title: How a CT-Direct Protocol at an American Comprehensive Stroke Center Led to Door-to-Needle Times Less Than 30 Minutes.
abstract: OBJECTIVE
  The safety and efficacy of intravenous tissue plasminogen activator (IV tPA) following acute ischemic stroke (AIS) is dependent on its timely administration. In 2014, our Comprehensive Stroke Center designed and implemented a computed tomography-Direct protocol to streamline the evaluation process of suspected patients with AIS, with the aim of reducing door-to-needle (DTN) times. The objectives of our study were to describe the protocol development and implementation process, and to compare DTN times and symptomatic intracranial hemorrhage (sICH) rates before and after protocol implementation.
  
  
  METHODS
  Data were prospectively collected for patients with AIS receiving IV tPA between January 1, 2010, and May 31, 2015. The DTN times, examined as median times and time treatment windows, and sICH rates were compared pre- and postimplementation.
  
  
  RESULTS
  Two hundred ninety-five patients were included in the study. After protocol implementation, median DTN times were significantly reduced (38 vs 28 minutes;P< .001). The distribution of patients treated in the three time treatment windows described below changed significantly, with an increase in patients with DTN times of 30 minutes or less, and a decrease in patients with DTN times 31 to 60 minutes and over 60 minutes (P< .001). There were two cases of sICH prior to implementation and one sICH case postimplementation.
  
  
  CONCLUSIONS
  The implementation of a protocol that streamlined the processing of suspected patients with AIS significantly reduced DTN time without negatively impacting patient safety.
authors.affiliation: Department of Trauma and Stroke Research, Swedish Medical Center, Englewood, CO, USA.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Caputo
authors.affiliation: Department of Neurology, Swedish Medical Center, Englewood, CO, USA.
authors.forename: Judd
authors.initials: J
authors.lastname: Jensen
authors.affiliation: Department of Neurology, Swedish Medical Center, Englewood, CO, USA.
authors.forename: Michelle
authors.initials: M
authors.lastname: Whaley
authors.affiliation: Emergency Department, Swedish Medical Center, Englewood, CO, USA.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Kozlowski
authors.affiliation: Department of Neurology, Swedish Medical Center, Englewood, CO, USA.
authors.forename: Christopher V
authors.initials: CV
authors.lastname: Fanale
authors.affiliation: Department of Neurology, Swedish Medical Center, Englewood, CO, USA.
authors.forename: Jeffrey C
authors.initials: JC
authors.lastname: Wagner
authors.affiliation: Department of Trauma and Stroke Research, Swedish Medical Center, Englewood, CO, USA.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Orlando
authors.affiliation: Department of Trauma and Stroke Research, Swedish Medical Center, Englewood, CO, USA.
authors.forename: David
authors.initials: D
authors.lastname: Bar-Or
keywords: acute stroke; door-to-needle time; evidence-based medicine; ischemic stroke; tissue-type plasminogen activator