Time is Brain: A Systematic Review of Quality Improvement Interventions to Reduce Door to Needle Times in Acute Ischemic Stroke
CCCF ePoster library. Siarkowski M. Nov 2, 2016; 150994
Michael Siarkowski
Michael Siarkowski
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Topic: Systematic Review, Meta-analysis, or Meta-synthesis

Time is Brain: A Systematic Review of Quality Improvement Interventions to Reduce Door to Needle Times in Acute Ischemic Stroke

Siarkowski, Michael1 ; Sultan, Abdulaziz2 ; Kamal, Noreen3 ; Lin, Katie4 ; Li, Shari5 ; Ganshorn, Heather6 ; Hill, Michael7 ; Lang, Eddy8

1Alberta Health Services – Emergency Strategic Clinical Network & Stroke-Cardiovascular Strategic Clinical Network, Calgary, Canada;
2University of Calgary Cumming School of Medicine, Calgary, Canada;
3QuICR Alberta Stroke Program, Calgary, Canada;
4University of Calgary Cumming School of Medicine, Calgary, Canada;
5Queen's University School of Medicine, Kingston, Canada;
6University of Calgary Cumming School of Medicine, Calgary, Canada;
7Hotchkiss Brain Institute, University of Calgary – Cumming School of Medicine, Calgary, Canada;
8University of Calgary Cumming School of Medicine, Calgary, Canada;

Grant acknowledgements:
This project was funded through the Alberta Health Services Emergency Strategic Clinical Network 2016 grant competition.


Door-to-needle time (DTN) has an important impact on thrombolysis and reperfusion outcomes in the treatment of acute ischemic stroke. This systematic review is a critical synthesis of quality improvement (QI) studies evaluating DTN improvement strategies.
The review was conducted in compliance with PRISMA guidelines and registered with PROSPERO. Ovid MEDLINE, PubMed, Cochrane Database of Systematic Reviews, CINAHL, ProQuest Dissertations, and LILACS were used as primary search engines. CIHI, Health Quality Council of Alberta, Health Quality Ontario, and websites of heart and stroke associations in Canada, US, UK, Australia, and New Zealand were used as sources of grey literature. Searched reports were screened by title and abstract and full texts were located for review. References from the selected articles and relevant background papers were hand searched for additional reports. Articles were assessed by two reviewers and evaluated for risk of bias using the NIH’s Study Quality Assessment tools. Disagreements were resolved through arbitration by the Principal Investigators. In-article methods for improving DTN were categorized under the following eight labels: (i) Organizational changes (restructuring of existing system elements, including algorithm implementation, equipment relocation, decision trees, etc), (ii) Pre-hospital notification systems, (iii) Technology-based initiatives, (iv) Tele-medicine systems, (v) Educational interventions, (vi) Auditing processes, (vii) other (presence of family members), and (viii) Combination approaches. The results were meta-analyzed and subjected to sensitivity analysis.
42 papers were included in the review. Individual study quality was low to moderate. Pre-hospital notification, audits, technology, education, organizational changes, and combinations of strategies were all associated with improvements in DTN. Combination-QI approaches were the most effective at reducing DTN (SMD = 1.27, 95%CI = 1.19, 1.34), and were more effective than single-QI approaches (​p = 0.015). The implementation of auditing processes resulted in the greatest DTN improvement of all single-QI strategies (SMD = 0.89, 95%CI  = 0.64, 1.13). Longer QI/study duration periods also corresponded with DTN reduction (​r​ = 0.047, ​p < 0.001). Sensitivity analysis excluding the three largest sample size outliers strengthened the positive effect of combination interventions on DTN improvement and altered the effect size results to show organizational change as a single-QI strategy outperforming combination-QI approaches.
Combinations of QI strategies implemented simultaneously were found to be more effective than single-QI strategies at reducing DTN. Auditing practices were the most effective single-QI initiative for DTN reduction. Overall, DTN showed a positive correlation with QI/study duration.

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