AT AAN 2017

BOSTON (FRONTLINE MEDICAL NEWS) – Around-the-clock availability of a neurologist for acute stroke treatment significantly reduced door-to-needle times at a community-based primary stroke center serving as a regional tertiary referral center for western North Carolina.

For each minute of reduction in time to having a neurologist at the bedside for Code Stroke patients, a 138-second improvement occurred in door-to-needle time. This reduction in door-to-needle time was associated with nearly one-third lower mortality, Alexander Schneider, MD, reported at the annual meeting of the American Academy of Neurology

The program involving the 24/7 availability of a neurologist in the hospital was implemented in October 2015 at Mission Hospital, a 763-bed hospital in Asheville, N.C., where nighttime emergency stroke coverage had historically been provided by a neurologist on-call from home. The implementation was partly in preparation for an application for Joint Commission–certified comprehensive stroke center status, which was approved in 2016.

A review of 2,022 Code Stroke activations in the emergency department from January 2012 through September 2016 that included only patients treated with intravenous tissue plasminogen activator revealed a significant decrease in door-to-neurologist time from an average of 7.1 minutes before the 24/7 in-hospital availability to 2.5 minutes after implementation. The analysis included 1,524 cases occurring prior to implementation and 498 cases occurring after.

The impact was most significant at night.

“Our nighttime reduction to the bedside went down from 13.6 minutes to 3.4 minutes, and our daytime reduction also improved from 5.2 minutes to 2.2 minutes,” said Dr. Schneider , a vascular neurologist at Mission Hospital.

Door-to-needle times were significantly reduced from 48.3 to 37.8 minutes overall, from 52 minutes to 40 minutes at night, and from 46.6 to 34.5 minutes during the day.

“We think that the trend toward significance at nighttime was mitigated by the fact there were just lesser numbers at night,” he said.

In-hospital mortality was reduced by 31% from 8.94% to 6.13%, he said.

Another variable that improved after the intervention was timing of prenotification by emergency medical services. The overall rate of prenotification did not improve (likely because of a ceiling effect; the rate of notification was already about 90%), but notifications improved from 12.5 minutes before arrival to 10.7 minutes.

There was no significant change in door-to-computed tomography times, which averaged about 15 minutes, Dr. Schneider said.

Though limited by a smaller number of postimplementation cases and lack of 3-month poststroke functional outcome data, the findings suggest that 24/7 in-hospital availability of a neurologist improves door to intravenous tissue plasminogen activator treatment times and in-hospital stroke mortality, Dr. Schneider concluded, noting that ongoing monitoring of outcomes will be necessary to assess for enduring impact.

Dr. Schneider reported having no disclosures.


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