Are All Stroke Patients Eligible for Fast Alteplase Treatment? An Analysis of Unavoidable Delays
Are All Stroke Patients Eligible for Fast Alteplase Treatment? An Analysis of Unavoidable Delays
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DOI：
10.1111/acem.12914
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发表时间：
2016-04-01
影响因子：
4.4
通讯作者：
Smith, Eric E.
中科院分区：
文献类型：
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作者：
Choi, Philip M. C.;Desai, Jamsheed A.;Smith, Eric E.
目的：国家质量论坛最近批准了一项静脉溶栓治疗时间的绩效指标，该指标允许排除快速阿替普酶治疗可能不可能的情况。然而，在临床实践中，不可避免的患者原因（如需要医疗稳定）导致从门到针的时间过长（DNT）的频率和影响在很大程度上是未知的。作为匆忙急性卒中治疗和评估-2 （HASTE-2）项目的一部分，我们试图确定与更长的DNT相关的患者和系统原因。方法：从2012年6月至2013年6月，我们收集了102例在症状出现4.5小时内直接到急诊科接受阿替普酶治疗的连续患者的DNT和潜在延迟原因的数据。结果患者平均年龄71岁，女性56/113 (54%)，NIH卒中量表评分中位数为13分，DNT中位数为53分钟。59/102（58%）指出了潜在的延误，其中31/102（31%）是不可避免的患者相关或资格原因。当患者相关或有资格的延迟原因存在时（60分钟），中位DNT比缺席时（45分钟，p = 0.005）更长。多变量模型显示，需要紧急医疗稳定、出现癫痫和无法确认资格与35%-50%的DNT时间延长相关。结论高达31%的患者由于医疗或资格相关原因延迟提供阿替普酶，这可能是延迟提供阿替普酶的合理原因。
ObjectivesThe National Quality Forum recently endorsed a performance measure for time to intravenous thrombolytic therapy which allows exclusions for circumstances in which fast alteplase treatment may not be possible. However, the frequency and impact of unavoidable patient reasons for long door-to-needle time (DNT), such as need for medical stabilization, are largely unknown in clinical practice. As part of the Hurry Acute Stroke Treatment and Evaluation-2 (HASTE-2) project, we sought to identify patient and systems reasons associated with longer DNT.MethodsFrom June 2012 to June 2013 we collected data on DNT and potential reasons for delays from 102 consecutive patients presenting directly to the emergency department who were treated with alteplase within 4.5 hours of symptom onset.ResultsMean age was 71 years, 56/113 (54%) were women, median NIH Stroke Scale score was 13, and median DNT was 53 minutes. Potential delays were noted in 59/102 (58%), of which 31/102 (31%) were unavoidable patient-related or eligibility reasons. Median DNT was longer when patient-related or eligibility reasons for delay were present (60 minutes) than when absent (45 minutes, p = 0.005). Multivariable modeling showed that need for urgent medical stabilization, presentation with seizure and inability to confirm eligibility were associated with 35%-50% longer DNT times.ConclusionsUp to 31% of patients have delays due to medical or eligibility-related causes that may be legitimate reasons for providing alteplase later than the benchmark time of 60 minutes.