Ye et al.1212 Ye S, Hu S, Lei Z, et al. Shenzhen stroke emergency map improves access to rt-PA for patients with acute ischaemic stroke. Stroke Vasc Neurol 2019;4(03):115–122. Doi: 10.1136/svn-2018-000212 https://doi.org/10.1136/svn-2018-000212...
/StrokeVasc Neurol/201 9/ China |
Before-after cohort |
Evaluate the effectiveness of the Shenzhen stroke emergency map to optimize access to thrombolysis for patients with acute ischemic stroke. |
6,843 patients before and 8,268 after; 568 had thrombolysis before and 802 after |
Madhok et al.1313 Madhok DY, Keenan KJ, Cole SB, Martin C, Hemphill JC III. Prehospital and Emergency Department-Focused Mission Protocol Improves Thrombolysis Metrics for Suspected Acute Stroke Patients. J Stroke Cerebrovasc Dis 2019;28(12):104423. Doi: 10.1016/j.jstrokecerebrovasdis.2019.104423 https://doi.org/10.1016/j.jstrokecerebro...
/J Stroke Cerebrovasc Dis/2019/USA |
Retrospective cross-sectional |
To assess whether the implanted protocol for prehospital and emergency care increases the percentage of patients treated with thrombolysis in a door-to-needle time of up to 45 minutes. |
112 patients before and 236 after; 45 patients underwent thrombolysis before and 50 after. |
Ajmi et al.1414 Ajmi SC, Advani R, Fjetland L, et al. Reducing door-to-needle times in stroke thrombolysis to 13 min through protocol revision and simulation training: a quality improvement project in a Norwegian stroke centre. BMJ Qual Saf 2019;28(11):939-948. Doi: 10.1016/j.jstrokecerebrovasdis.2019.104423 https://doi.org/10.1016/j.jstrokecerebro...
/BMJ Qual Saf/2019/Norway |
Cohort |
To describe quality improvement project with the objective of reducing door-to-needle time and improving patient results. |
446 patients before and 204 after |
Vanhoucke et al.1515 VanhouckeJ, Hemelsoet D, Achten E, et al. Impact of a code stroke protocol on the door-to-needle time for IV thrombolysis: a feasibility study. Acta Clin Belg 2020;75(04):267-274. Doi: 10.1080/17843286.2019.1607991 https://doi.org/10.1080/17843286.2019.16...
/Acta Clin Belg/2019/Belgium |
Before-after cohort |
To evaluate the impact of a stroke code protocol on the door-to-needle time for the use of thrombolysis. |
110 patients before and 71 after |
Silsby et al.1616 Silsby M, Duma SR, Fois AF, et al. Time to acute stroke treatment in-hours was more than halved after the introduction of the Helsinki Model at Westmead Hospital. Intern Med J 2019;49(11): 1386-1392. Doi: 10.1111/imj.14290 https://doi.org/10.1111/imj.14290...
/lntern Med J/2019/Australia |
Retrospective |
To assess whether simple and cost-free changes of a protocol could improve treatment time for acute ischemic stroke cases in a tertiary hospital. |
143 patients before and 134 after; 30 received thrombolysis before and 14 after |
Kansagra et al.1717 Kansagra AP, Wallace AN, Curfman DR, et al. Streamlined triage and transfer protocols improve door-to-puncture time for endovascular thrombectomy in acute ischemic stroke. Clin Neurol Neurosurg 2018;166:71-75. Doi: 10.1016/j.clineuro.2018.01.026 https://doi.org/10.1016/j.clineuro.2018....
/Clin Neurol Neurosurg/2018/USA |
Retrospective |
To evaluate improvements in the prethrombectomy process in a multihospital network and report the puncture time in patients undergoing mechanical thrombectomy. |
104 patients underwent thrombolysis /78 underwent thrombectomy** |
Nguyen-Huynh et al.1818 Nguyen-Huynh MN, Klingman JG, Avins AL, et al; KPNC Stroke FORCE Team. Novel Telestroke Program Improves Thrombolysis for Acute Stroke Across 21 Hospitals of an Integrated Healthcare System. Stroke 2018;49(01):133-139. Doi: 10.1161/stro-keaha.117.018413 https://doi.org/10.1161/stro-keaha.117.0...
