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BACKGROUND AND PURPOSE: Rapid access to acute stroke treatment improves clinical outcomes in patients with ischemic stroke. We aimed to shorten the time to admission and to acute stroke treatment for patients with acute stroke in the Hamburg metropolitan area by collaborative multilevel measures involving all hospitals with stroke units, the Emergency Medical Services (EMS), and health-care authorities. METHODS: In 2007, an area-wide stroke care quality project was initiated. The project included mandatory admission of all stroke patients in Hamburg exclusively to hospitals with stroke units, harmonized acute treatment algorithms among all hospitals, repeated training of the EMS staff, a multimedia educational campaign, and a mandatory stroke care quality monitoring system based on structured data assessment and quality indicators for procedural measures. We analyzed data of all patients with acute stroke who received inhospital treatment in the city of Hamburg during the evaluation period from the quality assurance database data and evaluated trends of key quality indicators over time. RESULTS: From 2007 to 2016, a total of 83,395 patients with acute stroke were registered. During this period, the proportion of patients admitted within ≤3 h from symptom onset increased over time from 27.8% in 2007 to 35.2% in 2016 (p < 0.001). The proportion of patients who received rapid thrombolysis (within ≤30 min after admission) increased from 7.7 to 54.1% (p < 0.001). CONCLUSIONS: Collaborative stroke care quality projects are suitable and effective to improve acute stroke care.

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BACKGROUND: Door to needle (DTN) time provides valuable insight into stroke care workflow and is a performance indicator of an acute stroke unit. The aim of the current study was to ascertain whether a door to needle time of less than 60 min can be achieved for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) and maintained long term in a comprehensive stroke unit. METHODS: Patients with AIS treated with IVT in the stroke unit formed the study group. Demographic and clinical characteristics including door to imaging (DTI) time, DTN time, and 3 month functional outcome were abstracted. Pairwise comparison was done of yearly median DTI and DTN times with Bonferroni correction. RESULTS: Over a period of 6 years a total of 196 patients with mean age of 61.5 ± 13.1 years and median (IQR) NIHSS 11 (8-16) underwent IVT. The median DTI time and DTN time over the study period was 15 (12-21) minutes and 40 (30-50) minutes respectively. A total of 90.1%, 69.4% and 29.1% patients received IVT within 60 min, 45 min and 30 min respectively. On pairwise comparison of the median yearly DTN Year 2016 and 2017 were lower compared to most of the earlier years (p < 0.0001). Good functional outcome (mRS ≤ 2) was noted in 68.7% patients at 3 months follow-up. CONCLUSION: It is possible to sustainably reduce DTN time for IVT in AIS to well below the current 60 min benchmark with hospital system training and teamwork.

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INTRODUCTION: Based on data from the Baden-Wuerttemberg stroke registry, we aimed to explore the diurnal variation of acute ischemic stroke (IS) care delivery. MATERIALS AND METHODS: 92,530 IS patients were included, of whom 37,471 (40%) presented within an onset-to-door time ≤4.5 h. Daytime was stratified in 3-h time intervals and working vs. non-working hours. Stroke onset and hospital admission time, rate of door-to-neurological examination time ≤30 min, onset-/door-to-imaging time IV thrombolysis (IVT) rates, and onset-/door-to-needle time were determined. Multivariable regression models were used stratified by stroke onset and hospital admission time to assess the relationship between IVT rates, quality performance parameters, and daytime. The time interval 0:00 h to 3:00 h and working hours, respectively, were taken as reference. RESULTS: The IVT rate of the whole study population was strongly associated with the sleep-wake cycle. In patients presenting within the 4.5-h time window and potentially eligible for IVT stratification by hospital admission time identified two time intervals with lower IVT rates. First, between 3:01 h and 6:00 h (IVT rate 18%) and likely attributed to in-hospital delays with the lowest diurnal rate of door-to-neurological examination time ≤30 min and the longest door-to-needle time Second, between 6:01 h and 15:00 h (IVT rate 23-25%) compared to the late afternoon and evening hours (IVT rate 27-29%) due to a longer onset-to-imaging time and door-to-imaging time. No evidence for a compromised stroke service during non-working hours was observed. CONCLUSION: The analysis provides evidence that acute IS care is subject to diurnal variation which may affect stroke outcome. An optimization of IS care aiming at constantly high IVT rates over the course of the day therefore appears desirable.

