Differences in process management and in-hospital delays in treatment with iv thrombolysis.
OBJECTIVE
Rapid initiation of intravenous thrombolysis improves patient's outcome in acute stroke. We analyzed inter-center variability and factors that influence the door-to-needle time with a special focus on process measurements in all Austrian stroke units.


METHODS
Case level data of patients receiving intravenous thrombolysis in the Austrian Stroke Unit Registry were enriched with information of a structured questionnaire on center specific process measures of all Austrian stroke units. Influence of case and center specific variables was determined by LASSO procedure.


RESULTS
Center specific median door-to-needle time ranged between 30 and 78 minutes. Between April 2004 and November 2012, 6246 of 57991 patients treated in Austrian stroke units with acute ischemic stroke received intravenous thrombolysis. An onset-to-door time >120 minutes, patients with total anterior circulation stroke, recent year of admission, patient transportation with ambulance crew and emergency physician, the use of point of care tests reduced the door-to-needle time, whereas onset-to-door ≤ 60 minutes, unknown onset-to-door, patients with an NIHSS ≤ 4 or posterior circulation stroke, initial admission to a general emergency department, a distant radiology department, primary imaging modality other than plain CT and waiting for the lab results were associated with an increase in door-to-needle time. Case level and center specific factors could explain the inter center variability of door-to-needle times in 31 of 34 stroke units in Austria.


CONCLUSIONS
In light of our results it seems crucial that every single stroke center documents and critically reviews possibilities of optimizing practice strategies in acute stroke care.
Department of Neurology, Hospital Barmherzige Brueder, Vienna, Austria.
Julia
J
Ferrari
Michael
M
Knoflach
Leonhard
L
Seyfang
Wilfried
W
Lang
D061605:Administration, Intravenous; D000368:Aged; D000369:Aged, 80 and over; D001317:Austria / Q000453:epidemiology; D019468:Disease Management; D004636:Emergency Service, Hospital; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D012042:Registries; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D011795:Surveys and Questionnaires; D015912:Thrombolytic Therapy; D013997:Time Factors
D005343:Fibrinolytic Agents