TY - JOUR
T1 - Components and Trends in Door to Treatment Times for Endovascular Therapy in Get With The Guidelines-Stroke Hospitals
AU - Menon, Bijoy K.
AU - Xu, Haolin
AU - Cox, Margueritte
AU - Saver, Jeffrey L.
AU - Goyal, Mayank
AU - Peterson, Eric
AU - Xian, Ying
AU - Matsuoka, Roland
AU - Jehan, Reza
AU - Yavagal, Dileep
AU - Gupta, Rishi
AU - Mehta, Brijesh
AU - Bhatt, Deepak L.
AU - Fonarow, Gregg C.
AU - Schwamm, Lee H.
AU - Smith, Eric E.
N1 - Publisher Copyright:
© 2018 American Heart Association, Inc.
PY - 2019/1/8
Y1 - 2019/1/8
N2 - Background: Endovascular therapy (EVT) is standard of care in patients with acute disabling ischemic stroke attributable to large-vessel occlusion and is more effective when delivered quickly. It is currently unclear whether time targets achieved in clinical trials can be achieved in clinical practice. We describe interval times from patient arrival in the emergency department (door) to first pass (treatment initiation) in patients receiving EVT within Get With The Guidelines-Stroke hospitals and analyze patient- and hospital-level variables associated with these times. Methods: Data are from sites participating fully as Comprehensive Stroke Centers within Get With The Guidelines-Stroke hospitals from October 2014 to September 2016. Workflow times analyzed include door to imaging, imaging to arterial access, arterial access to first pass, and the composite door to first pass time. Data are described overall and by calendar-year quarters. Multivariable modeling was used to identify patient- and hospital-level variables associated with workflow times. Results: Among 2929 patients with EVT from 195 hospitals (median age, 71 years [interquartile range {IQR}, 60-81]; 50.7% female; median baseline National Institute of Health Stroke Score, 17 [IQR, 12-22]; median annual EVT administration number, 16 [IQR, 10-27]), median door to first pass time was 130 minutes (IQR, 101-170 minutes), door to imaging time was 12 minutes (IQR, 7-20 minutes), imaging to arterial puncture time was 93 minutes (IQR, 68-126 minutes), and arterial puncture to first pass time was 18 minutes (IQR, 4-31 minutes). Overall, 3% patients achieved a door to first pass time ≤60 minutes. A statistically significant linear time trend was noted for door to first pass time (quarter 4 year 2014 median time, 134.5 minutes to quarter 3 year 2016 median time, 128 minutes, P=0.002). In multivariable analysis, older age, arrival during nonregular hours, and history of diabetes mellitus were associated with longer door to first pass time. Hospitals achieving shorter door to intravenous alteplase administration (door to needle) times were more likely to achieve faster door to first pass time (P<0.001). Each 5 cases/y increase in EVT case volume was associated with a 3% shorter door to first pass time, up to a case volume of 40 per year (P<0.001). Conclusions: Although EVT treatment times are modestly improving, additional efforts are needed to streamline workflow so that the true potential of this treatment is realized. These data may inform benchmark goals for EVT workflow times.
AB - Background: Endovascular therapy (EVT) is standard of care in patients with acute disabling ischemic stroke attributable to large-vessel occlusion and is more effective when delivered quickly. It is currently unclear whether time targets achieved in clinical trials can be achieved in clinical practice. We describe interval times from patient arrival in the emergency department (door) to first pass (treatment initiation) in patients receiving EVT within Get With The Guidelines-Stroke hospitals and analyze patient- and hospital-level variables associated with these times. Methods: Data are from sites participating fully as Comprehensive Stroke Centers within Get With The Guidelines-Stroke hospitals from October 2014 to September 2016. Workflow times analyzed include door to imaging, imaging to arterial access, arterial access to first pass, and the composite door to first pass time. Data are described overall and by calendar-year quarters. Multivariable modeling was used to identify patient- and hospital-level variables associated with workflow times. Results: Among 2929 patients with EVT from 195 hospitals (median age, 71 years [interquartile range {IQR}, 60-81]; 50.7% female; median baseline National Institute of Health Stroke Score, 17 [IQR, 12-22]; median annual EVT administration number, 16 [IQR, 10-27]), median door to first pass time was 130 minutes (IQR, 101-170 minutes), door to imaging time was 12 minutes (IQR, 7-20 minutes), imaging to arterial puncture time was 93 minutes (IQR, 68-126 minutes), and arterial puncture to first pass time was 18 minutes (IQR, 4-31 minutes). Overall, 3% patients achieved a door to first pass time ≤60 minutes. A statistically significant linear time trend was noted for door to first pass time (quarter 4 year 2014 median time, 134.5 minutes to quarter 3 year 2016 median time, 128 minutes, P=0.002). In multivariable analysis, older age, arrival during nonregular hours, and history of diabetes mellitus were associated with longer door to first pass time. Hospitals achieving shorter door to intravenous alteplase administration (door to needle) times were more likely to achieve faster door to first pass time (P<0.001). Each 5 cases/y increase in EVT case volume was associated with a 3% shorter door to first pass time, up to a case volume of 40 per year (P<0.001). Conclusions: Although EVT treatment times are modestly improving, additional efforts are needed to streamline workflow so that the true potential of this treatment is realized. These data may inform benchmark goals for EVT workflow times.
KW - endovascular procedures
KW - ischemic attack, transient
KW - registries
KW - stroke
KW - treatment outcome
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U2 - 10.1161/CIRCULATIONAHA.118.036701
DO - 10.1161/CIRCULATIONAHA.118.036701
M3 - Article
C2 - 30586703
AN - SCOPUS:85059928832
SN - 0009-7322
VL - 139
SP - 169
EP - 179
JO - Circulation
JF - Circulation
IS - 2
ER -