Emergency Department Factors that Negatively Impact Door To Needle Time In Acute Stroke
Andrew Hanna1, Joshua Tsau1, Tej Stead2, Ankur Garg3, Mohammed Khan4, Paul Banerjee1, Latha Ganti1,5
1University of Central Florida, 2Brown University, 3Orlando Neurosurgery, 4Osceola Regional Medical Center, 5Envision Physician Services
Objective:

The current study aimed to identify which emergency department (ED) factors impact door to needle time (DTN) in acute stroke patients eligible for intravenous thrombolysis.

Background:

Shorter time to thrombolytics reduces mortality and symptomatic intracranial hemorrhage, and results in higher rates of independent ambulation at discharge and discharge to home following acute ischemic stroke. These findings support intensive efforts to accelerate time thrombolytic treatment.

Design/Methods:

This was an IRB approved prospective observational quality registry study that included all patients that received alteplase (tPA) in the ED. The time of patent arrival to the ED was captured via the timestamp in the electronic health record, and categorized as either being during the “day shift” (6a-6p), or the “night shift” (6p-6a). Arriving between Friday 6pm and Monday 6 am was classified as “weekend,” regardless of time of arrival.

Results:

The majority of the cohort (n=100) presented during day shift (47%), followed by weekend (30%) and night shift (23%). 85% arrived via emergency medical services (EMS). The median age was 67 years (IQR 55-80). The median time to CT read was 22  minutes (IQR 17-31, range 5-102 minutes). A dedicated advanced practice provider (ARNP) was present 63% of the time.

Arriving on Night shift was associated with significantly longer DTN (P<0.0001, R2=19.2%). Patients who arrived as walk-ins, were significantly more likely to have longer DTNs (P=0.0131, 95% CI 4.58 to 38.0). Longer time to CT read also meant longer DTN (P<0.0001, R2=19.1%). Conversely, the presence of an ARNP was associated with a significantly shorter DTN (P<0.0001, R2=22.1%).  Older patients were also more likely to have shorter DTN (P=0.0146, 95% CI -0.0102 to -0.0012).

Conclusions:

Factors that contribute most to delay in DTN include arrival during the night shift, lack of dedicated stroke team provider, longer time to CT read, arrival as a walk in and younger age.