Delays in Door-to-Needle Times and Their Impact on Treatment Time and Outcomes in Get With The Guidelines-Stroke
Delays in Door-to-Needle Times and Their Impact on Treatment Time and Outcomes in Get With The Guidelines-Stroke
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DOI：
10.1161/strokeaha.116.015712
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发表时间：
2017-04-01
期刊：
影响因子：
8.3
通讯作者：
Smith, Eric E.
中科院分区：
文献类型：
--
作者：
Kamal, Noreen;Sheng, Shubin;Smith, Eric E.
背景和目的：尽管美国心脏协会/美国卒中协会目标卒中倡议等质量改善项目，很大一部分急性缺血性卒中患者仍然在到达后60分钟后使用组织型纤溶酶原激活剂（阿替普酶）治疗。本研究旨在描述文献记载的延误原因，以及延误原因与患者预后之间的关系。方法：分析2012年10月至2015年4月1422家医院参与《指南-卒中》的55296例静脉注射阿替普酶患者的特征，不包括转院患者和住院卒中患者。我们评估了从门到针的时间延迟的资格、医疗和医院原因。结果：27778例患者（50.2%）在60分钟内接受治疗，10086例患者（18.2%）在60分钟内接受治疗，无记录的延迟，17432例患者（31.5%）在60分钟内接受治疗，有一个或多个记录的延迟原因。延迟上门到针的时间与延迟诊断（比没有延迟诊断的时间长36分钟）和低血糖或癫痫发作（比没有这些情况的时间长34分钟）相关。在对患者和医院特征进行校正后，记录的延迟与住院死亡率（优势比为1.2,95%可信区间为1.1-1.3）和症状性颅内出血（优势比为1.2,95%可信区间为1.1-1.3）的较高几率以及出院时独立行走的较低几率（优势比为0.92,95%可信区间为0.9-1.0）相关。结论：医院和资格延迟，如延迟诊断和无法确定资格，与较长的门到针的时间有关。改进卒中识别和急性合并症的管理可能有助于减少从门到针的时间。
Background and Purpose-Despite quality improvement programs such as the American Heart Association/American Stroke Association Target Stroke initiative, a substantial portion of acute ischemic stroke patients are still treated with tissue-type plasminogen activator (alteplase) later than 60 minutes from arrival. This study aims to describe the documented reasons for delays and the associations between reasons for delays and patient outcomes.Methods-We analyzed the characteristics of 55296 patients who received intravenous alteplase in 1422 hospitals participating in Get With The Guidelines-Stroke from October 2012 to April 2015, excluding transferred patients and inpatient strokes. We assessed eligibility, medical, and hospital reasons for delays in door-to-needle time.Results-There were 27778 patients (50.2%) treated within 60 minutes, 10086 patients (18.2%) treated >60 minutes without documented delays, and 17432 patients (31.5%) treated >60 minutes with one or more documented reasons for delay. Delayed door-to-needle times were associated with delayed diagnosis (36 minutes longer than those without delay in diagnosis) and hypoglycemia or seizure (34 minutes longer than without those conditions). The presence of documented delays was associated with higher odds of in-hospital mortality (odds ratio, 1.2; 95% confidence interval, 1.1-1.3) and symptomatic intracranial hemorrhage (odds ratio, 1.2; 95% confidence interval, 1.1-1.3) and lower odds of independent ambulation at discharge (odds ratio, 0.92; 95% confidence interval, 0.9-1.0) after adjusting for patient and hospital characteristics.Conclusions-Hospital and eligibility delays such as delay diagnosis and inability to determine eligibility were associated with longer door-to-needle times. Improved stroke recognition and management of acute comorbidities may help to reduce door-to-needle times.