title: In-hospital delays to stroke thrombolysis: paradoxical effect of early arrival.
abstract: OBJECTIVE
  To determine the causes of in-hospital delays for thrombolysis.
  
  
  METHODS
  We performed a 4 year retrospective chart analysis of i.v. tPA-treated patients at an academic medical center. Data collected included age, stroke severity by the National Institutes of Health Stroke Scale (NIHSS) and the following time points: symptom onset, hospital arrival, computed tomography (CT), i.v. tPA order and i.v. tPA initiation of infusion.
  
  
  RESULTS
  Thirty-one cases with sufficient information for analysis were identified. Mean time from onset to arrival was 58 minutes, from arrival to brain CT was 32 minutes, and from onset to i.v. rtPA infusion was 169 minutes. The mean delay between i.v. tPA order and infusion was 32 minutes. Delay between order and administration of i.v. tPA resulted in treatment after 3 hours in 9/31 cases. An inverse relationship between early hospital arrival and delayed thrombolysis was noted. Age and stroke severity did not impact treatment times.
  
  
  CONCLUSIONS
  An unexpected delay between order and actual initiation of i.v. tPA infusion resulted in almost one-third of patients receiving thrombolytics after 3 hours from symptom onset. The cause of this delay could not be discerned by this study. The paradoxical effect between early arrival to hospital and delayed treatment may be related to a sense of urgency in those arriving close to 3 hours after onset. Critical reviews such as this permit identification of hospital delays in stroke treatment, thus allowing institution of appropriate strategies to ensure prompt treatment.
authors.affiliation: Department of Neurology, University of Miami Medical School, Miami, FL 33136, USA. jromano@med.miami.edu
authors.forename: Jose G
authors.initials: JG
authors.lastname: Romano
authors.forename: Nils
authors.initials: N
authors.lastname: Muller
authors.forename: Jose G
authors.initials: JG
authors.lastname: Merino
authors.forename: Alejandro M
authors.initials: AM
authors.lastname: Forteza
authors.forename: Sebastian
authors.initials: S
authors.lastname: Koch
authors.forename: Alejandro A
authors.initials: AA
authors.lastname: Rabinstein
mesh_terms: D000046:Academic Medical Centers / Q000592:standards*; D000368:Aged; D000369:Aged, 80 and over; D017723:Drug Utilization Review; D004636:Emergency Service, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D004638:Emergency Treatment / Q000592:standards*; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007262:Infusions, Intravenous; D008485:Medical Audit; D008875:Middle Aged; D011787:Quality of Health Care / Q000706:statistics & numerical data; D012189:Retrospective Studies; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data*; D013997:Time Factors; D013996:Time and Motion Studies; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D014187:Transportation of Patients / Q000592:standards; D014218:Triage / Q000592:standards
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator