Emergency Department Door-to-Puncture Time Since 2014

Alexandra L Czap; James C Grotta; Stephanie A Parker; Jose-Miguel Yamal; Ritvij Bowry; Sunil A Sheth; Suja S Rajan; Hyunsoo Hwang; Noopur Singh; Patti Bratina; Tomas Bryndziar; Andrei V Alexandrov; Anne W Alexandrov; Wendy Dusenbury; Victoria Swatzell; William Jones; Kimberly Ackerson; Brandi Schimpf; Patrick Wright; Amanda L Jagolino-Cole

doi:10.1161/STROKEAHA.119.025106

Emergency Department Door-to-Puncture Time Since 2014

Stroke. 2019 Jul;50(7):1774-1780. doi: 10.1161/STROKEAHA.119.025106. Epub 2019 Jun 11.

Authors

Alexandra L Czap¹, James C Grotta², Stephanie A Parker¹, Jose-Miguel Yamal³, Ritvij Bowry¹, Sunil A Sheth¹, Suja S Rajan³, Hyunsoo Hwang³, Noopur Singh³, Patti Bratina¹, Tomas Bryndziar⁴, Andrei V Alexandrov⁴, Anne W Alexandrov⁴, Wendy Dusenbury⁴, Victoria Swatzell⁴, William Jones⁵, Kimberly Ackerson⁵, Brandi Schimpf⁶, Patrick Wright⁷, Amanda L Jagolino-Cole¹

Affiliations

¹ From the McGovern Medical School at the University of Texas Health Science Center, Houston (A.L.C., S.A.P., R.B., S.A.S., P.B., A.L.J-C.).
² Memorial Hermann Hospital, Houston, TX (J.C.G.).
³ School of Public Health at the University of Texas Health Science Center at Houston (J.-M.Y., S.S.R., H.H., N.S.).
⁴ The University of Tennessee Health Science Center, Memphis (T.B., A.V.A., A.W.A., W.D., V.S.).
⁵ The University of Colorado, Denver (W.J., K.A.).
⁶ The University of Colorado Hospital, Denver (B.S.).
⁷ The University of Colorado, Colorado Springs (P.W.).

Abstract

Background and Purpose- The impact of a mobile stroke unit (MSU) on access to intraarterial thrombectomy (IAT) is a prespecified BEST-MSU substudy (Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit Compared to Standard Management by Emergency Medical Services). On the MSU, IAT decision-making steps, such as computed tomography, neurological exam, and tPA (tissue-type plasminogen activator) treatment are completed before emergency department arrival. We hypothesized that such pre-ED assessment of potential IAT patients on an MSU improves the time from ED arrival to skin puncture time (door-to-puncture-time, DTPT). Methods- BEST-MSU is a prospective comparative effectiveness study of MSU versus standard management by emergency medical services (EMS). We compared ED DTPT among the following groups of MSU and EMS patients: all IAT patients, IAT patients post-tPA, and IAT patients post-tPA meeting thrombolytic adjudication criteria over the first 4 years of the study. Results- From August 2014 to July 2018, a total of 161 patients underwent IAT. Ninety-four patients presented to the ED via the MSU and 67 by EMS. One hundred forty patients received tPA before IAT, 85 in the MSU arm, and 55 in the EMS arm. One hundred twenty-six patients received tPA within thrombolytic adjudication criteria: 76 MSU and 50 EMS. DTPT in minutes was shorter for MSU patients (all IAT MSU versus EMS 89 versus 99, P=0.01; IAT post-tPA MSU versus EMS 93 versus 100, P=0.03; and IAT post-tPA within adjudicated criteria MSU versus EMS 93 versus 99.5, P=0.03). From 2014 to 2018, DTPT decreased at a faster rate for EMS compared with MSU-managed patients, improving by about an hour. Conclusions- Pre-ED IAT evaluation on an MSU results in faster DTPT compared with arrival by EMS. Since 2014, dramatic improvement in ED IAT metrics has attenuated this difference. However, DTPT in all groups indicates substantial room for improvement.

Keywords: decision making; emergency department; emergency medical services; hospital; puncture; stroke; thrombectomy.

Publication types

Multicenter Study
Research Support, Non-U.S. Gov't

MeSH terms

Adult
Aged
Aged, 80 and over
Ambulances / statistics & numerical data*
Clinical Decision-Making
Emergency Service, Hospital / statistics & numerical data*
Female
Fibrinolytic Agents / therapeutic use
Humans
Male
Middle Aged
Neurologic Examination
Prospective Studies
Stroke / therapy*
Thrombectomy
Time-to-Treatment / statistics & numerical data*
Tissue Plasminogen Activator / therapeutic use
Treatment Outcome

Substances

Fibrinolytic Agents
Tissue Plasminogen Activator

Grants and funding

T32 NS007412/NS/NINDS NIH HHS/United States