title: Improving Door-to-Needle Times for Acute Ischemic Stroke: Effect of Rapid Patient Registration, Moving Directly to Computed Tomography, and Giving Alteplase at the Computed Tomography Scanner.
abstract: The effectiveness of specific systems changes to reduce DTN (door-to-needle) time has not been fully evaluated. We analyzed the impact of 4 specific DTN time reduction strategies implemented prospectively in a staggered fashion.
  
  
  
  The HASTE (Hurry Acute Stroke Treatment and Evaluation) project was implemented in 3 phases at a single academic medical center. In HASTE I (June 6, 2012 to June 5, 2013), baseline performance was analyzed. In HASTE II (June 6, 2013 to January 24, 2015), 3 changes were implemented: (1) a STAT stroke protocol to prenotify the stroke team about incoming stroke patients; (2) administering alteplase at the computed tomography (CT) scanner; and (3) registering the patient as unknown to allow immediate order entry. In HASTE III (January 25, 2015 to June 29, 2015), we implemented a process to bring the patient directly to CT on the emergency medical services stretcher. Log-transformed DTN time was modeled. Data from 350 consecutive alteplase-treated patients were analyzed. Multivariable regression showed the following factors to be significant: giving alteplase in the CT (32% decrease in DTN time, 95% confidence interval [CI] 38%-55%), stretcher to CT (30% decrease in DTN time, 95% CI 16%-42%), patient registered as unknown (12% decrease in DTN time, 95% CI 3%-20%), STAT stroke protocol (11% decrease in DTN time, 95% CI 1%-20%), and stroke severity (National Institutes of Health Stroke Scale score 6-8: 19% decrease in DTN time, 95% CI 6%-31%; National Institutes of Health Stroke Scale score >8: 27% decrease in DTN time, 95% CI 17%-37%).
  
  
  
  Taking the patient to CT on the emergency medical services stretcher, registering the patient as unknown, STAT stroke protocol, and administering alteplase in CT are associated with lower DTN time.
authors.affiliation: From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada.
authors.forename: Noreen
authors.initials: N
authors.lastname: Kamal
authors.affiliation: From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada.
authors.forename: Jessalyn K
authors.initials: JK
authors.lastname: Holodinsky
authors.affiliation: From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada.
authors.forename: Caroline
authors.initials: C
authors.lastname: Stephenson
authors.affiliation: From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada.
authors.forename: Devika
authors.initials: D
authors.lastname: Kashayp
authors.affiliation: From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada.
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Demchuk
authors.affiliation: From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Hill
authors.affiliation: From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada.
authors.forename: Renee L
authors.initials: RL
authors.lastname: Vilneff
authors.affiliation: From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada.
authors.forename: Erin
authors.initials: E
authors.lastname: Bugbee
authors.affiliation: From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Zerna
authors.affiliation: From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada.
authors.forename: Nancy
authors.initials: N
authors.lastname: Newcommon
authors.affiliation: From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada.
authors.forename: Eddy
authors.initials: E
authors.lastname: Lang
authors.affiliation: From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada.
authors.forename: Darren
authors.initials: D
authors.lastname: Knox
authors.affiliation: From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada. eesmith@ucalgary.ca.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Smith
mesh_terms: D000046:Academic Medical Centers; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000000981:diagnostic imaging* / Q000188:drug therapy*; D019091:Critical Pathways; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010343:Patient Admission / Q000592:standards; D011237:Predictive Value of Tests; D011446:Prospective Studies; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D020521:Stroke / Q000000981:diagnostic imaging* / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000379:methods* / Q000592:standards; D013997:Time Factors; D061665:Time-to-Treatment; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000009:adverse effects; D014057:Tomography, X-Ray Computed / Q000592:standards; D014218:Triage
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: acute stroke; computed tomography; door-to-needle time; quality improvement; thrombolysis