Hospital Arrival Times and Post-Imaging Delays in Stroke Thrombolysis Implementation

Background: Rapid alteplase delivery for ischemic stroke patients has been shown to increase the likelihood of disability-free life. Identification of barriers to rapid alteplase delivery and streamlining processes around imaging assessments are important. Our aim was to examine the relationships between hospital arrival time and postimaging processes in stroke thrombolysis. Methods: De-identified data of patients who underwent intravenous alteplase therapy at 20 hospitals in Australia were entered into the Thrombolysis ImPlementation in Stroke (TIPS) audit tool. During the pre-intervention phase, 601 patients who received alteplase ≤ 270 minutes of stroke onset were analysed. Onset-to-door (OTD), door-to-needle (DTN), door-to-imaging (DTI), and imaging-to-needle (ITN) times were assessed using univariable and multivariable linear regression analyses. Results: The age was 71.3 ± 13.4years, and the median NIHSS score was 11. The median OTD, DTN, DTI, ITN times were 73, 85, 32, and 46 minutes, respectively. Every minute earlier of OTD resulted in 0.24 minutes slower DTN (p<0.01), 0.06 minutes slower DTI (p=0.02), and 0.17 minutes slower ITN times (p<0.01). Every point decrease of baseline NIHSS score resulted in 0.66 minutes slower DTN (p =0.01) and 0.47 minutes slower DTI (p =0.01), however ITN had no significant association with baseline NIHSS score. Conclusions: Early arrival time was a greater contributor to delayed treatment, in particular post-imaging processes compared with pre-imaging processes, in patients with alteplase therapy for ischemic stroke. Improved processes to reduce post-imaging delays are needed for rapid alteplase treatment.