From the Guidelines
Door to needle time refers to the critical interval between a patient's arrival at the hospital and the administration of tissue plasminogen activator (tPA) for acute ischemic stroke treatment, and it should ideally be less than 60 minutes. This time period is crucial in determining the outcome of stroke treatment, with faster treatment associated with better outcomes, as every 15-minute reduction of door-to-needle time results in a 5% lower odds of in-hospital mortality 1. The medication, tPA (also known by the generic name alteplase), is typically administered at a dose of 0.9 mg/kg with a maximum dose of 90 mg, with 10% given as an initial bolus and the remainder infused over 60 minutes, as recommended by the Canadian Stroke Best Practice Recommendations 1. The goal is to administer tPA as soon as possible after hospital arrival, with a target door-to-needle time of less than 60 min in 90% of treated patients and a median door-to-needle time of 30 min 1. Rapid door to needle times are achieved through streamlined hospital protocols, including pre-notification by emergency medical services, direct transport to CT scanning, and having stroke teams ready to evaluate patients immediately upon arrival. Every minute saved in delivering tPA preserves approximately 1.9 million neurons, which explains why hospitals continuously work to minimize this time interval and why "time is brain" has become a fundamental principle in stroke care. According to the most recent and highest quality study, the target door-to-needle time should be less than 60 minutes, with a median door-to-needle time of 30 minutes 1. Key factors that influence door-to-needle time include hospital protocols, emergency medical services, and stroke team readiness, and identifying barriers and enablers for implementation of evidence-based practices is crucial to improve the quality of patient care 1. In summary, door to needle time is a critical factor in stroke treatment, and hospitals should strive to achieve a door-to-needle time of less than 60 minutes, with a median time of 30 minutes, to improve patient outcomes 1.
Some key points to consider:
- Door to needle time should be less than 60 minutes
- tPA should be administered as soon as possible after hospital arrival
- The dose of tPA is 0.9 mg/kg with a maximum dose of 90 mg
- Rapid door to needle times are achieved through streamlined hospital protocols
- Every minute saved in delivering tPA preserves approximately 1.9 million neurons
- The target door-to-needle time should be less than 60 minutes, with a median door-to-needle time of 30 minutes 1
From the Research
Definition of Door to Needle Time
- Door to needle time refers to the time from hospital arrival to administration of tissue plasminogen activator (tPA) in patients with acute ischemic stroke 2, 3, 4.
- This time period is critical in determining patient outcomes, with decreased door-to-needle time associated with improved patient outcomes 2.
Importance of Reducing Door to Needle Time
- Reducing door-to-needle time is essential to improve patient outcomes in acute ischemic stroke 2, 3, 4.
- Several studies have shown that reducing door-to-needle time can lead to significant improvements in patient outcomes, including reduced morbidity and mortality 2, 4.
Strategies to Improve Door to Needle Time
- Implementation of an Acute Stroke Triage Pathway can help reduce door-to-needle time by rapidly identifying patients eligible for tPA treatment and streamlining the treatment process 4.
- Involvement of emergency medicine pharmacists in stroke care can also improve door-to-needle time by expediting the administration of tPA 2.
- Optimizing the order of diagnostic studies, such as performing electrocardiogram (ECG) after head computed tomography (CT), can also help reduce door-to-needle time 3.
Current Challenges and Future Directions
- Despite the importance of reducing door-to-needle time, many patients still experience delays in receiving tPA treatment, highlighting the need for continued improvement in stroke care 3, 4.
- Further research is needed to identify effective strategies for reducing door-to-needle time and improving patient outcomes in acute ischemic stroke 2, 3, 4.