/Stroke/2018/USA |
Before-after cohort |
To present the results of the Kaiser Permanente Northern California stroke protocol, which combines the modified Helsinki protocol and telemedicine, according to the door-to-needle time, use of thrombolysis and symptomatic intracranial hemorrhage rates. |
310 patients before and 557 after |
Koge et al.1919 Koge J, Matsumoto S, Nakahara I, et al. Improving treatment times for patients with in-hospital stroke using a standardized protocol. J Neurol Sci 2017;381:68-73. Doi: 10.1016/j.nrleng.2018.03.009 https://doi.org/10.1016/j.nrleng.2018.03...
/J Neurol Sci/ 2017/Japan |
Retrospective |
To assess the effectiveness and safety of our standardized protocol for intrahospital stroke |
25 patients before and 30 after |
Psychogios et al.2020 Psychogios M-N, Behme D, Schregel K, et al. One-Stop Management of Acute Stroke Patients: Minimizing Door-to-Reperfusion Times. Stroke 2017;48(11):3152-3155. Doi: 10.1161/strokeaha.117.018077 https://doi.org/10.1161/strokeaha.117.01...
/ Stroke/ 2017/Germany |
Retrospective observational |
To determine whether centralized treatment can reduce intrahospital treatment times for patients with acute occlusion of large vessels. |
44 patients** |
Kalnins et al.2121 Kalnins A, Mickelsen LJ, Marsh D, et al. Decreasing Stroke Code to CT Time in Patients Presenting with Stroke Symptoms. Radiographics 2017;37(05):1559-1568. Doi: 10.1148/rg.2017160190 https://doi.org/10.1148/rg.2017160190...
/ Radiographics/2017/USA |
Cohort |
To decrease stroke code time to CT for patients with non-prenotified stroke code from a reference mean of 20 minutes to 1 5 minutes or less. |
107 patients before and 298 after |
Caputo et al.2222 Caputo LM, Jensen J, Whaley M, et al. How a CT-Direct Protocol at an American Comprehensive Stroke Center Led to Door-to-Needle Times Less Than 30 Minutes. Neurohospitalist 2017;7 (02):70-73/ Neurohospitalist/2017/USA |
Prospective cohort |
To describe the process of developing and implementing a protocol and comparing the door-to-needle times and rates of symptomatic intracranial hemorrhage before and after the implementation of the protocol. |
295 patients** |
Zinkstok et al.2323 Zinkstok SM, Beenen LF, Luitse JS, Majoie CB, Nederkoorn PJ, Roos YB. Thrombolysis in Stroke within 30 Minutes: Results of the Acute Brain Care Intervention Study. PLoS One 2016;11(11): e0166668. Doi: 10.1371/journal.pone.0166668 https://doi.org/10.1371/journal.pone.016...
/ PLoS One/ 2016/Netherlands |
Before-after cohort |
To reduce the door-to-needle time to 30 minutes or less with the optimization of intrahospital stroke treatment. |
373 patients** |
Busby et al.2424 Busby L, Owada K, Dhungana S, et al. CODE FAST: a quality improvement initiative to reduce door-to-needle times. J Neurointerv Surg 2016;8(07):661-664. Doi: 10.1136/neurintsurg-2015-011806 https://doi.org/10.1136/neurintsurg-2015...
/ J Neurointerv Surg/2016/USA |
Retrospective |
To initiate a quality improvement project called CODE FAST to reduce the door-to-needle time in the institution. |
41 patients before and 52 after |
Liang et al.2525 Liang Z, Ren L, Wang T, et al. Effective management of patients with acute ischemic stroke based on lean production on thrombolytic flow optimization. Australas Phys Eng Sci Med 2016;39 (04):987-996. Doi: 10.1007/s13246-016-0442-1 https://doi.org/10.1007/s13246-016-0442-...
/ Australasian Physical and Engineering Sciences in Medicine/ 2016/ China |
Prospective |
To determine whether the application of lean principles for flow optimization could accelerate the start of thrombolysis. |
13 patients before and 20 after |
Moran et al.2626 Moran JL, Nakagawa K, Asai SM, Koenig MA. 24/7 Neurocritical Care Nurse Practitioner Coverage Reduced Door-to-Needle Time in Stroke Patients Treated with Tissue Plasminogen Activator. J Stroke Cerebrovasc Dis 2016;25(05):1148-1152. Doi: 10.1016/j.jstrokecerebrovasdis.2016.01.033 https://doi.org/10.1016/j.jstrokecerebro...
