Ischemic strokes are caused by a clot obstructing important arteries that supply the brain. The best treatment for this problem is to promptly degrade this clot with a process called thrombolysis. Thrombolysis is most commonly achieved using Alteplase IV tissue plasminogen activator (rt-PA)¹. The administration of rt-PA in a timely manner allows blood to return to the region of stroke and help to mitigate possible long-term damage.  

Door to needle time refers to the time that elapses from initial presentation to the emergency department and administration of rt-PA. The American Heart Association/American Stroke Association recommends that administration of rt-PA occur less than 60 minutes from when the patient first enters the emergency department². Achieving the recommended benchmark for this metric is vital in ensuring the best possible outcome for the stroke patient¹.  

The data from the Arkansas Stroke Registry (ASR) shows that the percentage of patients recieving timely rt-PA has been increasing since 2014, and is slowly approaching 75%.   

Source: ¹Robinson, T., Zaheer, Z., & Mistri, A. K. (2011). Thrombolysis in acute ischaemic stroke: an update. Therapeutic advances in chronic disease, 2(2), 119-31.

Source:² https://www.heart.org/idc/groups/ahaecc-public/@wcm/@gwtg/documents/downloadable/ucm_491528.pdf

• Acute Stroke Care Task Force
• American College of Cardiology 
• Arkansas Department of Health Tobacco Cessation and Prevention Branch 
• Arkansas Department of Health Trauma Branch – Stroke and STEMI Section 
• Arkansas Department of Health Chronic Disease Branch 
• Heart Disease and Stroke Prevention Coalition 
• Mercy Telestroke System 
• UAMS Center for Distance Health - AR SAVES (Arkansas Stroke Assistance through Virtual Emergency Support)

Evidence demonstrates that rapid initiation of thrombolytic therapy is imperative for positive patient outcomes in the setting of acute stroke¹. These outcomes include mortality as well as functional ability after stroke. This particular study found that with every 10-minute delay in thrombolysis within the 3-hour window, 0.9 fewer patients had an improved disability outcome. Additionally, for every 15 minutes that rt-tPA was initiated sooner, patients demonstrated having a 4% greater odds of walking indecently at discharge, a 3% greater odds of being discharged to home, and a 4% lower odds of death before discharge². These results stress the need for action to time to IV thrombolysis benchmarks established by the American Heart Association. 

Source: ¹Robinson, T., Zaheer, Z., & Mistri, A. K. (2011). Thrombolysis in acute ischaemic stroke: an update. Therapeutic advances in chronic disease, 2(2), 119-31.

Source: ²Saver JL, Fonarow GC, Smith EE, et al. Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke. JAMA. 2013;309(23):2480–2488. doi:10.1001/jama.2013.6959

The Arkansas Department of Health (ADH) has implemented a quality improvement initiative that addresses the issue of prompt rt-tPA administration. A series of questions are discussed with Arkansas hospitals’ stroke teams which include:

1. If IV-tPA is given is the patient kept at the facility or transferred post-administration
2. Are you using the “patient-related delays” to remove appropriate patients from the denominator
3. Is tele-medicine used to administer IV-tPA
4. Is the lack of adherence to the measure related to delays in administration?

This an opportunity to review this specific time targets, which is critical for timely administration of IV-tPA. Timely administration increases the potential for a favorable outcome, while decreasing the risk for a complication, and all hospitals’ stroke nurse coordinators and stroke data abstractors are asked to know and review inclusion and exclusion criteria for IV-tPA. The complexity of determining eligibility criteria and the availability of expertise and required resources may negatively impact door-to-needle treatment time. Hospitals’ stroke nurse coordinators conduct a filtering report to identify why stroke cases fall out this measure and identify any gaps such as too much time on assessments, too much time drawing and receiving lab results, and/or reaching the CT scan. Once possible gaps are identified, improvement initiatives may be discussed and implemented to improve this measure. Hospitals’ stroke team performs a routine audit monthly or quarterly of each stroke case to determine if the low adherence rate is related to missed documentation. If so, this information can be uploaded into GWTG-SPMT and a second report can be generated to show an improved adherence rate.

The ADH State Stroke Coordinators works with hospitals’ stroke team to develop if it’s not already in use, a single call notification for acute stroke patients. This single call notification will be considered the “Code Stroke Activation Number” and will be provided to every medical staff involved in treating acute stroke patients. If this next quality improvement initiative is not already in effect, it is recommended to integrate “priority in CT scanning” as a standard in acute stroke protocols. One of the major causes for increased door-to-CT times is the delayed wait time for a CT scan. By integrating a CT priority, after activation of a “Code Stroke” this standard of practice for treating acute strokes has greatly improved adherence rates. Also, assistance is given to hospitals’ stroke teams to make the reporting of lab results a priority for all suspected acute stroke patients. Hospitals’ stroke nurse coordinators are asked to collaborate with hospitals’ lab managers to ensure that blood samples of suspected stroke patients receive precedence. This quality improvement initiative has improved the available lab results within 20-30 minutes.