title: Results of a 1-year quality-improvement process to reduce door-to-needle time in acute ischemic stroke with MRI screening.
abstract: OBJECTIVE
  To determine the effects of a 1-year quality-improvement (QI) process to reduce door-to-needle (DTN) time in a secondary general hospital in which multimodal MRI screening is used before tissue plasminogen activator (tPA) administration in patients with acute ischemic stroke (AIS).
  
  
  METHODS
  The QI process was initiated in January 2015. Patients who received intravenous (iv) tPA<4.5h after AIS onset between 26 February 2015 to 25 February 2016 (during implementation of the QI process; the "2015 cohort") were identified (n=130), and their demographic and clinical characteristics and timing metrics compared with those of patients treated by iv tPA in 2014 (the "2014 cohort", n=135).
  
  
  RESULTS
  Of the 130 patients in the 2015 cohort, 120 (92.3%) of them were screened by MRI. The median DTN time was significantly reduced by 30% (from 84min in 2014 to 59min; P<0.003), while the proportion of treated patients with a DTN time≤60min increased from 21% to 52% (P<0.0001). Demographic and baseline characteristics did not significantly differ between cohorts, and the improvement in DTN time was associated with better outcomes after discharge (patients with a 0-2 score on the modified rankin scale: 59% in the 2015 cohort vs 42.4% in the 2014 cohort; P<0.01). During the 1-year QI process, the median DTN time decreased by 15% (from 65min in the first trimester to 55min in the last trimester; P≤0.04) with a non-significant 1.5-fold increase in the proportion of treated patients with a DTN time≤60min (from 41% to 62%; P=0.09).
  
  
  CONCLUSIONS
  It is feasible to deliver tPA to patients with AIS within 60min in a general hospital, using MRI as the routine screening modality, making this QI process to reduce DTN time widely applicable to other secondary general hospitals.
authors.affiliation: Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France; Agence régionale de santé Languedoc-Roussillon et Midi-Pyrénées (ARS-LRMP), 28, parc club du Millénaire, 1025, avenue Henri-Becquerel, 34067 Montpellier, France. Electronic address: denis.sablot@ch-perpignan.fr.
authors.forename: D
authors.initials: D
authors.lastname: Sablot
authors.affiliation: Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: N
authors.initials: N
authors.lastname: Gaillard
authors.affiliation: Service d'accueil des urgences/SMUR 66, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: C
authors.initials: C
authors.lastname: Colas
authors.affiliation: Service de radiologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: P
authors.initials: P
authors.lastname: Smadja
authors.affiliation: Service d'accueil des urgences/SMUR 66, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: C
authors.initials: C
authors.lastname: Gely
authors.affiliation: Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: A
authors.initials: A
authors.lastname: Dutray
authors.affiliation: Service d'accueil des urgences/SMUR 66, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: J-M
authors.initials: JM
authors.lastname: Bonnec
authors.affiliation: Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: S
authors.initials: S
authors.lastname: Jurici
authors.affiliation: Service de radiologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: G
authors.initials: G
authors.lastname: Farouil
authors.affiliation: Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: A
authors.initials: A
authors.lastname: Ferraro-Allou
authors.affiliation: Service d'accueil des urgences/SMUR 66, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: M
authors.initials: M
authors.lastname: Jantac
authors.affiliation: Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: T
authors.initials: T
authors.lastname: Allou
authors.affiliation: Service d'accueil des urgences/SMUR 66, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: C
authors.initials: C
authors.lastname: Pujol
authors.affiliation: Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: N
authors.initials: N
authors.lastname: Olivier
authors.affiliation: Service d'accueil des urgences/SMUR 66, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: A
authors.initials: A
authors.lastname: Laverdure
authors.affiliation: Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: B
authors.initials: B
authors.lastname: Fadat
authors.affiliation: Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: J
authors.initials: J
authors.lastname: Mas
authors.affiliation: Service de neurologie, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: A
authors.initials: A
authors.lastname: Dumitrana
authors.affiliation: Service d'accueil des urgences/SMUR 66, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: Y
authors.initials: Y
authors.lastname: Garcia
authors.affiliation: Service de neurologie, centre hospitalier, boulevard Dr-Lacroix, 11100 Narbonne, France.
authors.forename: H
authors.initials: H
authors.lastname: Touzani
authors.affiliation: Service de la qualité, centre hospitalier Saint-Jean, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France.
authors.forename: P
authors.initials: P
authors.lastname: Perucho
authors.affiliation: Service de neurologie, CHU Minjoz, 3, boulevard A-Flemming, 25030 Besançon, France.
authors.forename: T
authors.initials: T
authors.lastname: Moulin
authors.affiliation: Agence régionale de santé Languedoc-Roussillon et Midi-Pyrénées (ARS-LRMP), 28, parc club du Millénaire, 1025, avenue Henri-Becquerel, 34067 Montpellier, France.
authors.forename: C
authors.initials: C
authors.lastname: Richard
authors.affiliation: Agence régionale de santé Languedoc-Roussillon et Midi-Pyrénées (ARS-LRMP), 28, parc club du Millénaire, 1025, avenue Henri-Becquerel, 34067 Montpellier, France.
authors.forename: C
authors.initials: C
authors.lastname: Heroum
authors.affiliation: Agence régionale de santé Languedoc-Roussillon et Midi-Pyrénées (ARS-LRMP), 28, parc club du Millénaire, 1025, avenue Henri-Becquerel, 34067 Montpellier, France.
authors.forename: S
authors.initials: S
authors.lastname: Bouly
authors.affiliation: Agence régionale de santé Languedoc-Roussillon et Midi-Pyrénées (ARS-LRMP), 28, parc club du Millénaire, 1025, avenue Henri-Becquerel, 34067 Montpellier, France.
authors.forename: C
authors.initials: C
authors.lastname: Sagnes-Raffy
authors.affiliation: Agence régionale de santé Languedoc-Roussillon et Midi-Pyrénées (ARS-LRMP), 28, parc club du Millénaire, 1025, avenue Henri-Becquerel, 34067 Montpellier, France.
authors.forename: D
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authors.lastname: Heve
mesh_terms: D061605:Administration, Intravenous; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000175:diagnosis* / Q000188:drug therapy*; D004632:Emergency Medical Services / Q000592:standards; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D005602:France; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009339:Needles; D058996:Quality Improvement; D020521:Stroke / Q000175:diagnosis* / Q000188:drug therapy*; D013997:Time Factors; D061665:Time-to-Treatment / Q000592:standards*
chemical_list: D005343:Fibrinolytic Agents
keywords: Acute stroke therapy; Door-to-needle; Ischemic stroke; Quality improvement; Reperfusion; Stroke; Stroke management; Stroke units; Thrombectomy; Thrombolysis; tPA