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Data from clinical practice show that median door-to-needle time (DNT) for intravenous thrombolysis (IVT) remains around 60 minutes [1]. However, many reports documented that hospital logistics could be substantially streamlined and DNT shortened below 30 minutes [2]. Given Czech stroke care reform, many stroke centers have recently been changing their logistical pathways with the aim to initiate IVT quicker than before [3]. Several stroke centers introduced one-stop management, which means that all suspected acute ischemic stroke (AIS) patients are admitted directly to the computed tomography (CT) room and IVT is initiated on the CT table. As a consequence, our national data show that some hospitals were able to reach an extremely short DNT, while others were not. The aim of this nationwide study was to understand how logistical pathways are being used, and how they impact quality of patient care as measured by DNT.
This is a nationwide prospective study combining hospital-level data from a questionnaire and patient-level data from the Safe Implementation of Treatments in Stroke (SITS) registry from January 2017 to March 2018 to define differences in logistical pathways for IVT between stroke centers, and to analyze the impact of such differences on DNT. A description of the questionnaire, collection of data on DNT from the SITS registry and statistical analysis is shown in the Supplementary methods [2,4-7].
All 45 stroke centers in the Czech Republic responded. Of these, six centers reported one reorganization and two centers reported two reorganizations in their acute stroke care. During the study period, four centers introduced one-stop management and following differences in median DNT before versus after introduction of one-stop management were reported: 30 minutes vs. 17.5 minutes, 30 minutes vs. 28.5 minutes, 30 minutes vs. 20 minutes, and 45 minutes vs. 28 minutes. The change of proportion of patients with DNT ≤20 minutes in these centers is shown in the Supplementary Table 1. Thus, 55 center-datasets were included in the analysis. Altogether, 5,889 patients were treated with IVT in the study period and had available DNT in the SITS registry. Median DNT ≤20 minutes was achieved in 12 (22%) centers. Overall, 18 (33%) centers reported direct patient admission to CT room, 26 (47%) admission to emergency department, and 11 (20%) to out-patient office. Notably, median DNT was 20 minutes (interquartile range [IQR], 18 to 26) in centers without any transfers, 28 minutes (IQR, 22 to 30) with one transfer and 37 minutes (IQR, 30 to 43) with two transfers before initiation of IVT. Data on stroke logistics stratified based on the place of admission are shown in Supplementary Table 2.
Our study investigated current practice in logistics of IVT in a nationwide sample in the Czech Republic, a country with a large number of thrombolytic treatments and a median national DNT of only 28 minutes in 2017 to 2018. During this period, all stroke centers already met the target of 60 minutes recommended by the most recent guidelines [8] and this happened regardless of differences in stroke pathways. Within the short national DNT, there were still differences in the DNT between stroke centers, with approximately one-fifth of hospitals achieving ultrashort median DNT ≤20 minutes. Logistical pathways in stroke centers have been substantially restructured in many stroke centers allowing direct transport of AIS patients into CT room. Such change increased proportion of patients with DNT ≤20 minutes from 28% to 54%. We found that in one-third of stroke centers AIS patients were still transferred two times within a hospital before initiation of IVT which resulted in nearly doubled DNT compared to hospitals where patients were admitted directly to the CT room and treated on the CT table (37 minutes vs. 20 minutes).
The limitations of our study are inherent to a survey based on a questionnaire. We cannot exclude that there might have been some inaccuracies in reported data. However, all stroke centers collect data on all patients treated with IVT and these data are reported monthly to the Czech Stroke Society and annually to the Ministry of Health. It is also unlikely that hospitals would have provided an incorrect description of their usual logistical pathway, although this pathway does not necessarily apply to all cases. Furthermore, safety and efficacy of ultrafast delivery of recombinant tissue plasminogen activator needs to be documented and is a subject of our ongoing analysis. Applicability of direct transports to CT room is possible only in those countries, which have well functioning emergency medical service (EMS) and a network of stroke centers with adequate capacities and training. In the Czech Republic, EMS always transfers AIS patients to neurologists and there are no legal barriers for direct transfers to CT rooms. As at least one previous study demonstrated national median DNT of 25 minutes [2], our results are independent from specifics of one country’s health care system and should be thus generalizable also to other countries. In our study we demonstrated benefits of direct transport to CT rooms but it is also possible to transfer patients directly to an angio-suite. Such logistics was not reported in our country. Although previous reports documented shortened door-to-groin time for mechanical thrombectomy, generalizability could be even more challenging especially due to technical requirement for angiograms, and availability of interventional team in short time manner [9].
In conclusion, one-third of hospitals nationally adopted one-stop management of IVT on the CT table and this approach provided thrombolytic treatment faster than any other mode of logistics.
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