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Objective@#To investigate the feasibility of parameter-optimized magnetic resonance imaging (MRI) as the first choice for imaging examination in patients with acute ischemic stroke (AIS), and to assess the effects of quality improvement (QI) measures on shortening the door-to-needle time (DNT).@*Methods@#A retrospective case-control study was conducted. A total of 69 AIS patients hospitalized at the Department of Neurology of the People's Hospital of Wuzhou from August 2015 to July 2018 were enrolled in the study, and the head MRI was used as the first choice for imaging examination. All patients received the intravenous thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA). Patients with AIS undergoing intravenous thrombolysis from August 2015 to March 2017 were included in the control group, and those receiving intravenous thrombolysis after QI measures from April 2017 to July 2018 were included in the experimental group. QI included informing the stroke team in advance by emergency physicians, treatment process changing from serial procedure to the parallel one, optimization of MRI scanning parameters, and use of rapid test instruments. The MRI scanning time was compared between the two groups. The DNT of the two groups was compared, and paired-samples t test was used. The proportion of patients who underwent MRI scan and DNT<60 min was compared between the two groups, and the χ2 test was used.@*Results@#Compared with the control group, the proportion of patients undergoing MRI scan in the experimental group was increased (82% vs 58%, χ2=4.58, P=0.032); MRI scanning time was shortened (4 min 37 s vs 10 min 21 s); DNT (min) was shortened (59.32±10.19 vs 93.48±24.81, t=7.189, P<0.01); and the proportion of patients with DNT<60 min was significantly increased (68% vs 6%, χ2=27.190, P<0.01).@*Conclusion@#Parameter-optimized MRI as the first choice for imaging examination in AIS patients with the onset time <4.5 h was feasible, and the DNT was significantly shortened by QI measures.
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INTRODUCTION@#Telestroke allows for remote determination of suitability for treatment with thrombolysis in patients with acute ischaemic stroke. However, this approach is time-dependent and most centres have yet to achieve the recommended treatment times. We describe a quality improvement initiative aimed at improving the telestroke workflow and treatment times at our centre.@*METHODS@#A multidisciplinary workgroup comprising clinicians, stroke case managers and radiology staff was formed to oversee the initiative. A phase-by-phase review of the existing workflow was done to identify the reasons for delay. Phase-specific measures were then introduced to address these delays, and a data-monitoring system was established to track the impact of these measures. The initiatives were implemented through four Plan-Do-Study-Act cycles. The door-to-needle (DTN) times for thrombolysis and clinical outcomes before and after the interventions were compared.@*RESULTS@#A total of 104 patients were evaluated. The median DTN time improved from 96 minutes to 78 minutes post implementation of initiatives (p = 0.003). Fewer patients had symptomatic intracranial haemorrhages (8.5% vs. 24.2%; p = 0.03), and more patients had improvements in their National Institutes of Health Stroke Scale score (47.9% vs. 25.0%; p = 0.031) after the initiatives were introduced.@*CONCLUSION@#The quality improvement initiative resulted in a reduction in median DTN time. Our approach allowed for a systematic method to resolve delays within the telestroke workflow. This initiative is part of an ongoing effort aimed at providing thrombolysis safely to eligible patients in the shortest possible time.
Subject(s)
Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Emergency Service, Hospital , Interprofessional Relations , Intracranial Hemorrhages , Quality Improvement , Severity of Illness Index , Singapore , Stroke , Therapeutics , Telemedicine , Methods , Reference Standards , Thrombolytic Therapy , Methods , Time , Tissue Plasminogen Activator , Therapeutic Uses , Treatment OutcomeABSTRACT
Objective To investigate the feasibility of parameter-optimized magnetic resonance imaging (MRI) as the first choice for imaging examination in patients with acute ischemic stroke (AIS), and to assess the effects of quality improvement (QI) measures on shortening the door-to-needle time (DNT).Methods A retrospective case-control study was conducted. A total of 69 AIS patients hospitalized at the Department of Neurology of the People's Hospital of Wuzhou from August 2015 to July 2018 were enrolled in the study, and the head MRI was used as the first choice for imaging examination. All patients received the intravenous thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA). Patients with AIS undergoing intravenous thrombolysis from August 2015 to March 2017 were included in the control group, and those receiving intravenous thrombolysis after QI measures from April 2017 to July 2018 were included in the experimental group. QI included informing the stroke team in advance by emergency physicians, treatment process changing from serial procedure to the parallel one, optimization of MRI scanning parameters, and use of rapid test instruments. The MRI scanning time was compared between the two groups. The DNT of the two groups was compared, and paired-samplest test was used. The proportion of patients who underwent MRI scan and DNT<60 min was compared between the two groups, and theχ2 test was used.Results Compared with the control group, the proportion of patients undergoing MRI scan in the experimental group was increased (82％ vs 58％,χ2=4.58,P=0.032); MRI scanning time was shortened (4 min 37 svs 10 min 21 s); DNT (min) was shortened (59.32±10.19 vs 93.48±24.81,t=7.189,P<0.01); and the proportion of patients with DNT<60 min was significantly increased (68％vs 6％,χ2=27.190,P<0.01).Conclusion Parameter-optimized MRI as the first choice for imaging examination in AIS patients with the onset time <4.5 h was feasible, and the DNT was significantly shortened by QI measures.
