• Kori Sauser, Deborah A Levine, Adrienne V Nickles, and Mathew J Reeves.
• Robert Wood Johnson Foundation Clinical Scholars Program and Department of Emergency Medicine, University of Michigan, Ann Arbor2Department of Veterans Affairs, VA Center for Clinical Management and Research, Ann Arbor VA Healthcare System, Ann Arbor, Mic.
• JAMA Neurol. 2014 Sep 1;71(9):1155-61.

ImportanceGiven the limited time window available for treatment with tissue plasminogen activator (tPA) in patients with acute ischemic stroke, guidelines recommend door-to-imaging time (DIT) within 25 minutes of hospital arrival and door-to-needle (DTN) time within 60 minutes for patients with acute ischemic stroke. Despite improvements in DITs, DTN times for tPA treatment in patients with acute ischemic stroke remain suboptimal.ObjectivesTo examine the contributions of DIT and imaging-to-needle (ITN) time to delays in timely delivery of tPA to patients with acute ischemic stroke and to assess between-hospital variation in DTN times.Design, Setting, And ParticipantsA cohort analysis of 1193 patients having acute ischemic stroke treated with intravenous tPA between January 2009 and December 2012. Multilevel linear regression models included random effects for 25 Michigan hospitals participating in the Paul Coverdell National Acute Stroke Registry.Main Outcomes And MeasuresThe primary outcome was a continuous measure of DTN time, in minutes, from emergency department arrival to thrombolytic delivery.ResultsThe mean age was 68.1 years, the median National Institutes of Health Stroke Scale score was 11.0 (interquartile range, 6-17), 51.4% were female, and 37.5% were of nonwhite race/ethnicity.The mean (SD) DTN time was 82.9 (35.4) minutes, the mean (SD) DIT was 22.8 (15.9) minutes, and the mean (SD) ITN time was 60.1 (32.3) minutes. Most patients (68.4%) had DIT within 25 minutes, while 28.7% had DTN time within 60 minutes. Hospital variation accounted for 12.7% of variability in DTN times. Neither annual stroke volume nor primary stroke center designation was a significant predictor of shorter DTN time. Patient factors (age, sex, race/ethnicity, arrival mode, onset-to-arrival time, and stroke severity) explained 15.4% of the between-hospital variation in DTN times. After adjustment for patient-level factors, DIT explained 10.8% of the variation in hospital risk-adjusted DTN times, while ITN time explained 64.6%.Conclusions And RelevanceCompared with DIT, ITN time is a much greater source of variability in hospital DTN times and is a more common contributor to delays in timely tPA therapy for acute ischemic stroke. More attention is needed to determine systems changes that can decrease ITN time for patients with acute ischemic stroke.

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