Door-to-Needle Times for Tissue Plasminogen Activator Administration and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative
Door-to-Needle Times for Tissue Plasminogen Activator Administration and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative
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DOI：
10.1001/jama.2014.3203
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发表时间：
2014-04-23
影响因子：
120.7
通讯作者：
Schwamm, Lee H.
中科院分区：
文献类型：
--
作者：
Fonarow, Gregg C.;Zhao, Xin;Schwamm, Lee H.
重要性急性缺血性卒中（AIS）患者静脉注射组织纤溶酶原激活剂（tPA）的益处是时间依赖性的，指南建议60分钟或更短的门到针（DTN）时间。然而，研究发现，在此时间窗内接受治疗的美国患者不到30%。目的地：Stroke被设计为一项国家质量改进计划，旨在改善AIS患者tPA给药的DTN时间。目的评估tPA给药的DTN时间以及质量改进计划启动前后时间为60分钟或更短的患者比例，并确定DTN时间的潜在改善是否与临床结局的改善相关。设计、设置目标：卒中倡议传播了10种护理策略，以实现tPA给药的更快DTN时间，提供临床决策支持工具，促进医院参与，并鼓励分享最佳实践。本研究纳入了71169例接受tPA治疗的AIS患者（2003年4月至2009年12月的干预前期间为27 319例，2010年1月至2013年9月的干预后期间为43 850例）主要结果和测量tPA给药的DTN时间为60分钟或更短，以及院内风险调整的死亡率、症状性颅内出血、出院时的行走状态和出院目的地。结果：与干预前相比，干预后tPA给药的DTN时间测量值和临床结局显著改善。[图表]结论和相关性国家质量改进计划的实施与在全国范围内AIS后tPA给药的及时性改善相关，这种改善与院内死亡率和颅内出血降低相关，沿着出院回家的患者百分比增加。
IMPORTANCE The benefits of intravenous tissue plasminogen activator (tPA) in patients with acute ischemic stroke (AIS) are time dependent and guidelines recommend a door-to-needle (DTN) time of 60 minutes or less. However, studies have found that less than 30% of US patients are treated within this time window. Target: Stroke was designed as a national quality improvement initiative to improve DTN times for tPA administration in patients with AIS.OBJECTIVES To evaluate DTN times for tPA administration and the proportion of patients with times of 60 minutes or less before and after initiation of a quality improvement initiative and to determine whether potential improvements in DTN times were associated with improvements in clinical outcomes.DESIGN, SETTING, AND PATIENTS The Target: Stroke initiative disseminated 10 care strategies to achieve faster DTN times for tPA administration, provided clinical decision support tools, facilitated hospital participation, and encouraged sharing of best practices. This study included 71 169 patients with AIS treated with tPA(27 319 during the preintervention period from April 2003-December 2009 and 43 850 during the postintervention period from January 2010-September 2013) from 1030 Get With The Guidelines-Stroke participating hospitals (52.8% of total).MAIN OUTCOMES AND MEASURES The DTN times for tPA administration of 60 minutes or less and in-hospital risk-adjusted mortality, symptomatic intracranial hemorrhage, ambulatory status at discharge, and discharge destination. RESULTS Measures of DTN time for tPA administration improved significantly during the postintervention period compared with the preintervention period as did clinical outcomes.[GRAPHICS]CONCLUSIONS AND RELEVANCE Implementation of a national quality improvement initiative was associated with improved timeliness of tPA administration following AIS on a national scale, and this improvement was associated with lower in-hospital mortality and intracranial hemorrhage, along with an increase in the percentage of patients discharged home.