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Objective Analyze the effect of emergency thrombolytic therapy on door to needle time (DNT) in patients with acute ischemic stroke (AIS) and effect.Method Selected 182 cases of AIS patients underwent intravenous thrombolysis at the First Hospital of Qinhuangdao from May 2015 to June 2017.Thrombolytic therapy group (83 cases),for the May 2015-May 2016 after neurological consultation intravenous thrombolysis patients;Emergency thrombolytic group(99 cases),for the June 2016-June 2017 emergency thrombolysis group Emergency Department of intravenous thrombolysis patients.Compare the two groups of DNT,thrombolytic therapy 24 h symptomatic hemorrhage conversion rate,Thrombolysis 24 h,7 dNIHSS score,7 dthrombolysis and 3 months thrombolysis and thrombolysis 3 months improved Rankin score (mRs).Results There was no significant difference in baseline characteristics between the two groups (P＞0.05).Compared with the consultation group,the DNT[(69.77±11.66)min vs (80.12±15.49) min,t=5.745,P ＜ 0.01] of emergency thrombolytic group was significantly shortened,and the good score[39(39.4％) vs 21(25.3％),x2=4.272,P=0.039] at 3 months after treatment was significantly higher (P＜0.05);Treatment of 24 h intracranial hemorrhage conversion rate[12(12.12％) vs 5(6.02％),x2=1.982,P=0.159]、Treatment 7d mortality rate [10(10.10％) vs 6(7.22％),x2=0.464,P=0.496],3 months mortality rate [14(14.14％) vs 11 (13.25％),x2=0.030,P=0.862]、There was no significant difference in the 24h effective rate [57(57.6％) vs 53(63.8％),x2=0.745,P=0.388] and 7d effective rate [50(50.5％) vs 46(55.4％),x2=0.438,P0.508] after treatment (P＞0.05).Conclusions The emergency thrombolytic model can shorten the DNT of rt-PA intravenous thrombolysis in patients with AIS.The safety and efficacy of DNT are not different from the neurological consultation mode,and can improve the good prognosis rate.
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@#Door to needle (DTN) time for thrombolysis in the Emergency Department, Universiti Kebangsaan Malaysia Medical Centre (ED, UKMMC) is an indicator that can reduce mortality and morbidity of patients with ST Elevation Myocardial Infarction (STEMI). This study was conducted to determine factors that influence DTN time for acute ST Elevation Myocardial Infarction (STEMI) and whether it has achieved the recommended time of 30 minutes. A cross-sectional study was conducted among patients diagnosed with acute STEMI and thrombolysed in ED, UKMMC from June 2016 until March 2017. A data collection sheet was used to collect patient’s demographic data and clinical data which included time of arrival to ED, time of initial electrocardiogram (ECG), time of drug preparation and time of thrombolytic delivery to the patient. A total of 98 patients were included in this study. Majority of patients (77.6%) were thrombolysed more than 30 minutes following ED arrival. Mean DTN in ED, UKKMC was 59.28 + 36.01 minutes. The mean door to ECG time was 7.19 + 8.08 minutes and the mean drug preparation time was 9.86 + 7.51 minutes. Out of 76 (77.6%) patients that were thrombolysed after 30 minutes of ED arrival, 59.2% (n=45) were due to multiple disciplinary referral. Other factors were delay in performing initial ECG 19.8% (n=15), incorrect initial ECG interpretation 9.2% (n=7) and unavoidable need for prior resuscitation 9.2% (n=7). As a conclusion this study showed that there was an unacceptable delay in hospital thrombolysis for acute STEMI.