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Introducción: El ataque cerebrovascular (ACV) isquémico es una patología frecuente, con una prevalencia de 500-600 por 100.000 personas en población blanca y una tasa de 5,54 millones de muertes al año. La terapia trombolítica mejora el pronóstico a largo plazo del ACV cuando es usada dentro de las 4,5 horas de ingreso. El uso de vía clínica ha demostrado reducir los tiempos de atención en patologías con un tratamiento específico como el ACV. Objetivo: Determinar el efecto de la implementación de una vía clínica para la atención de los pacientes con ACV hiperagudo en la reducción del tiempo puerta-tomografía de cráneo (TAC) simple. Materiales y métodos: Estudio del antes y después de la implementación de una vía clínica para la atención de los pacientes con ACV hiperagudo en el servicio de urgencias. Se midieron las variables demográficas y los intervalos de tiempo puerta-TAC, puerta-valoración por neurología y puerta-trombolisis. Resultados: La media de edad antes fue de 68,8 años (DE 13), y después, de 70 años (DE 12). La mediana (RIQ) de tiempo puerta-TAC simple fue de 33 (18,5-54) minutos antes y 6,5 (-9 - 30) después. La mediana (RIQ) del tiempo ingreso - val. neurología 90 (16-116) antes y 38 (11,5-110) después. La mediana (RIQ) del tiempo ingreso - trombolisis fue 74 (53-119) antes y 86 (45-100) después. Aumentó el porcentaje de pacientes con ecocardiograma y doppler de carótidas solicitados al ingreso. El porcentaje de pacientes llevados a terapia trombolítica fue similar. Conclusión: la implementación de una vía clínica reduce el tiempo puerta-TAC simple, encontrándose una diferencia estadística (p: 0,017) entre las medianas de tiempo antes y después.

Introduction: The Acute Ischemic Stroke (AIS) is pathology with an approximate prevalence of 500-600 per 100,000 people in white population and a rate to 5.54 million deaths annually. The thrombolytic therapy within 4.5 hours improvement the ACV long-term prognosis. The use of clinical pathways has demonstrated reduce the attention time in pathologies with specific treatment like ACV. Objective: To determine the effect of implementing the pathway for patients' care with hyperacute ischemic stroke in reducing door-to-imaging time. Materials and methods: Study before and after implementation of the pathway for patients' care with hyperacute ischemic stroke who were admitted to the emergency department. Demographic variables and time intervals of door-to-imaging time, door to neurology evaluation and door-to- needle-time were measured. Results: The mean age was 68.8 years (SD13) before and 70 years (SD 12) after. The median (IQR) door-to-imaging time was 33 (18.5-54) minutes before and 6,5 (-9-30) after p: 0,017. The median (IQR) door to - neurology evaluation was 90 (16-116) before and 38 (11.5-110) after. The median (IQR) door-to thrombolysis time was 74 (53-119) before and 86 (45-100) after. The percentage of patients undergoing thrombolytic therapy was similar. Conclusion: The implementing the pathway for patients' care with hyperacute ischemic stroke in reduces door-to-imaging time.

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BACKGROUND: Brain imaging is logistically the most difficult step before thrombolysis. To improve door-to-needle time (DNT), it is important to understand if (1) longer door-to-imaging time (DIT) results in longer DNT, (2) hospitals have different DIT performances, and (3) patient and hospital characteristics predict DIT. METHODS: Prospectively collected data in the Safe Implementation of Treatments in Stroke-EAST (SITS-EAST) registry from Central/Eastern European countries between 2008 and 2011 were analyzed. Hospital characteristics were obtained by questionnaire from each center. Patient- and hospital-level predictors of DIT of 25 minutes or less were identified by the method of generalized estimating equations. RESULTS: Altogether 6 of 9 SITS-EAST countries participated with 4212 patients entered into the database of which 3631 (86%) had all required variables. DIT of 25 minutes or less was achieved in 2464 (68%) patients (range, 3%-93%; median, 65%; and interquartile range, 50%-80% between centers). Patients with DIT of 25 minutes or less had shorter DNT (median, 60 minutes) than patients with DIT of more than 25 minutes (median, 86 minutes; P < .001). Four variables independently predicted DIT of 25 minutes or less: longer time from stroke onset to admission (91-180 versus 0-90 minutes; odds ratio [OR], 1.6; 95% confidence interval [CI], 1.3-1.8), transport time of 5 minutes or less (OR, 2.9; 95% CI, 1.7-4.7) between the place of admission and a computed tomography (CT) scanner, no or minimal neurologic deficit before stroke (OR, 1.3; 95% CI, 1.02-1.5), and diabetes mellitus (OR, .8; 95% CI, .7-.97). CONCLUSIONS: DIT should be improved in patients arriving early and late. Place of admission should allow transport time to a CT scanner under 5 minutes.

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