Factor Delaying Intravenous Thrombolytic Treatment with Acute Ischemic Stroke Patients in Chonburi Hospital

Abstract

Objective: In acute ischemic stroke patients, AHA/ASA guideline recommends a door-to-needle time (DNT) of less than of 60 minutes from the time patients arrives at the emergency department to receive thrombolytic treatment. The purpose of this descriptive study is to explore the factors that result in in-hospital delay of thrombolytic treatment, rt-PA, in acute ischemic stroke patients at Chonburi hospital.

Material and methods: All patients with acute ischemic stroke that were treated with intravenous thrombolysis, 0.9 mg/kg alteplase, at Chonburi hospital from 1 July 2017 to 30 June 2019 were included. Medical record was retrospectively reviewed by a neurologist. Data of consecutive stroke patients were collected.  Age, sex, other comorbidities, body weight, blood pressure, blood sugar, presence of early ischemic change on CT, the clinical location of the stroke, arrival time during regular work hours, arrival mode (private vehicle and ambulance) and stroke severity on admission as measured with the national institutes of Health Stroke Scale(NIHSS) score were extracted. Data analyses was done by multivariable logistic regression model to identify independent predictors of a delayed DNT. P <0.5 was considered statistically significant. 

Result: A total 0f 227 patients were included in the study. Of those, 175 patients (77.1%) were treated within 60 minutes and 52 patients (22.9%)had a DNT >60 minutes. The overall median DNT was 47 minutes (interquartile range, 40-58). The median age was 61 years (interquartile range, 51-73). Patients with atrial fibrillation are 2.7 times more likely to have a delayed DNT compared to patients without any comorbidities. In addition, patients who arrived by private transport are 3.1 times more likely to have delayed DNT compared to walk-in patients when controlled for the remaining time before thrombolytic treatment and ASPECT score. Moreover, a delay in any of the steps tended to cause delay in other steps as well. For example, a 1-minute delay in the door-to-lab time caused a 0.7 times increased in DNT; a 1-minute delay in the door-to-CT time caused a 0.99 times increased in DNT; a 1-minute delay in the door-to-medical resident/neurologist caused a 0.87 increased in DNT; a 1-minute delay in the door-to-consent time caused a 0.96 increased in DNT.

Conclusion: The delay in the DNT can be caused by a delay in many steps in the process from patient arrival to consultation, neuroimaging, and treatment, etc. Identifying the details of each step, the limitations in each individual hospital, and finding and efficient way to carry out the treatment are the key to achieving a timely thrombolytic treatment in acute ischemic stroke patients.

Keywords: Ischemic stroke, Factor delaying, thrombolysis