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Decomposing door-to-needle time: insights into workflow delays and quality improvement in acute stroke care
Lianyan Wei1, Hongfei Li1, Zhuangzhuang Jiang1
1Department of Neurology, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, China.
Background:
Timely administration of intravenous recombinant tissue plasminogen activator (rtPA) significantly improves outcomes in acute ischemic stroke (AIS). However, substantial variability in door-to-needle (DTN) time persists in real-world settings. This study aimed to deconstruct DTN time into distinct workflow intervals to identify key determinants of delay and inform targeted quality improvement.
Methods:
This retrospective study included 322 consecutive AIS patients treated with intravenous rtPA at Dongyang People's Hospital between May 2023 and April 2025. DTN time was divided into four intervals: door-to-order time (ODT), order-to-imaging completion time (OCT), imaging completion-to-consent time (ICT), and consent-to-needle time (CNT). Real-time data were collected through beacon-based tracking and a time-tracking application. Linear regression, correlation, and subgroup analyses were used to explore factors associated with each interval and overall DTN time.
Results:
Among all intervals, ICT showed the strongest correlation with DTN time (r = 0.845, p < 0.01), followed by CNT and OCT. Imaging-guided thrombolysis significantly prolonged DTN time by 32.29 min (p < 0.0001), mainly through delays in ICT and OCT. Thrombolysis led by senior physicians was associated with a 7.61-min reduction in DTN time (p < 0.0001), driven by shorter ICT and CNT. MRI-negative strokes significantly prolonged DTN time by 6.28 min (p < 0.05), primarily due to a delay in ODT. Subgroup analysis revealed that junior physicians were more likely to cause delays during off-hours. Imaging-guided thrombolysis, such as CTP-guided and MRI-guided approaches, significantly prolonged DTN time due to extended OCT and ICT intervals (p < 0.001). Semiannual trends showed a gradual improvement in DTN performance until T3 (May-October 2024), followed by a plateau in T4 (November 2024-April 2025), possibly due to increased use of imaging-guided thrombolysis and more complex referrals.
Conclusion:
Physician seniority, thrombolysis strategy, and MRI-negative status significantly influence DTN time. Segmenting DTN time enables precise identification of key delays across different workflow stages and may enhance the efficiency of acute stroke care.
