Identification of Rate-Limiting Steps in the Provision of Thrombolytics for Acute Ischemic Stroke

Tissue plasminogen activator (tPA) is the only pharmacotherapy shown to improve outcomes in acute ischemic stroke. The American Heart Association (AHA) recommends a door-to-needle (DTN) time of <60 minutes in at least 50% of patients presenting with acute ischemic stroke.

The purpose of this study was to analyze the possible barriers that may delay tPA administration within the emergency department (ED) of an academic medical center.

A retrospective chart review was conducted from February 2011 to October 2013. Patients were included if they were admitted through the ED with a diagnosis of acute ischemic stroke and received tPA.

Of the 130 patients who met inclusion criteria, 43.1% received tPA in ≤60 minutes. Several factors were identified to be significantly different in those with a DTN time of >60 minutes-time to ED physician consultation, neurologist arrival, blood sample acquisition, and result time ( P < .05 for all comparisons). Correlation analysis demonstrated several independent variables associated with DTN time of ≤60 minutes-time from admission to ED physician consultation, receipt of computed tomography (CT) scan, blood sample acquisition, laboratory results, and neurology service arrival ( P < .05 for all comparisons).

The findings from this study highlight the importance of prompt physician evaluation, direct transfer to the CT scanner, and a quick turnaround time on laboratory values. The development of protocols to ensure the rapid receipt of tPA therapy should focus on limiting any potential delay these steps may cause.