Hospital Variation in Thrombolysis Times Among Patients With Acute Ischemic Stroke The Contributions of Door-to-Imaging Time and Imaging-to-Needle Time
Hospital Variation in Thrombolysis Times Among Patients With Acute Ischemic Stroke The Contributions of Door-to-Imaging Time and Imaging-to-Needle Time
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DOI：
10.1001/jamaneurol.2014.1528
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发表时间：
2014-09-01
期刊：
影响因子：
29
通讯作者：
Reeves, Mathew J.
中科院分区：
文献类型：
--
作者：
Sauser, Kori;Levine, Deborah A.;Reeves, Mathew J.
重要性：考虑到急性缺血性卒中患者使用组织型纤溶酶原激活剂（tPA）治疗的时间窗口有限，指南建议急性缺血性卒中患者从到达医院25分钟到成像时间（DIT）和从到达医院60分钟到针头时间（DTN）。尽管dit有所改善，急性缺血性脑卒中患者tPA治疗的DTN时间仍然不理想。目的探讨DIT和成像到针时间（ITN）对急性缺血性脑卒中患者tPA及时递送延迟的影响，并评估不同医院间DTN时间的差异。设计、环境和参与者：对2009年1月至2012年12月接受静脉注射tPA治疗的1193例急性缺血性卒中患者进行队列分析。多水平线性回归模型包括25家密歇根医院参与Paul Coverdell国家急性中风登记处的随机效应。主要结局和测量主要结局是连续测量从急诊科到达溶栓分娩的DTN时间（以分钟为单位）。结果患者平均年龄为68.1岁，美国国立卫生研究院卒中量表评分中位数为11.0（四分位数范围为6-17），女性占51.4%，非白种人占37.5%。DTN平均（SD）时间为82.9 (35.4)min， DIT平均（SD）时间为22.8 (15.9)min， ITN平均（SD）时间为60.1 (32.3)min。大多数患者（68.4%）在25分钟内进行DIT， 28.7%的患者在60分钟内进行DTN。医院差异占DTN时间变异的12.7%。年卒中量和主要卒中中心指定都不是缩短DTN时间的显著预测因子。患者因素（年龄、性别、种族/民族、到达方式、起病至到达时间和中风严重程度）解释了医院间DTN时间差异的15.4%。在调整患者层面因素后，DIT解释了医院风险调整后DTN次数变异的10.8%，而ITN时间解释了64.6%。结论和相关性与DIT相比，ITN时间是医院DTN时间变异性的更大来源，并且是急性缺血性卒中tPA治疗及时延迟的更常见因素。需要更多的关注来确定系统的改变，可以减少急性缺血性卒中患者的ITN时间。
IMPORTANCE Given the limited time window available for treatment with tissue plasminogen activator (tPA) in patients with acute ischemic stroke, guidelines recommend door-to-imaging time (DIT) within 25 minutes of hospital arrival and door-to-needle (DTN) time within 60 minutes for patients with acute ischemic stroke. Despite improvements in DITs, DTN times for tPA treatment in patients with acute ischemic stroke remain suboptimal.OBJECTIVES To examine the contributions of DIT and imaging-to-needle (ITN) time to delays in timely delivery of tPA to patients with acute ischemic stroke and to assess between-hospital variation in DTN times.DESIGN, SETTING, AND PARTICIPANTS A cohort analysis of 1193 patients having acute ischemic stroke treated with intravenous tPA between January 2009 and December 2012. Multilevel linear regression models included random effects for 25 Michigan hospitals participating in the Paul Coverdell National Acute Stroke Registry.MAIN OUTCOMES AND MEASURES The primary outcome was a continuous measure of DTN time, in minutes, from emergency department arrival to thrombolytic delivery.RESULTS The mean age was 68.1 years, the median National Institutes of Health Stroke Scale score was 11.0 (interquartile range, 6-17), 51.4% were female, and 37.5% were of nonwhite race/ethnicity. The mean (SD) DTN time was 82.9 (35.4) minutes, the mean (SD) DIT was 22.8 (15.9) minutes, and the mean (SD) ITN time was 60.1 (32.3) minutes. Most patients (68.4%) had DIT within 25 minutes, while 28.7% had DTN time within 60 minutes. Hospital variation accounted for 12.7% of variability in DTN times. Neither annual stroke volume nor primary stroke center designation was a significant predictor of shorter DTN time. Patient factors (age, sex, race/ethnicity, arrival mode, onset-to-arrival time, and stroke severity) explained 15.4% of the between-hospital variation in DTN times. After adjustment for patient-level factors, DIT explained 10.8% of the variation in hospital risk-adjusted DTN times, while ITN time explained 64.6%.CONCLUSIONS AND RELEVANCE Compared with DIT, ITN time is a much greater source of variability in hospital DTN times and is a more common contributor to delays in timely tPA therapy for acute ischemic stroke. More attention is needed to determine systems changes that can decrease ITN time for patients with acute ischemic stroke.