/ Journal of Stroke and Cerebrovascular Diseases/ 2016/USA |
Retrospective Cohort |
To assess the impact of the provision of neurocritical nursing care 24 hours a day, 7 days a week, according to the first aid coverage in the "stroke code" on delays in the treatment of patients with acute stroke who received thrombolysis. |
44 patients before and 122 after |
Marto et al.2727 Marto JP, Borbinha C, Calado S, Viana-Baptista M. The Stroke Chronometer-A New Strategy to Reduce Door-to-Needle Time. J Stroke Cerebrovasc Dis 2016;25(09):2305-2307. Doi: 10.1016/j.jstrokecerebrovasdis.2016.05.023 https://doi.org/10.1016/j.jstrokecerebro...
/ J Stroke Cerebrovasc Dis/ 2016/ Portugal |
Retrospective |
To evaluate the effect of implementing a regressive timer in the acute stroke emergency room, in the door-to-CT and door-to-needle times. |
30 patients before and 41 after |
Ibrahim et al.2828 Ibrahim F, Akhtar N, Salam A, et al. Stroke Thrombolysis Protocol Shortens “Door-to-Needle Time” and Improves Outcomes-Experience at a Tertiary Care Center in Qatar. J Stroke Cerebrovasc Dis 2016;25(08):2043-2046. Doi: 10.1016/j.jstrokecerebrovasdis.2016.03.047 https://doi.org/10.1016/j.jstrokecerebro...
/ J Stroke Cerebrovasc Dis/ 2016/ Qatar |
Retrospective |
To assess the effect of the acute thrombolysis protocol on "door-to-needle time" and on the prognosis of acute stroke cases. |
102 patients before and 102 after |
Heikkilä et al.2929 Heikkilä I, Kuusisto H, Stolberg A, Palomäki A. Stroke thrombolysis given by emergency physicians cuts in-hospital delays significantly immediately after implementing a new treatment protocol. Scand J Trauma Resusc Emerg Med 2016;24:46. Doi: 10.1186/s13049-016-0237-0 https://doi.org/10.1186/s13049-016-0237-...
/ Scand J Trauma Resusc Emerg Med/ 2016/ Finland |
Retrospective |
To describe a new protocol for patients with acute ischemic stroke and thrombolysis administered by emergency physicians in the Emergency Department - the so-called Hämeenlinna model and present preliminary results regarding the door-to-needle and treatment initiation times. |
31 patients before and 33 after |
Rai et al.3030 Rai AT, Smith MS, Boo S, Tarabishy AR, Hobbs GR, Carpenter JS. The ‘pit-crew’ model for improving door-to-needle times in endovascular stroke therapy: a Six-Sigma project. J Neurointerv Surg 2016;8(05):447-452. Doi: 10.1136/neurintsurg-2015-012219 https://doi.org/10.1136/neurintsurg-2015...
/ J Neurointerv Surg/2016/ USA |
Prospective |
To present the results of a quality improvement process aimed at reducing stroke treatment time in a tertiary academic medical center. |
64 patients before and 30 after |
Zuckerman et al.3131 Zuckerman SL, Magarik JA, Espaillat KB, et al. Implementation of an institution-wide acute stroke algorithm: Improving stroke quality metrics. Surg Neurol Int 2016;7(Suppl 41):S1041-S1048. Doi: 10.4103/2152-7806.196366 https://doi.org/10.4103/2152-7806.196366...
/ Surg Neurol Int/2016/ USA |
Retrospective |
To describe the process of implementing a new stroke algorithm, compare the pre- and postalgorithm quality improvement metrics, specifically door-to-CT, door-to-neurologist, and door-to-needle times. |
Not described** |
Kendall et al.3232 Kendall J, Dutta D, Brown E. Reducing delay to stroke thrombolysis-lessons learnt from the Stroke 90 Project. Emerg Med J 2015; 32(02):100-104. Doi: 10.1136/emermed-2013-202993 https://doi.org/10.1136/emermed-2013-202...
/ Emerg Med J/ 2015/England |
Before-after |
To describe how the Stroke 90 project was configured and what interventions were implemented, report the results and discuss lessons learned from it. |
136 patients before and 215 after |
Atsumi et al.3333 Atsumi C, Hasegawa Y, Tsumura K, et al. Quality assurance monitoring of a citywide transportation protocol improves clinical indicators of intravenous tissue plasminogen activator therapy: a community-based, longitudinal study. J Stroke Cerebrovasc Dis 2015;24(01):183-188. Doi: 10.1016/j.jstrokecerebrovasdis.2014.08.013 https://doi.org/10.1016/j.jstrokecerebro...
