1. “Door to Needle (DTN) Time in Stroke Thrombolysis” Audit Care of the Elderly Department Dr Nikoletta Petrou, Foundation Year 1 Doctor Dr Prasanna Aghoram, Consultant Physician in Stroke Medicine

2. Reason for the Audit: Agreement in Stroke Network: Aim DTNt <60min This audit is a local initiative to measure current DTN times This audit aims to: ①Evaluate if appropriate patients are thrombolysed within 1 hour of A&E arrival ②Evaluate if patients with delayed DTN times have clear reasons for their delays ③Suggest appropriate action plans to improve patient care How did this Audit come about?

3. Stroke facts Every minute 1.9 million neurons and 14 billion synapses are destroyed Every hour that treatment is delayed, the ischaemic brain ages 3.6 years Time = Brain The Golden hour No current NICE guidelines on DTN time in Stroke Thrombolysis Recommendations to date have been consistent re: DTN <60min American Heart Association/American Stroke Association: Get with the Guidelines® Joint Committee (USA) sets a standard of 80% for DTN <60min National Institute of Neurological Disorders and Stroke Brain Attack Coalition sets a standard of 80% for DTN <60min International Stroke Conference – Only 27% of patients have DTNt <60min G. Fonarow et al, University of California, Los Angeles (2011) “Time Lost is Brain Lost”

4. THROMBOLYSIS PATHWAY ➊ Arrival to A&E ➋ A&E assessment ➌ Stroke team notified ➍ Priority CT Head ➎ Stroke team Assessment ➏ CT scan performed ➐ CT report obtained ➑ Patient informed and consent obtained ➒ Reconstitution and drawing up of Alteplase ➓ Thrombolysis is initiated INCLUSION CRITERIA Clinical signs and symptoms of definite acute stroke Clear time of onset Presentation within 3 hrs of acute onset Haemorrhage excluded by CT scan Age 18 - 80 years old NIHSS less than 25 Consent to treat (every effort must be made to contact next of kin) EXCLUSION CRITERIA Rapidly improving or minor stroke symptoms Stroke or serious head injury 3 months Major surgery, obstetrical delivery, external heart massage last 14 days, Seizure at onset of stroke Prior stroke and concomitant diabetes Severe haemorrhage last 21 days Increase bleeding risk History of central nervous damage (neoplasm, haemorrhage, aneurysm, spinal or intracranial surgery or haemorrhagic retinopathy) Blood pressure above 185 mmHg systolic or 110 mmHg diastolic Symptoms suggestive of SAH (even if CT is normal) Known clotting disorder Patient on heparin or warfarin Suspected iron deficient anaemia or thrombocytopenia Suspected hypoglycaemia or hyper glycaemia >3 mmol/l > 22 mmol/l Bacterial endocarditis, pericarditis Acute pancreatitis Ulcerative GI disease last 3 months, oesophageal varices, arterial- aneurysm, arterial/venous malformation. Severe liver disease including cirrhosis, acute hepatitis DTN The Golden Hour

5. Standard 1 Appropriate patients should have DTNt <60min Target 80% Exempted: patients in international trials and patients whose hypertension required immediate treatment to allow thrombolysis to be considered Standard 2 Patients with DTNt >60min should have a reason for the delay Target 80% Standards

6. Analysis of Stroke Database Demographics and Consultant Time of symptom onset Time of arrival to A&E Time of stroke team arrival Time of Head CT scan Time of Alteplase given Prior BP control noted DTNt was calculated Reasons for delay were noted Four categories of DTN: 90min delay Methods Audit tool

7. ✘ Target of 80% was not met Standard 1 43 patients thrombolysed ** 30 included ** Median DTNt 85 min

8. 10% had DTN <60min 13% had DTN <65min 17% had DTN <70min 27% had DTN <75min 63% had DTN <90min Analysis

9. ●More patients are thrombolysed in under 90 min compared to previous years ●More patients are thrombolysed in under 75 min compared to previous years Results by Year

10. All patients with DTN time > 90min have clear reasons documented by the Consultant Minor time losses are spread across the pathway and not documented Standard 2 59% have identified reasons for delay

11. Analysis

12. Analysis No difference in service speed between day-time and “out of hours” service

13. ●10% of patients were thrombolysed within 60min of arrival to A&E and 63% within 90min. ●Only 27% have DTNt<60min according to the largest study to-date. ●27% can be achieved by reducing pathway delays by 15min. ●15% had DTNt<60min in 2011, an improvement on previous years. ●100% of severe delays (DTNt>90min) have documented reasons and these are predominantly (75%) due to difficult-to-modify patient-related factors Conclusions

14. ●Important to track minor delays that are usually spread across the pathway ●Priority is ensuring safety of treatment at all times ●In some cases the delay may be inevitable. Alternative is no treatment Conclusions

15. Action Plan ICE 2

16. Monitoring tool Important to start completing when the patient arrives in A&E to track potential time losses in real time

17. References American Heart Association/American Stroke Association (2011). The Get With The Guidelines®– Stroke (GWTG-Stroke) program. Website: http://www.strokeassociation.org/STROKEORG Fonarow GC, Smith EE, Saver JL (2011). Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: Patient characteristics, hospital factors, and outcomes associated with door- to-needle times within 60 minutes. Circulation 2011: DOI:10.1161 Mikita M (2011). Reducing Door-to-Needle Time for tPA Use Remains and Elusive Goal in Stroke Care. JAMA. 2011;305(13):1288-1289 Sinha D, et al (2009). Door-toNeedle Time for Stroke Thrombolysis. Reasons for delays at busy District General Hospital. Southend Hospital. Availble online at: www.stroke.org.uk/document.rm?id=2494 Susan Boorman (2011). Thrombolysis Audit. Onset-to-alteplase time. Darent Valley Hospital, Audit Meeting September 2011

18. Thank you Questions?

19. THROMBOLYSIS PATHWAY ➊ Arrival to A&E ➋ A&E assessment ➌ Stroke team notified ➍ Priority CT Head ➎ Stroke team Assessment ➏ CT scan performed ➐ CT report obtained ➑ Patient informed and consent obtained ➒ Reconstitution and drawing up of Alteplase ➓ Thrombolysis is initiated INCLUSION CRITERIA Clinical signs and symptoms of definite acute stroke Clear time of onset Presentation within 3 hrs of acute onset Haemorrhage excluded by CT scan Age 18 - 80 years old NIHSS less than 25 Consent to treat (every effort must be made to contact next of kin) EXCLUSION CRITERIA Rapidly improving or minor stroke symptoms Stroke or serious head injury 3 months Major surgery, obstetrical delivery, external heart massage last 14 days, Seizure at onset of stroke Prior stroke and concomitant diabetes Severe haemorrhage last 21 days Increase bleeding risk History of central nervous damage (neoplasm, haemorrhage, aneurysm, spinal or intracranial surgery or haemorrhagic retinopathy) Blood pressure above 185 mmHg systolic or 110 mmHg diastolic Symptoms suggestive of SAH (even if CT is normal) Known clotting disorder Patient on heparin or warfarin Suspected iron deficient anaemia or thrombocytopenia Suspected hypoglycaemia or hyper glycaemia >3 mmol/l > 22 mmol/l Bacterial endocarditis, pericarditis Acute pancreatitis Ulcerative GI disease last 3 months, oesophageal varices, arterial- aneurysm, arterial/venous malformation. Severe liver disease including cirrhosis, acute hepatitis DTN The Golden Hour