Timely treatment is essential in acute ischemic stroke as the chances of recovery diminish over time, so efforts are necessary to streamline in-hospital pathways and reduce delays. Here, we analyse the interventions to reduce door-to-needle time in stroke patients suitable for intravenous thrombolysis at the Emergency Department of San Carlo Borromeo Hospital, Milan, Italy. All stroke patients consecutively treated with intravenous thrombolysis at our centre from January 1, 2013 to December 31, 2015 were included in this analysis. The main interventions adopted were (1) continuous education of personnel, (2) reconsideration of blood tests and identify the ones really affecting treatment decision, (3) approval of a new high-urgency Stroke Code activated as soon as the triage nurse comes to know of a potential thrombolysis candidate. Median door-to-needle time progressively decreased from 103 min (iqr 78-120) in 2013, to 92 min (iqr 72-112) in 2014, and to 37 min (iqr 27-58) with the new Stroke Code (p < 0.001) in 2015. Simultaneously, median onset-to-treatment time decreased from 177 min (iqr 142-188) in 2013, to 155 min (iqr 141-198) in 2014, and to 114 min (iqr 86-160) with the new Stroke Code (p < 0.001 and p 0.005, respectively). We did not observe any significant difference in bleeding risks or deaths, whereas the likelihood of favourable outcome (mRS 0-2) increased. Streamlining in-hospital pathways with progressive interventions significantly decreases door-to-needle time and onset-to-treatment time and may contribute to improve stroke outcomes.
Keywords: In-hospital delay; Stroke; Stroke management; Stroke team; Thrombolysis.