/ J Stroke Cerebrovasc Dis/ 2015/ Japan |
Prospective |
To investigate whether prehospital and hospital thrombolysis indicators improved after using a single prehospital scale in a municipal transport protocol, and examine whether a deleterious effect of admission on weekends was observed. |
2,049 patients** |
Van Schaik et al.3434 Van Schaik SM, Van der Veen B, Van den Berg-Vos RM, Weinstein HC, Bosboom WMJ. Achieving a door-to-needle time of 25 minutes in thrombolysis for acute ischemic stroke: a quality improvement project. J Stroke Cerebrovasc Dis 2014;23(10): 2900-2906. Doi: 10.1016/j.jstrokecerebrovasdis.2014.07.025 https://doi.org/10.1016/j.jstrokecerebro...
/ J Stroke Cerebrovasc Dis/ 2014/ Netherlands |
Before-after |
To reduce the delay in intrahospital treatment of patients with acute ischemic stroke through the implementation of a standard operating procedure and the creation of a greater and sustained awareness of the importance of this time-oriented protocol among all health professionals involved in the process. |
41 patients before and 185 after |
Advani et al.3535 Advani R, Naess H, Kurz MW. Evaluation of the implementation of a rapid response treatment protocol for patients with acute onset stroke: can we increase the number of patients treated and shorten the time needed? Cerebrovasc Dis Extra 2014;4(02): 115-121. Doi: 10.1159/000363050 https://doi.org/10.1159/000363050...
/ Cerebrovasc Dis Extra/ 2014/ Norway |
Retrospective |
To retrospectively evaluate the importance of streamlining the treatment chain for patients with acute ischemic stroke, reviewing and improving the pre- and intrahospital routines around the treatment of these patients in the procedure in relation to the number of patients treated with thrombolysis. The secondary objective of the study was to assess changes in door-to-needle times and onset of symptoms-to-needle resulting from changes in pre- and intrahospital routines. |
320 patients** |
Chen et al.3636 Chen C-H, Tang S-C, Tsai L-K, et al. Stroke code improves intravenous thrombolysis administration in acute ischemic stroke. PLoS One 2014;9(08):e104862. Doi: 10.1371/journal.pone.0104862 https://doi.org/10.1371/journal.pone.010...
/ PLoS One/ 2014/China |
Prospective |
To investigate the impact of the stroke code on the performance of thrombolytic therapy and functional results for patients with acute ischemic stroke. |
91 patients before and 216 after |
Fonarow et al.3737 Fonarow GC, Zhao X, Smith EE, et al. 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;311(16):1632-1640. Doi: 10.1001/jama.2014.3203 https://doi.org/10.1001/jama.2014.3203...
/ JAMA/ 2014/ USA |
Before-after |
To analyze the time trend of the door-to-needle time for the administration of thrombolysis and determine the proportion of patients with a time of 60 minutes or less before and after the beginning of the program; to evaluate whether improvement in the door-to-needle time was associated with improved clinical results, including hospital mortality, destination of discharge, ambulatory status, the presence of symptomatic intracranial hemorrhage 36 hours after thrombolysis and complications of thrombolysis. |
27,319 patients before and 43,850 after |
Ruff et al.3838 Ruff IM, Ali SF, Goldstein JN, et al. Improving door-to-needle times: a single center validation of the target stroke hypothesis. Stroke 2014;45(02):504-508. Doi: 10.1161/strokeaha.113.004073 https://doi.org/10.1161/strokeaha.113.00...
/ Stroke/ 2014/ USA |
Retrospective |
To assess whether the incorporation of a stroke protocol into the Target Stroke initiative significantly changed the mean door-to-CT and door-to-needle times. |
1,413 patients before and 925 after |
Ford et al.3939 Ford AL, Williams JA, Spencer M, et al. Reducing door-to-needle times using Toyota’s lean manufacturing principles and value stream analysis. Stroke 2012;43(12):3395-3398. Doi: 10.1161/strokeaha.112.670687 https://doi.org/10.1161/strokeaha.112.67...
/ Stroke/ 2012/ USA |
Prospective |
The "current state analysis" mapped operations with waste and those that added value. A "future state analysis" removed useless steps and retained value-added steps. An "action plan" was created to implement the simplified protocol and provide feedback for continuous improvement. The efficiency and safety metrics of the protocol were compared before and after implementation. |
132 patients before and 87 after |
Lin et al.4040 Lin CB, Peterson ED, Smith EE, et al. Emergency medical service hospital prenotification is associated with improved evaluation and treatment of acute ischemic stroke. Circ Cardiovasc Qual Outcomes 2012;5(04):514-522. Doi: 10.1161/CIRCOUT-COMES.112.965210 https://doi.org/10.1161/CIRCOUT-COMES.11...
