National Initiative Improves Time to tPA Administration in Stroke

VBCN - July 2014 Volume 1, No 2

When administered early, intravenous tissue plasminogen activator (tPA), an enzyme that helps dissolve clots, reduces long-term disability in patients with stroke. Because rapid treatment is crucial, national guidelines recommend that hospitals complete the evaluation of patients with acute ischemic stroke and begin tPA therapy for eligible patients within 60 minutes of their arrival at the hos­pital. However, evidence shows that <30% of patients receive tPA within this window, and that this has improved minimally over time. A new study reviewing the results of the Target: Stroke program, a national quality improvement initiative launched in 2010, shows that hospitals participating in this program have significantly reduced the time to tPA administration (Fonarow GC, et al. JAMA. 2014;311:1632-1640).

The data come from 71,169 patients with acute ischemic stroke who received tPA at 1030 participating hospitals. The time to treatment and incidence of complications were compared before the initiative was launched (2003-2009) and after its implementation (2010-2013). The initiative included 10 key strategies to achieve faster door-to-needle (DTN) times for tPA administration, provided clinical decision support tools, facilitated hospital participation, and encouraged sharing of best practices. The primary end points were DTN times for tPA administration in ≤60 minutes and the in-hospital risk-adjusted mortality, symptomatic intracranial hemorrhage, ambulatory status, and discharge destination.

The average median DTN time for tPA administration preintervention was 77 minutes, which decreased to 67 minutes postintervention. The median DTN was 74 minutes during the fourth quarter of 2009, immediately before the initiation of Target: Stroke; this declined to 59 minutes by the third quarter of 2013, resulting in a 15-minute reduction. The rate of tPA administration in ≤60 minutes increased from 29.6% preintervention to 53.3% postintervention. In addition, there was more than a 4-fold increase in the annual rate of improvement in the proportion of patients with DTN of ≤60 minutes after the initiation of the intervention.

This faster treatment time resulted in improved clinical outcomes in the postintervention period versus in the preintervention period. Improvements included reduced in-hospital deaths (8.2% vs 9.9%, respectively); fewer treatment complications (5.5% vs 6.7%, respectively); more frequent independence with walking (45.4% vs 42.2%, respectively); symptomatic intracranial hemorrhage within 36 hours (4.7% vs 5.7%, respectively); and discharge to home (42.7% vs 37.6%, respectively).

These improved outcomes reinforce the importance of faster administration of intravenous tPA, as shown with the implementation of Target: Stroke.

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