title: Delays in Door-to-Needle Times and Their Impact on Treatment Time and Outcomes in Get With The Guidelines-Stroke.
abstract: Despite quality improvement programs such as the American Heart Association/American Stroke Association Target Stroke initiative, a substantial portion of acute ischemic stroke patients are still treated with tissue-type plasminogen activator (alteplase) later than 60 minutes from arrival. This study aims to describe the documented reasons for delays and the associations between reasons for delays and patient outcomes.
  
  
  
  We analyzed the characteristics of 55 296 patients who received intravenous alteplase in 1422 hospitals participating in Get With The Guidelines-Stroke from October 2012 to April 2015, excluding transferred patients and inpatient strokes. We assessed eligibility, medical, and hospital reasons for delays in door-to-needle time.
  
  
  
  There were 27 778 patients (50.2%) treated within 60 minutes, 10 086 patients (18.2%) treated >60 minutes without documented delays, and 17 432 patients (31.5%) treated >60 minutes with one or more documented reasons for delay. Delayed door-to-needle times were associated with delayed diagnosis (36 minutes longer than those without delay in diagnosis) and hypoglycemia or seizure (34 minutes longer than without those conditions). The presence of documented delays was associated with higher odds of in-hospital mortality (odds ratio, 1.2; 95% confidence interval, 1.1-1.3) and symptomatic intracranial hemorrhage (odds ratio, 1.2; 95% confidence interval, 1.1-1.3) and lower odds of independent ambulation at discharge (odds ratio, 0.92; 95% confidence interval, 0.9-1.0) after adjusting for patient and hospital characteristics.
  
  
  
  Hospital and eligibility delays such as delay diagnosis and inability to determine eligibility were associated with longer door-to-needle times. Improved stroke recognition and management of acute comorbidities may help to reduce door-to-needle times.
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California Los Angeles; Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); and Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.). nrkamal@ucalgary.ca.
authors.forename: Noreen
authors.initials: N
authors.lastname: Kamal
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California Los Angeles; Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); and Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.).
authors.forename: Shubin
authors.initials: S
authors.lastname: Sheng
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California Los Angeles; Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); and Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.).
authors.forename: Ying
authors.initials: Y
authors.lastname: Xian
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California Los Angeles; Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); and Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.).
authors.forename: Roland
authors.initials: R
authors.lastname: Matsouaka
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California Los Angeles; Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); and Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.).
authors.forename: Michael D
authors.initials: MD
authors.lastname: Hill
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California Los Angeles; Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); and Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.).
authors.forename: Deepak L
authors.initials: DL
authors.lastname: Bhatt
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California Los Angeles; Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); and Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.).
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Saver
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California Los Angeles; Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); and Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.).
authors.forename: Mathew J
authors.initials: MJ
authors.lastname: Reeves
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California Los Angeles; Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); and Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.).
authors.forename: Gregg C
authors.initials: GC
authors.lastname: Fonarow
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California Los Angeles; Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); and Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.).
authors.forename: Lee H
authors.initials: LH
authors.lastname: Schwamm
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brian Institute, University of Calgary, Canada (N.K., M.D.H., E.E.S.); Duke Clinical Research Institute, Duke University, Durham, NC (S.S., Y.X., R.M.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X.); Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.M.); Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California Los Angeles; Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); and Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.).
authors.forename: Eric E
authors.initials: EE
authors.lastname: Smith
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000000981:diagnostic imaging* / Q000188:drug therapy*; D003695:Delivery of Health Care / Q000592:standards / Q000706:statistics & numerical data*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D019983:Guideline Adherence; D017052:Hospital Mortality; D006801:Humans; D020300:Intracranial Hemorrhages / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data*; D020521:Stroke / Q000175:diagnosis* / Q000188:drug therapy* / Q000453:epidemiology / Q000401:mortality; D015912:Thrombolytic Therapy / Q000592:standards / Q000706:statistics & numerical data*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage
chemical_list: D005343:Fibrinolytic Agents; C067262:PLAT protein, human; D010959:Tissue Plasminogen Activator
keywords: diagnosis; hypertension; stroke; thrombolytic therapy; tissue-type plasminogen activator