title: Improving door-to-needle times: a single center validation of the target stroke hypothesis.
abstract: OBJECTIVE
  National guidelines recommend imaging within 25 minutes of emergency department arrival and intravenous tissue-type plasminogen activator within 60 minutes of emergency department arrival for patients with acute stroke. In 2007, we implemented a new institutional acute stroke care model to include 10 best practices and evaluated the effect of this intervention on improving door-to-computed tomography (CT) and door-to-needle (DTN) times at our hospital.
  
  
  METHODS
  We compared patients who presented directly to our hospital with acute ischemic stroke in the preintervention (2003-2006) and postintervention (2008-2011) periods. We did not include 2007, the year that the new protocol was established. Predictors of DTN ≤60 minutes before and after the intervention were assessed using χ(2) for categorical variables, and t test and Wilcoxon signed-rank test for continuous variables.
  
  
  RESULTS
  Among 2595 patients with acute stroke, 284 (11%) received intravenous tissue-type plasminogen activator. For patients arriving within an intravenous tissue-type plasminogen activator window, door-to-CT <25 improved from 26.7% pre intervention to 52.3% post intervention (P<0.001). Similarly, the percentage of patients with DTN <60 doubled from 32.4% to 70.3% (P<0.001). Patients with DTN ≤60 did not differ significantly with respect to demographics, comorbidities, or National Institutes of Health Stroke Scale score in comparison with those treated after 60 minutes.
  
  
  CONCLUSIONS
  Door-to-CT and DTN times improved dramatically after applying 10 best practices, all of which were later incorporated into the Target Stroke Guidelines created by the American Heart Association. The only factor that significantly affected DTN60 was the intervention itself, indicating that these best practices can result in improved DTN times.
authors.affiliation: From the Departments of Neurology (I.R., S.A., N.R., L.S.), Radiology (W.C., M.L.), and Emergency Medicine (J.G., J.M.), Massachusetts General Hospital, Harvard Medical School, Boston, MA.
authors.forename: Ilana M
authors.initials: IM
authors.lastname: Ruff
authors.forename: Syed F
authors.initials: SF
authors.lastname: Ali
authors.forename: Joshua N
authors.initials: JN
authors.lastname: Goldstein
authors.forename: Michael
authors.initials: M
authors.lastname: Lev
authors.forename: William A
authors.initials: WA
authors.lastname: Copen
authors.forename: Joyce
authors.initials: J
authors.lastname: McIntyre
authors.forename: Natalia S
authors.initials: NS
authors.lastname: Rost
authors.forename: Lee H
authors.initials: LH
authors.lastname: Schwamm
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002985:Clinical Protocols; D015897:Comorbidity; D003627:Data Interpretation, Statistical; D042241:Early Diagnosis; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D038801:International Classification of Diseases; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D058996:Quality Improvement; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D020521:Stroke / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000379:methods* / Q000592:standards / Q000639:trends; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: stroke; thrombolytic therapy