Door-to-Needle Times
Let’s Not Leave Smaller Hospitals Behind
Eric E. Smith, MD, MPH
See related article, p 1275.
n this issue of Stroke, Strbian et al1 present disappointing data on door-to-needle times (DNTs) for tissue-type
plasminogen activator (tPA) from the Safe Implementation
of Thrombolysis in Stroke (SITS) registry. Not only was the
median DNT 67 minutes long, but also there was little overall
change from 2003 to 2011 (see Figure 1 of Strbian et al1).
This means that more than half of patients were treated >60
minutes after emergency department arrival, an unacceptably
long interval.
DNTs in North America in this time period were slightly
longer. In the US national Get With The Guidelines-Stroke
(GWTG-Stroke) database, median DNT from 2003 to 2009
was 78 minutes.2 In the Registry of the Canadian Stroke
Network, median DNT from 2008 to 2009 was 72 minutes.3
However, hidden within these overall disappointing data
there is a glimmer of hope. The largest volume hospitals in
SITS, treating >75 to 100 patients per year, had not only
lower times overall but also a deep and sustained drop in
DNT over time.
The earliest joining large hospitals, treating >100 patients
per year, experienced a decrease in median DNT from just
>50 minutes in 2003 to ≈30 minutes by 2008, followed by a
sustained plateau through 2011 (Figure 2 of Strbian et al1).
Similar but not as dramatic decreases in DNT can be appreciated in hospitals treating 75 to 99 patients per year (Figures 1B
and 2 of Strbian et al1). Statistical modelling, adjusted for all
covariates, confirmed a highly significant interaction between
calendar year and hospital tPA volume, with the higher volume hospitals experiencing much larger decrease over time in
DNT compared with smaller volume hospitals (Table II in the
online-only Data Supplement of Strbian et al1).
Clearly, these larger hospitals have, over time, learned
how to shorten their DNTs. The problem is that because
there are few large volume hospitals, most patients are
treated at the smaller volume hospitals that struggle to give
tPA rapidly. Among the early adopters joining the registry in
2003, 81% of the patients were treated at hospitals with tPA
case volumes <75 patients per year and 49% were treated at
hospitals with tPA case volumes <25 patients per year (Table
1 of Strbian et al1). Registry growth from 2006 to 2011 has
almost exclusively consisted of new small volume hospitals.
In 2009 to 2011, 84% of newly joining hospitals treated <5
patients per year.
The challenge, then, is how to transfer DNT best practices
from large hospitals to small hospitals. This knowledge transfer could occur in the context of professional conferences,
symposia, and webinars. Registries, such as SITS and GWTGStroke, can facilitate such knowledge exchange among their
member hospitals.
However, not all best practices at larger volume hospitals
will transfer directly to smaller volume hospitals. Hospital
strategies associated with shorter DNT have been studied,
but not stratified by hospital case volume.4 Smaller hospitals
have their own, unique challenges, including fewer resources,
smaller stroke teams, lack of specialists, absence of trainees,
and less case volume with which to build experience. In
many cases, smaller hospitals need to access stroke specialist
expertise via telestroke. To facilitate transfer of knowledge
of best practices by smaller volume hospitals, more research
is needed on the distribution of DNT within these hospitals
to see which are consistently capable of giving tPA quickly.
These high performing smaller volume hospitals could be
surveyed to identify their secrets for success, which could
then be disseminated to their peer hospitals. In addition, more
research is needed to identify the factors affecting DNT in
telestroke.
Certification programs could provide incentives for smaller
volume hospitals to acquire the knowledge and skills to give
tPA rapidly. The American Heart Association/American
Stroke Association-sponsored Target: Stroke program successfully reduced DNT from 74 minutes in 2009 to 59 minutes in 20135; given the findings of Strbian et al, it will be
important to analyze whether DNT improvements in Target:
Stroke were seen in all hospitals or were limited to larger
hospitals. The ongoing Reduction of In-hospital Delays in
Stroke Thrombolysis (SITS-WATCH) study seeks to reduce
DNT to <45 minutes in SITS hospitals (clinicaltrials.gov
NCT018119001).
