Door to Needle (DTN) Time in Stroke

Thrombolysis Audit
Care of the Elderly Department
Dr Nikoletta Petrou, Foundation Year 1 Doctor
Dr Prasanna Aghoram, Consultant Physician in Stroke Medicine
How did this Audit come about?

Reason for the Audit:

Agreement in Stroke Network: Aim DTNt <60min

This audit is a local initiative to measure current DTN times

This audit aims to:

Evaluate if appropriate patients are thrombolysed within 1 hour of A&E

arrival

Evaluate if patients with delayed DTN times have clear reasons for their

delays

Suggest appropriate action plans to improve patient care

Time Lost is Brain Lost

Stroke facts
Every minute 1.9 million neurons and 14 billion synapses are destroyed
Every hour that treatment is delayed, the ischaemic brain ages 3.6 years
Time = Brain
The Golden hour

No current NICE guidelines on DTN time in Stroke Thrombolysis

Recommendations to date have been consistent re: DTN

<60min
American Heart Association/American Stroke Association: Get with the
Guidelines
Joint Committee (USA) sets a standard of 80% for DTN <60min
National Institute of Neurological Disorders and Stroke
Brain Attack Coalition sets a standard of 80% for DTN <60min

International Stroke Conference Only 27% of patients have

DTNt <60min
G. Fonarow et al, University of California, Los Angeles (2011)
 INCLUSION CRITERIA
The Golden Hour Clinical signs and symptoms of definite acute stroke
Clear time of onset
THROMBOLYSIS Presentation within 3 hrs of acute onset
Haemorrhage excluded by CT scan
PATHWAY Age 18 - 80 years old
NIHSS less than 25
Arrival to A&E Consent to treat (every effort must be made to contact
next of kin)
A&E assessment
EXCLUSION CRITERIA
Stroke team notified
Rapidly improving or minor stroke symptoms
Priority CT Head Stroke or serious head injury 3 months
Major surgery, obstetrical delivery, external heart massage
Stroke team Assessment last 14 days,
Seizure at onset of stroke
CT scan performed DTN Prior stroke and concomitant diabetes
Severe haemorrhage last 21 days
CT report obtained Increase bleeding risk
History of central nervous damage (neoplasm,
Patient informed and haemorrhage, aneurysm, spinal or intracranial surgery or
haemorrhagic retinopathy)
consent obtained Blood pressure above 185 mmHg systolic or 110 mmHg
diastolic
Reconstitution and Symptoms suggestive of SAH (even if CT is normal)
Known clotting disorder
drawing up of Alteplase Patient on heparin or warfarin
Suspected iron deficient anaemia or thrombocytopenia
Thrombolysis is Suspected hypoglycaemia or hyper glycaemia >3 mmol/l >
initiated 22 mmol/l
Bacterial endocarditis, pericarditis
Standards

Standard 1
Appropriate patients should have DTNt <60min

Target 80%

Exempted: patients in international trials and patients whose

hypertension required immediate treatment to allow
thrombolysis to be considered

Standard 2
Patients with DTNt >60min should have a reason for the
delay

Target 80%
Methods

Analysis of Stroke Database

Demographics and Consultant
Time of symptom onset
Time of arrival to A&E
Time of stroke team arrival
Time of Head CT scan
Time of Alteplase given
Prior BP control noted
DTNt was calculated
Reasons for delay were noted Audit tool
Four categories of DTN: <60min, 60-75min, 75-90min and
>90min delay
Standard 1

43 patients thrombolysed ** 30 included ** Median DTNt 85

min
Target of 80% was
Analysis

10% had DTN

<60min
13% had DTN
<65min
17% had DTN
<70min
27% had DTN
<75min
63% had DTN
<90min
Results by Year

More patients are thrombolysed in under

90 min compared to previous years

More patients are thrombolysed in under

75 min compared to previous years
Standard 2

59% have
identified
reasons for
delay

All patients with DTN time > 90min have clear reasons documented by
the Consultant
Minor time losses are spread across the pathway and not documented
Analysis
Analysis

No difference in service speed between day-time and out of hours

service
Conclusions

10% of patients were thrombolysed within 60min of arrival to A&E

and 63% within 90min.

Only 27% have DTNt<60min according to the largest study to-date.

27% can be achieved by reducing pathway delays by 15min.

15% had DTNt<60min in 2011, an improvement on previous years.

100% of severe delays (DTNt>90min) have documented reasons

and these are predominantly (75%) due to difficult-to-modify

patient-related factors
Conclusions

Important to track minor delays that are usually spread across the
pathway

Priority is ensuring safety of treatment at all times

In some cases the delay may be inevitable. Alternative is no

treatment
Action Plan

ICE 2
Monitoring tool

Important to
start
completing
when the
patient arrives
in A&E to track
potential time
losses in real
time
References

American Heart Association/American Stroke Association (2011). The Get With

The GuidelinesStroke (GWTG-Stroke) program. Website:
http://www.strokeassociation.org/STROKEORG
Fonarow GC, Smith EE, Saver JL (2011). 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: DOI:10.1161
Mikita M (2011). Reducing Door-to-Needle Time for tPA Use Remains and Elusive
Goal in Stroke Care. JAMA. 2011;305(13):1288-1289

Sinha D, et al (2009). Door-toNeedle Time for Stroke Thrombolysis. Reasons for

delays at busy District General Hospital. Southend Hospital. Availble online at:
www.stroke.org.uk/document.rm?id=2494

Susan Boorman (2011). Thrombolysis Audit. Onset-to-alteplase time. Darent

Valley Hospital, Audit Meeting September 2011
Thank you

Questions?
 INCLUSION CRITERIA
The Golden Hour Clinical signs and symptoms of definite acute stroke
Clear time of onset
THROMBOLYSIS Presentation within 3 hrs of acute onset
Haemorrhage excluded by CT scan
PATHWAY Age 18 - 80 years old
NIHSS less than 25
Arrival to A&E Consent to treat (every effort must be made to contact
next of kin)
A&E assessment
EXCLUSION CRITERIA
Stroke team notified
Rapidly improving or minor stroke symptoms
Priority CT Head Stroke or serious head injury 3 months
Major surgery, obstetrical delivery, external heart massage
Stroke team Assessment last 14 days,
Seizure at onset of stroke
CT scan performed DTN Prior stroke and concomitant diabetes
Severe haemorrhage last 21 days
CT report obtained Increase bleeding risk
History of central nervous damage (neoplasm,
haemorrhage, aneurysm, spinal or intracranial surgery or
Patient informed and haemorrhagic retinopathy)
Blood pressure above 185 mmHg systolic or 110 mmHg
consent obtained diastolic
Symptoms suggestive of SAH (even if CT is normal)
Reconstitution and
Known clotting disorder
drawing up of Alteplase Patient on heparin or warfarin
Suspected iron deficient anaemia or thrombocytopenia
Thrombolysis is Suspected hypoglycaemia or hyper glycaemia >3 mmol/l >
22 mmol/l
initiated Bacterial endocarditis, pericarditis