Door-to-Needle Times for Tissue Plasminogen Activator Administration and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative

Study Questions:

What was the impact of a quality improvement initiative (Target: Stroke, organized by the American Heart Association/American Stroke Association) aimed at improving door-to-needle (DTN) times for tissue plasminogen activator (tPA) administration in patients with stroke?


The Target: Stroke initiative disseminated 10 care strategies to achieve faster DTN times for tPA administration, provided clinical decision support tools, facilitated hospital participation, and encouraged sharing of best practices. These strategies included: promoting pre-notification of hospitals by emergency medical services personnel, activating the entire stroke team with a single call or page, rapid acquisition and interpretation of brain imaging, use of specific protocols and tools, premixing tPA for high likelihood candidates, a stroke team–based approach, and rapid feedback to the stroke team on performance. The authors evaluated the impact of this initiative among 71,169 stroke patients treated with tPA (27,319 during the pre-intervention period from April 2003–December 2009, and 43,850 during the post-intervention period from January 2010–September 2013) from 1,030 hospitals participating in Get With The Guidelines—Stroke.


The median DTN time improved from 77 minutes to 67 minutes, and the proportion of patients treated within 60 minutes increased from 26% to 41%. This was accompanied by a reduction in in-hospital mortality from 9.93% to 8.25% and an increase in the proportion of patients discharged home from 37% to 42% (all p < 0.001).


Implementation of a national quality improvement initiative was associated with a reduction in DTN time, and a reduction in mortality and morbidity among patients presenting with ischemic stroke.


This study demonstrates the remarkable impact of focused quality improvement initiatives on enhancing care of stroke patients across the country. Better risk factor control, rather than re-perfusion therapy, has been responsible for the marked decline in stroke-associated mortality over the last two decades (Lackland DT, et al., Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association. Stroke 2013;45:315-53). This study suggests that more timely administration of tPA is achievable in a majority of patients, and can result in reduction in mortality and morbidity. Despite the success of this initiative, a significant quality gap still persists, and ongoing efforts are needed to enhance timely tPA use in all eligible patients with stroke.

Clinical Topics: Dyslipidemia, Lipid Metabolism

Keywords: Quality Improvement, Stroke, Hospital Mortality, Emergency Medical Services, Tissue Plasminogen Activator, Patient Discharge, United States, Needles

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