title: Collaborative Interventions Reduce Time-to-Thrombolysis for Acute Ischemic Stroke in a Public Safety Net Hospital.
abstract: OBJECTIVE
  Shorter time-to-thrombolysis in acute ischemic stroke (AIS) is associated with improved functional outcome and reduced morbidity. We evaluate the effect of several interventions to reduce time-to-thrombolysis at an urban, public safety net hospital.
  
  
  METHODS
  All patients treated with tissue plasminogen activator for AIS at our institution between 2008 and 2015 were included in a retrospective analysis of door-to-needle (DTN) time and associated factors. Between 2011 and 2014, we implemented 11 distinct interventions to reduce DTN time. Here, we assess the relative impact of each intervention on DTN time.
  
  
  RESULTS
  The median DTN time pre- and postintervention decreased from 87 (interquartile range: 68-109) minutes to 49 (interquartile range: 39-63) minutes. The reduction was comprised primarily of a decrease in median time from computed tomography scan order to interpretation. The goal DTN time of 60 minutes or less was achieved in 9% (95% confidence interval: 5%-22%) of cases preintervention, compared with 70% (58%-81%) postintervention. Interventions with the greatest impact on DTN time included the implementation of a stroke group paging system, dedicated emergency department stroke pharmacists, and the development of a stroke code supply box.
  
  
  CONCLUSIONS
  Multidisciplinary, collaborative interventions are associated with a significant and substantial reduction in time-to-thrombolysis. Such targeted interventions are efficient and achievable in resource-limited settings, where they are most needed.
authors.affiliation: Department of Neurology, University of California, San Francisco, San Francisco, California; Department of Neurology, Zuckerberg San Francisco General Hospital, San Francisco, California; Department of Neurology, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Zachary D
authors.initials: ZD
authors.lastname: Threlkeld
authors.affiliation: School of Medicine, University of California, San Francisco, San Francisco, California.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Kozak
authors.affiliation: Department of Radiology, University of California, San Francisco, San Francisco, California.
authors.forename: David
authors.initials: D
authors.lastname: McCoy
authors.affiliation: Department of Neurology, Zuckerberg San Francisco General Hospital, San Francisco, California.
authors.forename: Sara
authors.initials: S
authors.lastname: Cole
authors.affiliation: Department of Neurology, Zuckerberg San Francisco General Hospital, San Francisco, California.
authors.forename: Christine
authors.initials: C
authors.lastname: Martin
authors.affiliation: Department of Neurology, University of California, San Francisco, San Francisco, California; Department of Neurology, Zuckerberg San Francisco General Hospital, San Francisco, California. Electronic address: Vineeta.Singh@ucsf.edu.
authors.forename: Vineeta
authors.initials: V
authors.lastname: Singh
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000188:drug therapy*; D002533:Cerebral Angiography / Q000379:methods; D000072226:Computed Tomography Angiography; D003299:Cooperative Behavior; D019091:Critical Pathways / Q000458:organization & administration; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006779:Hospitals, Public / Q000458:organization & administration*; D006801:Humans; D033183:Interdisciplinary Communication; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team / Q000458:organization & administration; D012189:Retrospective Studies; D064876:Safety-net Providers / Q000458:organization & administration*; D020521:Stroke / Q000000981:diagnostic imaging / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000379:methods*; D013997:Time Factors; D061665:Time-to-Treatment; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000009:adverse effects; D016896:Treatment Outcome; D057188:Workflow
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Stroke; cerebrovascular disorders; safety net hospital; thrombolytic therapy