title: Sequential analysis of pretreatment delays in stroke thrombolysis.
abstract: OBJECTIVE
  The aim was to determine if an intensive restructuring of the approach to acute stroke improved time to thrombolysis over a 3-year study period and to determine whether delay modifications correlated with increased thrombolytic intervention or functional outcome.
  
  
  METHODS
  The study examined the pretreatment process to define specific time intervals (delays) of interest in the acute management of 289 consecutive ischemic stroke patients who were transported by the emergency medical services (EMS) and received intravenous (IV) thrombolytic therapy in the emergency department (ED) of Helsinki University Central Hospital. Time interval changes of the 3-year period and use of thrombolytics was measured. Functional outcome, measured with the modified Rankin Scale (mRS) at 3 months, was assessed with multivariable statistical analysis.
  
  
  RESULTS
  During implementation of the restructuring program from 2003 to 2005, the median total time delay from symptom onset to drug administration dropped from 149 to 112 minutes (p < 0.0001). Prehospital delays did not change significantly during the study period. The median delay in calling an ambulance remained at 13 minutes, and the total median prehospital delay stayed at 71 minutes. In-hospital delays decreased from 67 to 34 minutes (p < 0.0001). The median call delay was 25 minutes in patients with mild symptoms (National Institute of Health Stroke Scale [NIHSS] score < 7) and 8 minutes with severe symptoms (NIHSS > 15). In the multivariate model, stroke severity (odds ratio [OR] = 0.83, 95% confidence interval [CI] = 0.78 to 0.88, p < 0.0001), age (OR = 0.57, 95% CI = 0.42 to 0.77, p < 0.0001), and in-hospital delay (OR = 0.47, 95% CI = 0.22 to 0.97, p = 0.04) were suggesting a good outcome.
  
  
  CONCLUSIONS
  Restructuring of the teamwork between the EMS personnel and the reorganized ED significantly reduced in-hospital, but not prehospital, delays. The present data suggest that a decreased in-hospital delay improves the accessibility of the benefits of thrombolysis.
authors.affiliation: Helsinki University Central Hospital, Finland. tuukka.puolakka@hus.fi
authors.forename: Tuukka
authors.initials: T
authors.lastname: Puolakka
authors.forename: Taneli
authors.initials: T
authors.lastname: Väyrynen
authors.forename: Olli
authors.initials: O
authors.lastname: Häppölä
authors.forename: Lauri
authors.initials: L
authors.lastname: Soinne
authors.forename: Markku
authors.initials: M
authors.lastname: Kuisma
authors.forename: Perttu J
authors.initials: PJ
authors.lastname: Lindsberg
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000188:drug therapy*; D004632:Emergency Medical Services / Q000379:methods* / Q000592:standards / Q000706:statistics & numerical data*; D005260:Female; D005387:Finland; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D015912:Thrombolytic Therapy; D013997:Time Factors; D014187:Transportation of Patients / Q000706:statistics & numerical data; D016896:Treatment Outcome