Transcript Door to Needle” (DTN) Time in Stroke Thrombolysis

“Door to Needle (DTN) Time in Stroke
Thrombolysis” Audit
Care of the Elderly Department
Dr Nikoletta Petrou, Foundation Year 1 Doctor
Dr Prasanna Aghoram, Consultant Physician in Stroke Medicine
How did this Audit come about?
Reason for the Audit:
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Agreement in Stroke Network: Aim DTNt <60min
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This audit is a local initiative to measure current DTN times
This audit aims to:
① Evaluate if appropriate patients are thrombolysed within 1 hour of A&E arrival
② Evaluate if patients with delayed DTN times have clear reasons for their delays
③ Suggest appropriate action plans to improve patient care
“Time Lost is Brain Lost”
 Stroke facts
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Every minute 1.9 million neurons and 14 billion synapses are destroyed
Every hour that treatment is delayed, the ischaemic brain ages 3.6 years
Time = Brain
The Golden hour
 No current NICE guidelines on DTN time in Stroke Thrombolysis
 Recommendations to date have been consistent re: DTN <60min
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American Heart Association/American Stroke Association: Get with the Guidelines®
Joint Committee (USA) sets a standard of 80% for DTN <60min
National Institute of Neurological Disorders and Stroke
Brain Attack Coalition sets a standard of 80% for DTN <60min
 International Stroke Conference – Only 27% of patients have DTNt <60min
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G. Fonarow et al, University of California, Los Angeles (2011)
INCLUSION CRITERIA
The Golden Hour
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THROMBOLYSIS PATHWAY
➊ Arrival to A&E
➋ A&E assessment
EXCLUSION CRITERIA
➌ Stroke team notified
➍ Priority CT Head
➎ Stroke team Assessment
➏ CT scan performed
➐ CT report obtained
➑ Patient informed and
consent obtained
➒ Reconstitution and drawing
up of Alteplase
➓ Thrombolysis is initiated
Clinical signs and symptoms of definite acute stroke
Clear time of onset
Presentation within 3 hrs of acute onset
Haemorrhage excluded by CT scan
Age 18 - 80 years old
NIHSS less than 25
Consent to treat (every effort must be made to contact next of kin)
DTN
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Rapidly improving or minor stroke symptoms
Stroke or serious head injury 3 months
Major surgery, obstetrical delivery, external heart massage last 14 days,
Seizure at onset of stroke
Prior stroke and concomitant diabetes
Severe haemorrhage last 21 days
Increase bleeding risk
History of central nervous damage (neoplasm, haemorrhage, aneurysm,
spinal or intracranial surgery or haemorrhagic retinopathy)
Blood pressure above 185 mmHg systolic or 110 mmHg diastolic
Symptoms suggestive of SAH (even if CT is normal)
Known clotting disorder
Patient on heparin or warfarin
Suspected iron deficient anaemia or thrombocytopenia
Suspected hypoglycaemia or hyper glycaemia >3 mmol/l > 22 mmol/l
Bacterial endocarditis, pericarditis
Acute pancreatitis
Ulcerative GI disease last 3 months, oesophageal varices, arterialaneurysm, arterial/venous malformation.
Severe liver disease including cirrhosis, acute hepatitis
Standards
Standard 1
• Appropriate patients should have DTNt <60min
• Target 80%
• Exempted: patients in international trials and patients whose
hypertension required immediate treatment to allow thrombolysis to be
considered
Standard 2
• Patients with DTNt >60min should have a reason for the delay
• Target 80%
Methods
 Analysis of Stroke Database
 Demographics and Consultant
 Time of symptom onset
 Time of arrival to A&E
 Time of stroke team arrival
 Time of Head CT scan
 Time of Alteplase given
 Prior BP control noted
 DTNt was calculated
 Reasons for delay were noted
Audit tool
 Four categories of DTN: <60min, 60-75min, 75-90min and >90min delay
Standard 1
DTN times of Thrombolysis in appropriate patients at DVH
(April 2009 - September 2011)
DTN Time (min)
>60
27
<60
3
0
5
10
15
20
Number of Patients
25
43 patients thrombolysed ** 30 included ** Median DTNt 85 min
✘Target of 80% was not met
30
Analysis
Cumulative results of DTN times
Number of patients
35
30
30
10% had DTN <60min
25
13% had DTN <65min
19
20
17% had DTN <70min
15
27% had DTN <75min
10
5
63% had DTN <90min
8
3
0
<60
<75
<90
DTN time (min)
Total
Results by Year
2009
2010
10%
40%
10%
<60
60-75
28%
43%
75-90
40%
60-75
75-90
>90
>90
29%
2011
● More patients are thrombolysed in under
15%
31%
90 min compared to previous years
15%
● More patients are thrombolysed in under
75 min compared to previous years
39%
<60
60-75
75-90
>90
Standard 2
Identified reasons for delay across all groups
DTN delay (min)
Total
16
>90
59% have identified
reasons for delay
11
11
75-90
5
Identified reason
6
No reason identified
60-75
5
0
5
10
15
20
Number of patients
25
30
 All patients with DTN time > 90min have clear reasons documented by the Consultant
 Minor time losses are spread across the pathway and not documented
Analysis
Reasons for DTN time delay in DVH
Reason for delay
Delay in Consent
7
Medical Reason
4
CT Delay
3
Language Barrier
2
Delayed Referral
1
Raised BP
12
0
2
4
6
8
10
Number of patients
12
14
Analysis
Patient vs. Hospital-related causes of delay in Patients
with delayed DTN times
6%
Patient Factors
19%
Hospital Factors
Overlap
75%
 No difference in service speed between day-time and “out of hours” service
Conclusions
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10% of patients were thrombolysed within 60min of arrival to A&E and
63% within 90min.
