Improving in-hospital stroke service utilization (MISSION) to shorten thrombolytic door-to-needle time in acute ischemic stroke patients: A cluster randomized controlled trial

ABSTRACT

Background and Aims: Rapid intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) is crucial for improving outcomes. However, randomized trials to reduce in-hospital delay are clearly limited in China. We aimed to evaluate the effect of a multi-component intervention on thrombolytic door-to needle time (DNT) of AIS patients via video teleconference based on the Behavior Change Wheel method. Methods: This trial randomly allocated 22 hospitals equally to PEITEM (Persuasion Environment reconstruction Incentivisation Training Education Modeling) intervention or routine care plus stroke registry and subsequently enrolled 1634 AIS patients who receiving IVT within 4.5 hours upon stroke onset from participant hospitals. The PEITEM group received a one-year PEITEM intervention based on the behavioral theory monthly via video teleconference. Results: A total of 1, 634 patients from the 22 hospitals were enrolled. The proportion of DNT ≤ 60 minutes was 82.0% in the PEITEM group and 73.7% in the control group (adjusted odds ratio, 1.85;95% confidence interval [CI], 1.42 to 2.42, P<0.001). The average DNT was 43 minutes in the PEITEM group and 50 minutes in the control group (β -9.00;95% CI, -11.37 to ≤6.63, P<0.001). Favorable neurological outcomes were achieved in 55.6% patients in the PEITEM group and 50.4% patients in the control group (adjusted odds ratio, 1.34;95% CI, 1.02 to 1.75;P=0.04). Conclusions: The teleconference-delivered PEITEM intervention resulted in a moderately but clinically relevant shorter DNT and better neurological outcomes in the AIS treated with the IVT. Video teleconference may be more appropriate and easier for quality improvement in the current global COVID-19 public health crisis disrupting healthcare services.