title: Reducing time delays in the management of ischemic stroke patients in Northern Italy.
abstract: OBJECTIVE
  Thrombolysis represents the best therapy for ischemic stroke but the main limitation of its administration is time. The avoidable delay is a concept reflecting the effectiveness of management pathway. For this reason, we projected a study concerning the detection of main delays with following introduction of corrective factors. In this paper we describe the results after these corrections.
  
  
  METHODS
  Consecutive patients admitted for ischemic stroke during a 3-months period to 35 hospitals of a macro-area of Northern Italy were enrolled. Each time of management was registered, identifying three main intervals: pre-hospital, in-hospital and total times. Previous corrective interventions were: 1.increasing of population awareness to use the Emergency Medical Service (EMS); 2.pre-notification of Emergency Department; 3.use of high urgency codes; 4.use of standardised operational algorithm. Statistical analysis was conducted using time-to-event analysis and Cox proportional hazard regression.
  
  
  RESULTS
  1084 patients were enrolled. EMS was alerted for 56.3% of subjects, mainly in females and severe strokes (p<0.001). Thrombolytic treatment was performed in 4.7% of patients. Median pre-hospital and in-hospital times were 113 and 105min, while total time was 240. High urgency codes at transport contributed to reduce pre-hospital and in-hospital time (p<0.05). EMS use and high urgency codes promoted thrombolysis. Treatment within 4.5hours from symptom onset was performed in 14% of patients more than the first phase of study.
  
  
  CONCLUSIONS
  The implementation of an organizational system based on EMS and concomitant high urgency codes use was effective to reduce avoidable delay and to increase thrombolysis.
authors.affiliation: Neurological Department & Stroke Unit, Sant'Anna Hospital, Como, Italy. Electronic address: simone.vidale@hsacomo.org.
authors.forename: Simone
authors.initials: S
authors.lastname: Vidale
authors.affiliation: Neurological Department & Stroke Unit, Sant'Anna Hospital, Como, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Arnaboldi
authors.affiliation: Neurological Department, Sondrio Hospital, Sondrio, Italy.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Bezzi
authors.affiliation: Neurological Department, Circolo Hospital, Varese, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Bono
authors.affiliation: Neurological Department, Circolo Hospital, Saronno, Italy.
authors.forename: Giampiero
authors.initials: G
authors.lastname: Grampa
authors.affiliation: Neurological Department, Valduce Hospital, Como, Italy.
authors.forename: Mario
authors.initials: M
authors.lastname: Guidotti
authors.affiliation: Neurological Department, Civil Hospital, Legnano, Italy.
authors.forename: Patrizia
authors.initials: P
authors.lastname: Perrone
authors.affiliation: Neurological Department, A. Manzoni Hospital, Lecco, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Salmaggi
authors.affiliation: Neurological Department, Sant'Antonio Abate Hospital, Gallarate, Italy.
authors.forename: Davide
authors.initials: D
authors.lastname: Zarcone
authors.affiliation: AREU Lombardy - Emergency-Urgency Regional Agency, Milan, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Zoli
authors.affiliation: Neurological Department, Niguarda Ca' Granda Hospital, Milan, Italy.
authors.forename: Elio
authors.initials: E
authors.lastname: Agostoni
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019468:Disease Management; D004632:Emergency Medical Services / Q000458:organization & administration* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000379:methods* / Q000706:statistics & numerical data; D061665:Time-to-Treatment; D016896:Treatment Outcome
keywords: Avoidable delay; Stroke management; Thrombolysis