:
The investigators analyzed the characteristics of 55,296 patients who received intravenous alteplase in 1,422 hospitals participating in Get With The Guidelines-Stroke from October 2012 to April 2015, excluding transferred patients and inpatient strokes. They assessed eligibility, medical, and hospital reasons for delays in door-to-needle time. The association between binary hospital discharge outcomes and reasons for treatment delays were similarly analyzed using multivariable logistic regression with generalized estimating equations, adjusted for the same covariates.
Results:
There were 27,778 patients (50.2%) treated within 60 minutes, 10,086 patients (18.2%) treated >60 minutes without documented delays, and 17,432 patients (31.5%) treated >60 minutes with one or more documented reasons for delay. Delayed door-to-needle times were associated with delayed diagnosis (36 minutes longer than those without delay in diagnosis) and hypoglycemia or seizure (34 minutes longer than without those conditions). The presence of documented delays was associated with higher odds of in-hospital mortality (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.1-1.3) and symptomatic intracranial hemorrhage (OR, 1.2; 95% CI, 1.1-1.3) and lower odds of independent ambulation at discharge (OR, 0.92; 95% CI, 0.9-1.0) after adjusting for patient and hospital characteristics.
Conclusions:
The authors concluded that hospital and eligibility delays such as delay in diagnosis and inability to determine eligibility were associated with longer door-to-needle times.
Perspective:
This study reports that both hospital and medical reasons contribute to delays in time to treatment with intravenous alteplase, leading to poorer outcomes for ischemic stroke patients. Hospital processes can be further improved to ensure that in-hospital delays are eliminated or minimized. In addition, there is a need to optimize processes to ensure that patients are medically treated effectively without comprising door-to-needle times, to ensure that these higher-risk patients are treated optimally to achieve the best possible outcome.
Keywords: Delayed Diagnosis, Hospital Mortality, Hypoglycemia, Intracranial Hemorrhages, Primary Prevention, Seizures, Stroke, Time-to-Treatment, Tissue Plasminogen Activator, Treatment Outcome, Vascular Diseases
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