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Only 27% have DTNt<60min according to the largest study to-date.
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27% can be achieved by reducing pathway delays by 15min.
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15% had DTNt<60min in 2011, an improvement on previous years.
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100% of severe delays (DTNt>90min) have documented reasons and these
are predominantly (75%) due to difficult-to-modify patient-related factors
Conclusions
Patient vs. Hospital-related causes of
delay
DTN times in 2011
31%
15%
15%
<60
60-75
75-90
>90
Patient Factors
6%
Hospital Factors
19%
Overlap
39%
75%
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Important to track minor delays that are usually spread across the pathway
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Priority is ensuring safety of treatment at all times
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In some cases the delay may be inevitable. Alternative is no treatment
Action Plan
Clearly document reasons for delay when DTN time >60min
Use Alteplase dose in whole numbers ** implemented
Use a monitoring tool to track and prevent delays in real-time
**implemented
Inform the relevant departments of current DTN times. Raise
awareness of delay points **implemented
Monitor performance against other UK institutions as data
becomes available
Re-audit annually
ICE 2
Monitoring tool
Important to start
completing when
the patient arrives
in A&E to track
potential time
losses in real time
References
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American Heart Association/American Stroke Association (2011). The Get With The Guidelines®–
Stroke (GWTG-Stroke) program. Website: http://www.strokeassociation.org/STROKEORG
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Fonarow GC, Smith EE, Saver JL (2011). Timeliness of tissue-type plasminogen activator therapy in
acute ischemic stroke: Patient characteristics, hospital factors, and outcomes associated with doorto-needle times within 60 minutes. Circulation 2011: DOI:10.1161
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Mikita M (2011). Reducing Door-to-Needle Time for tPA Use Remains and Elusive Goal in Stroke
Care. JAMA. 2011;305(13):1288-1289
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Sinha D, et al (2009). Door-toNeedle Time for Stroke Thrombolysis. Reasons for delays at busy
District General Hospital. Southend Hospital. Availble online at:
www.stroke.org.uk/document.rm?id=2494
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Susan Boorman (2011). Thrombolysis Audit. Onset-to-alteplase time. Darent Valley Hospital, Audit
Meeting September 2011
Thank you
Questions?
INCLUSION CRITERIA
The Golden Hour
•
•
•
•
•
•
•
THROMBOLYSIS PATHWAY
➊ Arrival to A&E
➋ A&E assessment
EXCLUSION CRITERIA
➌ Stroke team notified
➍ Priority CT Head
➎ Stroke team Assessment
➏ CT scan performed
➐ CT report obtained
➑ Patient informed and
consent obtained
➒ Reconstitution and drawing
up of Alteplase
➓ Thrombolysis is initiated
Clinical signs and symptoms of definite acute stroke
Clear time of onset
Presentation within 3 hrs of acute onset
Haemorrhage excluded by CT scan
Age 18 - 80 years old
NIHSS less than 25
Consent to treat (every effort must be made to contact next of kin)
DTN
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Rapidly improving or minor stroke symptoms
Stroke or serious head injury 3 months
Major surgery, obstetrical delivery, external heart massage last 14 days,
Seizure at onset of stroke
Prior stroke and concomitant diabetes
Severe haemorrhage last 21 days
Increase bleeding risk
History of central nervous damage (neoplasm, haemorrhage, aneurysm,
spinal or intracranial surgery or haemorrhagic retinopathy)
Blood pressure above 185 mmHg systolic or 110 mmHg diastolic
Symptoms suggestive of SAH (even if CT is normal)
Known clotting disorder
Patient on heparin or warfarin
Suspected iron deficient anaemia or thrombocytopenia
Suspected hypoglycaemia or hyper glycaemia >3 mmol/l > 22 mmol/l
Bacterial endocarditis, pericarditis
Acute pancreatitis
Ulcerative GI disease last 3 months, oesophageal varices, arterialaneurysm, arterial/venous malformation.
Severe liver disease including cirrhosis, acute hepatitis