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Objective@#To investigate the prehospital intervention based on emergency medical services (EMS) in patients with acute ischemic stroke (AIS) for door-to-needle time (DNT) with intravenous thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) impact.@*Methods@#112 emergency patients receiving rt-PA intravenous thrombolysis admitted to the First Hospital of Qinhuangdao City based on EMS from June 2016 to December 2017 were enrolled. According to whether or not to receive prehospital interventions, patients were divided into prehospital intervention group (n = 42) and routine treatment group (n = 70). Both groups followed the general principles of first aid, including assessment and support of the airway, respiration, and circulation, and blood glucose, electrocardiogram, and dynamic vital signs were monitored. Based on the general principle of EMS, first-aid personnel in the prehospital intervention group screened suspected acute stroke patients requiring prehospitalization according to Los Angeles prehospital stroke screening table (LAPSS), and established fluid ways, and got blood samples to evaluate rt-PA intravenous thrombolysis and risks. Factors influenced DNT compliance were analyzed through multivariate Logistic regression, which included the education level of the patient, whether there were risk factors related to cerebrovascular disease (hypertension, coronary heart disease, diabetes), visit time, National Institute of Health stroke scale (NIHSS) score, whether received EMS intervention or not. The average DNT, DNT ≤ 60 minutes compliance rate, communication time, and decision time for thrombolysis were compared between the two groups. NIHSS score was used to evaluate the effective rate of thrombolysis for 7 days. The modified Rankin score (mRs) was used to evaluate the neurological function after 3 months of thrombolysis (a mRs score of 0-2 was defined as a good nerve function).@*Results@#Univariate analysis showed that the DNT of patients with NIHSS score > 5 was significantly shorter than those with NIHSS score≤5, and DNT in patients received EMS intervention was significantly shorter than the non-receiver; but education level, visiting time, and risk factors associated with cerebrovascular disease had nothing to do with DNT. Multivariate Logistic regression analysis showed that NIHSS score and EMS intervention were the influencing factors of DNT compliance [NIHSS score: odds ratio (OR) = 0.452, 95% confidence interval (95%CI) = 0.162-1.263, P = 0.030; EMS intervention: OR = 3.077, 95%CI = 1.260-7.514, P = 0.014]. Compared with conventional treatment group, DNT of intravenous thrombolytic in prehospital intervention group was significantly shortened (minutes: 62.00±11.07 vs. 78.03±21.04), DNT≤60 minutes compliance rate was significantly increased [35.7% (15/42) vs. 12.9% (9/70)], communication time [minutes: 4 (3, 6) vs. 6 (5, 9)] and decision-making thrombolytic time (minutes: 5.81±2.48 vs. 6.70±2.15) were significantly shortened, the differences were statistically significant (all P < 0.05). The 7-day effective rate in the prehospital intervention group [33.3% (14/42) vs. 14.3% (10/70), χ2 = 5.657, P = 0.017] and the 3-mouth good rate of nerve function [38.1% (16/42) vs. 14.3% (10/70), χ2 = 10.759, P = 0.001] were significantly higher than those in the conventional treatment group.@*Conclusion@#Prehospital interventions based on EMS can shorten DNT of intravenous thrombolysis in the patients with AIS, improve treatment efficiency, and improve prognosis.
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Objective To discuss the impacts of stroke center construction upon therapeutic indexes for di-agnosing and treating patients with acute ischemic stroke. Methods Patients were divided into a control group (180 patients)and a formal group(245 patients)based on the time of stroke center construction.Patients in both groups were recorded time points in the course of diagnosis and treatment,and compared in number of cases with intravenous thrombolysis,number of cases receiving intravascular interventional therapies,DTN(door-to-needle) time,number of deaths,National Institutes of Health Stroke Scale(NIHSS)scores upon grouping,NIHSS scores after four weeks,NIHSS scores after 3 months,days of hospital stay and hospital charges.Results After the con-struction of the stroke center,time spent in different links were decreased.The number of cases with pure intrave-nous thrombolysis and DTN time(shorter than 60 min)were increased,and the difference were statistically signifi-cant(P<0.01).The number of cases who only received intravascular interventional therapies is increased,mean-while,DTN time was decreased,NIHSS scores after 4 weeks was increased and NIHSS scores after 3 months were also increased(P < 0.05)in these cases. No statistically significant differences existed in number of cases who were treated by bridging with intravenous thrombolysis in combination with intravascular interventional therapies and death cases(P=0.153,P=0.247).There were no statistically significant differences in days of hospital stay and hospital charges(P=0.152,P=0.406).Conclusions After the stroke center construction,it is helpful for significantly improving medical institutions′diagnosis and treatment of stroke,reducing time of such diagnosis and treatment in different links,shortening DTN time,increasing thrombolysis rate,improving patients′prognosis and bringing more benefits to patients with acute ischemic stroke by optimizing procedures for diagnosing and treating stroke.
