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Reducing Door-to-Needle Times for Ischaemic Stroke to a Median of 30 Minutes at a Community Hospital

  • Noreen Kamal (a1), Elaine Shand (a2), Robert Swanson (a2), Michael D. Hill (a1) (a3), Thomas Jeerakathil (a4), Oje Imoukhuede (a2), Irvin Heinrichs (a2), Jackie Bakker (a2), Carol Stoyberg (a2), Laura Fowler (a2), Sandy Duckett (a2), Scott Holsworth (a2), Balraj Mann (a5), Shelley Valaire (a5) and Jennifer Bestard (a3)...

Abstract

Background

Alteplase is an effective treatment for ischaemic stroke patients, and it is widely available at all primary stroke centres. The effectiveness of alteplase is highly time-dependent. Large tertiary centres have reported significant improvements in their door-to-needle (DTN) times. However, these same improvements have not been reported at community hospitals.

Methods

Red Deer Regional Hospital Centre (RDRHC) is a community hospital of 370 beds that serves approximately 150,000 people in their acute stroke catchment area. The RDRHC participated in a provincial DTN improvement initiative, and implemented a streamlined algorithm for the treatment of stroke patients. During this intervention period, they implemented the following changes: early alert of an incoming acute stroke patient to the neurologist and care team, meeting the patient immediately upon arrival, parallel work processes, keeping the patient on the Emergency Medical Service stretcher to the CT scanner, and administering alteplase in the imaging area. Door-to-needle data were collected from July 2007 to December 2017.

Results

A total of 289 patients were treated from July 2007 to December 2017. In the pre-intervention period, 165 patients received alteplase and the median DTN time was 77 minutes [interquartile range (IQR): 60–103 minutes]; in the post-intervention period, 104 patients received alteplase and the median DTN time was 30 minutes (IQR: 22–42 minutes) (p < 0.001). The annual number of patients that received alteplase increased from 9 to 29 in the pre-intervention period to annual numbers of 41 to 63 patients in the post-intervention period.

Conclusion

Community hospitals staffed with community neurologists can achieve median DTN times of 30 minutes or less.

Dans un hôpital communautaire, réduire à une médiane de 30 minutes le temps de réponse entre l’arrivée d’un patient victime d’un AVC ischémique et l’injection d’un traitement thrombolytique.

Contexte

L’altéplase est un traitement efficace dans le cas de patients victimes d’AVC ischémiques et demeure largement disponible dans les centres de soins de niveau primaire dédiés aux AVC. Cela dit, son efficacité dépend fortement des délais en fonction desquels on peut l’administrer. À cet égard, les centres de soins de niveau tertiaire ont fait état d’importantes améliorations en ce qui regarde leurs délais entre l’arrivée de patients et l’injection d’un traitement thrombolytique. Toutefois, il semble que de telles améliorations n’ont pas été signalées dans les hôpitaux communautaires.

Méthodes

Le Red Deer Regional Hospital Centre (RDRHC) est un hôpital communautaire de 370 lits qui dessert approximativement 150 000 personnes dans sa zone d’attraction. Cet hôpital a participé à une initiative provinciale de réduction des délais mentionnés ci-dessus. Pour ce faire, il a mis au point un algorithme simplifié en vue du traitement de patients victimes d’AVC. Au cours de cette période d’intervention, les mesures de changement suivantes ont donc été adoptées : des alertes précoces transmises à un neurologue et aux équipes soignantes au moment de l’admission de patients victimes d’AVC aigus ; des rencontres immédiates avec les patients, et ce, dès leur arrivée à l’hôpital ; des processus de travail menés de façon parallèle ; le maintien des patients dans une civière d’ambulance jusqu’à temps qu’on puisse les conduire à un tomodensitomètre ; enfin, le fait d’administrer l’altéplase en fonction de la zone atteinte révélée par imagerie. Soulignons enfin que nos données en matière de réduction des délais ont été collectées de juillet 2007 à décembre 2017.

Résultats

Au total, 289 patients ont été traités durant cette période. Au cours de la période antérieure à l’initiative évoquée précédemment, 165 patients ont bénéficié d’un traitement à l’altéplase ; les délais médians entre l’arrivée des patients et l’injection de ce médicament thrombolytique étaient alors de 77 minutes (EI : 60-103 minutes). Une fois mise en place l’initiative de réduction des délais, 104 patients ont reçu un traitement à l’altéplase ; cette fois, les délais médians du RDRHC étaient de 30 minutes (EI : 22-42 minutes ; p < 0,001). Fait à noter, le nombre annuel de patients ayant bénéficié de l’altéplase est passé de 9 à 29 durant la période pré-initiative et de 41 à 63 lors de la période post-initiative.

Conclusion

Dans le cas des hôpitaux communautaires disposant de neurologues réguliers, il est possible de parvenir à des délais de 30 minutes ou moins entre l’arrivée de patients et l’injection d’un traitement thrombolytique.

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Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corresponding author

Correspondence to: Noreen Kamal, HBA 2938, Health Sciences Centre, 3330 Hospital Drive NW, Calgary, AB, Canada T2N 4N1. Email: nrkamal@ucalgary.ca

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Canadian Journal of Neurological Sciences
  • ISSN: 0317-1671
  • EISSN: 2057-0155
  • URL: /core/journals/canadian-journal-of-neurological-sciences
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