Currently, many large, academic hospitals are focusing their
efforts on reducing DNT to the bare minimum.6 The question
for these centers is: how low can we go?7 However, let’s not
leave smaller hospitals behind—collectively, they are treating
many stroke patients.
I
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The opinions expressed in this article are not necessarily those of the
editors or of the American Heart Association.
From the Department of Clinical Neurosciences and Hotchkiss Brain
Institute, University of Calgary, AB.
Guest Editor for this article was Jeffrey L. Saver, MD.
Correspondence to Eric E. Smith, MD, MPH, Department of Clinical
Neurosciences and Hotchkiss Brain Institute, University of Calgary,
Foothills Medical Centre, Room C1212, 1403 29 St NW, Calgary, Alberta
T2N 2T9, Canada. E-mail [email protected]
(Stroke. 2015;46:1158-1159.
DOI: 10.1161/STROKEAHA.115.008974.)
© 2015 American Heart Association, Inc.
Disclosures
Dr Smith is a member of the Get With The Guidelines Steering
Committee, for which he receives no financial reimbursement.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.115.008974
1158
Smith Door-to-Needle Times in Small Hospitals 1159
References
1. Strbian D, Ahmed N, Wahlgren N, Lees KR, Toni D, Roffe C,et al. Trends in
door-to-thrombolysis time in the Safe Implementation of Stroke Thrombolysis
registry: effect of center volume and duration of registry membership. Stroke.
2015;46:1275–1280. doi: 10.1161/STROKEAHA.114.007170.
2. Fonarow GC, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Grau-Sepulveda
MV, et al. Timeliness of tissue-type plasminogen activator therapy in acute
ischemic stroke: patient characteristics, hospital factors, and outcomes
associated with door-to-needle times within 60 minutes. Circulation.
2011;123:750–758. doi: 10.1161/CIRCULATIONAHA.110.974675.
3. Lindsay P, Cote R, Hill MD, Kapral M, Kaczorowski J, Korner-Bitensky
N, et al. The Quality of Stroke Care in Canada. Canadian Stroke Best
Practices Web site. 2011. http://www.strokebestpractices.ca/wp-content/
uploads/2011/06/QoSC-EN.pdf. Accessed March 9, 2015.
4. Xian Y, Smith EE, Zhao X, Peterson ED, Olson DM, Hernandez AF, et al.
Strategies used by hospitals to improve speed of tissue-type plasminogen
activator treatment in acute ischemic stroke. Stroke. 2014;45:1387–1395.
doi: 10.1161/STROKEAHA.113.003898.
5. Fonarow GC, Zhao X, Smith EE, Saver JL, Reeves MJ, Bhatt DL, et
al. Door-to-needle times for tissue plasminogen activator administration
and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA. 2014;311:1632–1640. doi: 10.1001/
jama.2014.3203.
6. Meretoja A, Strbian D, Mustanoja S, Tatlisumak T, Lindsberg PJ, Kaste
M. Reducing in-hospital delay to 20 minutes in stroke thrombolysis.
Neurology. 2012;79:306–313. doi: 10.1212/WNL.0b013e31825d6011.
7. Smith EE, von Kummer R. Door-to-needle times in acute ischemic
stroke: how low can we go? Neurology. 2012;79:296–297. doi: 10.1212/
WNL.0b013e31825d602e.
Key Words: Editorials ◼ stroke
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Door-to-Needle Times: Let's Not Leave Smaller Hospitals Behind
Eric E. Smith
Downloaded from http://stroke.ahajournals.org/ by guest on July 28, 2017
Stroke. 2015;46:1158-1159; originally published online March 31, 2015;
doi: 10.1161/STROKEAHA.115.008974
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