Door-to-needle time [Neurosurgery Wiki]

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====== Door-to-needle time ======

The benefits of [[intravenous]] [[tissue plasminogen activator]] (tPA) in patients with [[acute ischemic stroke]] (AIS) are time-dependent and [[guideline]]s recommend a door-to-needle (DTN) time of 60 minutes or less.
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The neurosurgeon group showed similar [[door-to-needle time]] and clinical outcomes to the neurologist group in patients with AIS in the ER. This study suggests that neurosurgeons have comparable abilities to care for patients with AIS in the ER
((Lee SH, Nam TM, Jang JH, Kim YZ, Kim KH, Ryu KH, Kim DH, Kwan BS, Lee H, Kim SH. Role of Neurosurgeons in the Treatment of Acute Ischemic Stroke in the Emergency Room. J Korean Neurosurg Soc. 2022 Aug 17. doi: 10.3340/jkns.2022.0085. Epub ahead of print. PMID: 35974432.))
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[[Intravenous thrombolysis]] (IVT) plays a prominent role in [[acute ischemic stroke treatment]] (AIS). The sooner IVT is administered, the higher the [[odds]] of a good outcome. Therefore, registering the in-hospital time to treatment with IVT, i.e. the door-to-needle time (DNT), is a powerful way to measure quality improvement
((Kuhrij LS, Marang-van de Mheen PJ, van den Berg-Vos RM, de Leeuw FE, Nederkoorn PJ; Dutch Acute Stroke Audit consortium. Determinants of extended door-to-needle time in acute ischemic stroke and its influence on in-hospital mortality: results of a nationwide Dutch clinical audit. BMC Neurol. 2019 Nov 4;19(1):265. doi: 10.1186/s12883-019-1512-2. PMID: 31684901; PMCID: PMC6827229.)).
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Ren et al. demonstrated national marked and sustainable [[improvement]] in adherence to [[door-to-needle time]], [[door-to-puncture time]], and successful [[reperfusion therapy]] from 2013 to 2017 in [[Japan]] in [[acute ischemic stroke thrombolysis]]. Adhering to the key [[Quality Indicator]]s substantially affected in-hospital [[outcome]]s, underlining the importance of [[monitoring]] the [[quality of care]] using evidence-based [[Quality Indicator]]s and the nationwide Close The Gap-Stroke program
((Ren N, Ogata S, Kiyoshige E, Nishimura K, Nishimura A, Matsuo R, Kitazono T, Higashi T, Ogasawara K, Iihara K; Close The Gap-Stroke, J-ASPECT Study Collaborators. Associations Between Adherence to [[Evidence]]-Based, Stroke [[Quality Indicator]]s and Outcomes of Acute [[Reperfusion Therapy]]. Stroke. 2022 Aug 16:101161STROKEAHA121038483. doi: 10.1161/STROKEAHA.121.038483. Epub ahead of print. PMID: 35971841.)).
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Even though DNT in the Netherlands is short compared to other countries, lowering the DNT may be achievable by focusing on specific subgroups
((Kuhrij LS, Marang-van de Mheen PJ, van den Berg-Vos RM, de Leeuw FE, Nederkoorn PJ; Dutch Acute Stroke Audit consortium. Determinants of extended door-to-needle time in acute ischemic stroke and its influence on in-hospital mortality: results of a nationwide Dutch clinical audit. BMC Neurol. 2019 Nov 4;19(1):265. doi: 10.1186/s12883-019-1512-2. PMID: 31684901; PMCID: PMC6827229.)).
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One major contributing factor is the time for a doctor to come and assess and administer the thrombolytic agent to the patient. The change was implemented by ensuring that the core medical trainee on call is allocated to respond as a priority to all possible thrombolysis calls. This has resulted in a reduction of mean DTN time, from 74 minutes in November to 43 minutes in January. As well as improving patient outcomes, it is proposed that the implementation of change has benefitted the training experience and development of key skills of the core medical trainees
((Fernandes D, Umasankar U. Improving Door to Needle time in Patients for Thrombolysis. BMJ Qual Improv Rep. 2016 Aug 11;5(1):u212969.w5150. doi: 10.1136/bmjquality.u212969.w5150. PMID: 27559475; PMCID: PMC4994096.)).
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Implementation of a national quality improvement initiative was associated with improved timeliness of [[tPA]] administration following AIS on a national scale, and this improvement was associated with lower in-[[hospital mortality]] and intracranial hemorrhage, along with an increase in the percentage of patients discharged home
((Fonarow GC, Zhao X, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Xian Y, Hernandez AF, Peterson ED, Schwamm LH. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA. 2014 Apr 23-30;311(16):1632-40. doi: 10.1001/jama.2014.3203. PMID: 24756513.))