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Objective To analyze the efficacy and prognosis of intravenous thrombolysis in patients with acute ischemic stroke. so as to discuss the influence of time management on the thrombolysis outcome. Methods We retrospectively analyzed the clinical data of the 198 acute ischemic stroke patients who received intravenous thrombolysis in Changhti Hospital from Sep. 2013 to Dec. 2015. The patients were divided into two groups according to U. S. National Institutes of Health Stroke Scale (NIHSS) scores 24 h after thrombolysis: effective group and ineffective group. The clinical data of the two groups were compared to indentify the factors influencing the prognosis. The patients were also divided into two groups according to modified Rankin Scale (mRS) after 90d: good prognosis and poor prognosis groups; the clinical data of the two groups were also analyzed to identify the influencing factors. The differences were compared between the effective group and ineffective group from the onset to different medication periods. so as to evaluate the influence of time management on prognosis. Results The 198 consecutive acute ischemic stroke patients included 74 in the effective group and 124 in the ineffective group. Single-factor analysis indicated that the pre-thrombolysis baseline NIHSS score. time from onset to the beginning of thrombolysis. and history of coronary heart disease were significantly different between the effective group and ineffective group (P<0. 01. P<0. 05). Logistic regression analysis showed that low baseline NIHSS score before thrombolysis. shorter time from onset to the beginning of thrombolysis, and no history of coronary heart disease were the independent predictors of a good effect. Single-factor analysis of indicated that the age, blood glucose level prior to thrombolysis, history of diabetes mellitus, history of a trial fibrillation, baseline NIHSS score and GCS score prior to thrombolysis, time from onset to the beginning of thrombolysis and history of coronary heart disease were significantly different between the good prognosis group (157 cases) and the poor prognosis group (41 cases) (P<0. 01, P<0. 05). Logistic regression analysis showed that low baseline NIHSS score before thrombolysis were independent predictors of good prognosis. Concerning the time management, the time periods from onset to the beginning of thrombolysis were significantly different between the ineffective group and effective group (P<0. 01), which was mainly caused by the time from the onset to treatment (P<0. 01). Conclusion Lower pre-thrombolysis NIHSS score, shorter time from stroke onset to beginning of thrombolysis, no history of coronary heart disease are associated with good short term efficacy, and lower pre-thrombolysis NIHSS score is the independent factor of good prognosis for acute ischemic stroke. Early treatment may increase the efficacy of intravenous thrombolysis.
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Objective To analyze the effect of the changes of hospital diagnosis and treatment mode on the treatment time in patients with acute ischemic stroke before and after the establishment of Cerebrovascular Disease Center. Methods A total of 103 consecutive patients with acute ischemic stroke admitted to the Department of Neurology,Changhai Hospital,the Second Military Medical University between June 2008 and December 2012 were enrolled retrospectively. Thirty-one of them were excluded because of incomplete medical records. Finally,72 patients were enrolled as a control group and received series diagnosis and treatment mode. A total of 210 consecutive patients with acute ischemic stroke admitted to the Cerebrovascular Disease Center,Changhai Hospital,the Second Military Medical University from September 2013 to February 2015 were enrolled retrospectively. Thirteen patients were excluded (4 patients with recurrent transient ischemic attack were treated with recombinant tissue-type plasminogen activator,9 without complete data were treated with intravenous thrombolysis),197 were enrolled as an observation group finally,and they were received series diagnosis and treatment mode. The patients of both groups were visited within 4. 5 h after onset and received rt-PA treatment. The time-consuming changes of each time period from onset-to-door,door-to-imaging,imaging-to-needle,door-to-needle,and onset-to-needle time between the control group and the observation group were compared and analyzed. Results Compared with the control group,the door-to-imaging,imaging-to-needle,door-to-needle and onset-to-needle time were significantly shorter in the observation group. There were significant difference between the 2 groups (24 ± 12 min vs. 60 ± 20 min,27 ± 12 min vs. 62 ± 31 min,51 ± 17 min vs. 122 ± 52 min,and 153 ± 69 min vs. 230 ± 81 min,all P 0. 05). Conclusion The establishment of cerebral vascular disease center and the improvement of the processes have shortened the treatment time in patients with acute ischemic stroke within time window. The time from onset-to-door is still longer,and the propaganda and education of stroke should be strengthened.