• Benjamin Y Q Tan, Nicholas J H Ngiam, Sibi Sunny, Wan Yee Kong, Howen Tam, Tiong Beng Sim, Leong Benjamin S H BSH Department of Emergency Medicine, National University Health System, Singapore, Singapore., Chandra Bhartendu, Prakash R Paliwal, Seet Raymond C S RCS Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore., Chan Bernard P L BPL Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore., Teoh Hock Luen HL Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore., Vijay K Sharma, and Yeo Leonard L L LLL Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore; Department of Clinical Neuroscience, Karolinsk.
• Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore.
• J Stroke Cerebrovasc Dis. 2018 Jun 1; 27 (6): 1539-1545.

BackgroundIn acute ischemic stroke (AIS), treatment with intravenous tissue-type plasminogen activator (IV-tPA) is time-sensitive. All stroke centers make continual efforts to reduce door-to-needle time (DNT) with varying success. We present the impact of modifications to our stroke activation protocol on DNT.MethodsWe included 404 consecutive patients with AIS receiving IV-tPA between January 2014 and December 2016. First changes in stroke activation protocol were made in March 2015 in the form of prenotification by paramedics, direct transfer from ambulance to computed tomography (CT) scanner, and rapid en route neurological assessment by an emergency physician and neurologist. In March 2016, a second amendment was made where a stroke nurse accompanied the patient to expedite various steps in the treatment pathway, including endovascular treatment in eligible cases.ResultsBoth protocol amendments resulted in improvement in DNT and door-to-CT time from 84 ± 47 minutes before intervention to 69 ± 33 minutes after protocol amendment 1 to 59 ± 37 minutes after protocol amendment 2. In particular, the second amendment (144 patients) showed significant shortening of DNT compared with the 137 patients before (59 ± 37 minutes versus 69 ± 33 minutes, P = .020), with a higher percentage achieving the target of 60 minutes (68.1% versus 48.2%, P < .001). This finding was attributed to a reduction in both door-to-CT time and CT-to-needle time. This improvement remained consistent over subsequent months.ConclusionsThe application of a simple systems-based, multidisciplinary stroke activation protocol may help in significant reduction in DNT. Encouraging increased patient ownership by stroke nurses appeared to be a promising approach for timely administration of definitive acute therapies.Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.

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