/ Circ Cardiovasc Qual Outcomes/2012/ USA |
Retrospective |
To assess the association of prenotification of the emergency medical service with assessment and treatment of acute ischemic stroke, including door-to-CT and door-to-needle times, symptoms-door onset and thrombolytic treatment rates in eligible patients. |
249,197 patients before and 122,791 after |
Tai et al.4141 Tai YJ, Weir L, Hand P, Davis S, Yan B. Does a ‘code stroke’ rapid access protocol decrease door-to-needle time for thrombolysis? Intern Med J 2012;42(12):1316-1324. Doi: 10.1111/j.14455994.2011.02709.x https://doi.org/10.1111/j.14455994.2011....
/ Intern Med J/ 2012/ Australia |
Retrospective |
To perform a comprehensive qualitative analysis of the stroke code service at a Melbourne hospital to determine whether it had resulted in a reduction in door-to-needle and door-to-CT times, and increased the percentage of patients treated with thrombolysis. |
96 patients before and 189 after |
O'Brien et al.4242 O’Brien W, Crimmins D, Donaldson W, et al. FASTER (Face, Arm, Speech, Time, Emergency Response): experience of Central Coast Stroke Services implementation of a pre-hospital notification system for expedient management of acute stroke. J Clin Neurosci 2012;19(02):241-245. Doi: 10.1016/j.jocn.2011.06.009 https://doi.org/10.1016/j.jocn.2011.06.0...
/ J Clin Neurosci/2012/ Australia |
Prospective cohort pre- and postintervention |
To determine whether the introduction of a prehospital notification scheme based on an ambulance stroke service (FASTER) reduces the assessment time for thrombolysis and increases the use of thrombolysis in a health service in the Central Coast area. |
42 patients before and 67 after |
Sung et al.4343 Sung S-F, Huang Y-C, Ong C-T, Chen Y-W. A Parallel Thrombolysis Protocol with Nurse Practitioners As Coordinators Minimized Door-to-Needle Time for Acute Ischemic Stroke. Stroke Res Treat 2011;2011:198518. Doi: 10.4061/2011/198518 https://doi.org/10.4061/2011/198518...
/ Stroke Res Treat/2011/ China |
Before-after |
To determine whether modifying the protocol shortened intrahospital delay and facilitated thrombolytic therapy. |
338 patients before and 139 after |
Hoegerl et al.4444 Hoegerl C, Goldstein FJ, Sartorius J. Implementation of a stroke alert protocol in the emergency department: a pilot study. J Am Osteopath Assoc 2011;111(01):21-27/ Journal of the American Osteopathic Association/2011/ USA |
Prospective |
To determine whether implementing a stroke alert protocol, in conjunction with a limited education program, will reduce the arrival time for CT and the treatment time for stroke patients in the emergency department. |
132 patients before and 101 after |
Kamal et al.4545 Kamal N, Holodinsky JK, Stephenson C, et al. Improving Door-to-Needle Times for Acute Ischemic Stroke: Effect of Rapid Patient Registration, Moving Directly to Computed Tomography, and Giving Alteplase at the Computed Tomography Scanner. Circ Cardiovasc Qual Outcomes 2017;10(01):e003242. Doi: 10.1161/CIRCOUTCOMES.116.003242 https://doi.org/10.1161/CIRCOUTCOMES.116...
/ Circulation/ 2017/USA |
Prospective cohort |
To analyze the impact of four specific strategies (a new call activation system; registering the patient with suspected stroke as unknown on admission until laboratory confirmation/image; sending direct patient to CT in emergency services; applying thrombolysis on the CT table scan or imaging) to reduce the door-to-needle time in a single center. |
350 patients** |
Iglesias Mohedano et al.4646 Iglesias Mohedano AM, García Pastor A, Díaz Otero F, et al. A new protocol reduces median door-to-needle time to the benchmark of 30minutes in acute stroke treatment. Neurologia (Engl Ed) 2021;36(07):487–494. Doi: 10.1016/j.nrleng.2018.03.009 https://doi.org/10.1016/j.nrleng.2018.03...
/ Neurologia/ 2020/ Spain |
Before-after cohort |
To determine whether a new intra-hospital intravenous thrombolysis protocol is effective in reducing the door-to-needle time and correcting previously identified factors associated with delays. |
239 patients before and 222 after |