National Initiative Improves Treatment Times, Outcomes for Stroke Patients

The Target: Stroke initiative reduced the time before acute ischemic stroke patients were treated with intravenous tissue plasminogen activator, leading to reduced rates of in-hospital mortality and intracranial hemorrhage.

Implementation of a national quality improvement initiative, Target: Stroke, has led to faster administration of intravenous tissue plasminogen activator (tPA) in stroke patients, according to the results of a new study. The study also found that quicker treatment was associated with lower rates of in-hospital mortality and intracranial hemorrhage and an increased portion of patients discharged to their homes.

Although current guidelines recommend that eligible patients with acute ischemic stroke begin intravenous tPA therapy within 60 minutes after arrival at the hospital, previous research has indicated that less than 30% of patients are treated within this time frame. In an effort to improve door-to-needle times for stroke patients, Target: Stroke was launched in January 2010. Organized by the American Heart Association and the American Stroke Association, the initiative includes 10 care strategies for reducing door-to-needle times, provides clinical decision support tools, facilitates hospital participation, and encourages sharing of best practices among participating hospitals.

The new study, published in the April 23/30, 2014 issue of the Journal of the American Medical Association, evaluated the efficacy of the program by determining the portion of stroke patients treated with tPA within 60 minutes of arrival before and after the initiative began in hospitals participating in the Get With The Guidelines—Stroke program. The analysis also aimed to determine whether faster door-to-needle times were associated with improved clinical outcomes. A total of 71,169 acute ischemic stroke patients from 1030 participating hospitals who were treated with tPA before the initiative (2003 to 2009) or after its implementation (2010 to 2013) were included in the analysis.

The median door-to-needle time for tPA administration decreased from 77 minutes before the program began to 67 minutes after it was implemented. In addition, the portion of patients who received the treatment within 60 minutes increased from 26.5% to 41.3%. When the analysis focused on the end of the pre- and post-intervention periods, the median door-to-needle time decreased from 74 minutes during the fourth quarter of 2009 to 59 minutes by the third quarter of 2013. The portion of patients with door-to-needle times of at most 60 minutes also improved, increasing from 29.6% at the end of 2009 to 53.3% in the third quarter of 2013.

The results also found that the initiative was associated with improved clinical outcomes. Compared with the pre-intervention period, in-hospital all-cause mortality significantly decreased (9.93% to 8.25%), symptomatic intracranial hemorrhage within 36 hours occurred less frequently (5.68% to 4.68%), and more patients were discharged to their homes (37.6% to 42.7%) after the initiative was implemented. In addition, the portion of stroke patients treated with tPA significantly increased from 64.7% before to 85.2% after the program was implemented.

“[T]he stroke community now has data pointing to how, with some substantial effort and investment, tPA treatment can be administered more quickly,” James C. Grotta, MD, notes in an accompanying editorial.

Although more research is needed to address limitations of the study, Dr. Grotta concludes that its results provide evidence of “exactly where and how to direct efforts in improving treatment outcomes for patients with acute ischemic stroke—namely by reducing time from symptom onset to treatment.”