Stroke 20 20: Implementation goals for intravenous thrombolysis

Abstract

Introduction: Knowledge of the implementation gap would facilitate the use of intravenous thrombolysis in stroke, which is still low in many countries. The study was conducted to identify national implementation targets for the utilisation and logistics of intravenous thrombolysis.

Material and method: Multicomponent interventions by stakeholders in health care to optimise prehospital and hospital management with the goal of fast and accessible intravenous thrombolysis for every candidate. Implementation results were documented from prospectively collected cases in all 45 stroke centres nationally. The thrombolytic rate was calculated from the total number of all ischemic strokes in the population of the Czech Republic since 2004.

Results: Thrombolytic rates of 1.3 (95%CI 1.1 to 1.4), 5.4 (95%CI 5.1 to 5.7), 13.6 (95%CI 13.1 to 14.0), 23.3 (95%CI 22.8 to 23.9), and 23.5% (95%CI 23.0 to 24.1%) were achieved in 2005, 2009, 2014, 2017, and 2018, respectively. National median door-to-needle times were 60-70 minutes before 2012 and then decreased progressively every year to 25 minutes (IQR 17 to 36) in 2018. In 2018, 33% of both university and non-university hospitals achieved median door-to-needle time ≤20 minutes. In 2018, door-to-needle times ≤20, ≤45, and ≤60 minutes were achieved in 39, 85, and 93% of patients.

Discussion: Thrombolysis can be provided to ≥ 20% of all ischemic strokes nationwide and it is realistic to achieve median door-to-needle time 20 minutes.

Conclusion: Stroke 20-20 could serve as national implementation target for intravenous thrombolysis and country specific implementation policies should be applied to achieve such target.

Keywords: Thrombolytic rate; acute stroke care; implementation of thrombolysis; stroke care management.

Figure 1.

Door-to-needle time (DNT) during the period 2004–2018. (a) Median DNT in minutes and 95% confidence intervals from 2004 till 2018 in all stroke centers. (b) Median DNTs in minutes and 95% confidence intervals in Comprehensive Stroke Centres (boxes) as compared to Primary Stroke Centres (dots) from 2004 till 2018. Median DNT was significantly shorter in Comprehensive as compared to Primary Stroke Centres between 2013 and 2016 but become the same in 2017–2018.

Figure 2.

Comparison of treatment startup within the thrombolytic window. The graphs show that patients arriving to hospital towards the end of thrombolytic window used to be treated with thrombolysis faster (in 2005 and 2010) but in recent years (2015 and 2017), patients door-to-needle time (DNT) was the same regardless of onset-to-door time (ODT).

Figure 3.

The implementation and quality improvement puzzle. All components support each other and fall into four categories such as people, stakeholders, tools, and documents. Leadership by stroke society, communication with healthcare professional using emails, journal (in local language), and national conferences is the first line followed by stakeholders involvement such as hospitals and the Ministry of Health. Tools such as quality registry allow for data driven certification, monitoring of quality of health care, identification of gaps and setting the targets. Documents supporting the overall strategies such as national guidelines, regulations and hospital standard operating procedures are the final line.