Intravenous Access Intervention

Related to tPA Therapy

Abbigail Ballack, Nashaly Cruz, Jordan Lansky, Maria

Marquez, Victoria Stock, and Elizabeth Woodrum
 Introduction
● There is a controversy among physicians and clinicians about gaining IV access, to administer
tissue plasminogen activator (tPA), before a CT scan vs. after a CT scan
● There may be complications when getting IV access, such as the patient being dehydrated or having
been on dialysis for many years
○ This is when physicians start questioning if it is more important to get the CT scan without IV access or to
wait to gain IV access before getting the CT scan
● Door-to-needle (DTN) is the process from when the patient first arrives at the hospital to when they
receive tPA
● PICO Question: In adult patients suspected of suffering a stroke (P), does gaining IV access prior to
a CT scan (I) as opposed to after the CT scan (C) have an affect on door to needle (DTN) time of
the patient receiving tPA (O)?
○ This question will help determine if there is a significant difference in the time it takes a patient suffering from
a stroke to receive tPA if they get IV access before or after a CT scan

(American stroke Association, 2018, Bhatt, Lesko, Lucas, Kansara, & Baraban, 2016, Deline, Doyle, Lail, Mowla,
Rajabzadeh, Sawer, Shirrani, 2017, Gurav, et al. 2018, Hansen et al., 2017, Mowla et al., 2017, Thortveit et al., 2014).
Methods

Design

● The timing differences and the outcomes of performing a CT scan before and after an IV access on patients

suffering from an acute ischemic stroke were compared

● Studies were also compared and distinguished relative to the effect that time had on the overall IV-tPA treatment

Setting

● Studies took place in a variety of clinical settings such as stroke centers (primary and hyper-acute), emergency

departments, and hospital clinics

● Two of the studies were conducted in different countries, which included Maharashtra, India and Copenhagen,

Denmark

Subject

● Adult patients suffering from acute ischemic strokes

 Methods

Procedure
● The University of Florida library database was used to conduct our literature review
● The keywords that were used in the search:
○ “Door-to-needle”
○ “CT”
○ “Stroke”
● Numerous amounts of studies came up so to further limit our population, we specifically
looked for patients diagnosed with acute ischemic strokes
● Once the 6 articles were gathered, they were summarized respectively by a group
member
● After reviewing the summaries, it was confirmed that the articles supported the PICO
question

(American stroke Association, 2018, Bhatt, Lesko, Lucas, Kansara, & Baraban, 2016, Deline, Doyle, Lail, Mowla,

Rajabzadeh, Sawer, Shirrani, 2017, Gurav, et al. 2018, Hansen et al., 2017, Mowla et al., 2017, Thortveit et al., 2014).
Results
● The general consensus from multiple literature reviews confirm that gaining IV access as quickly as possible

improved outcomes and lowered door-to-needle times.

● IV tPA is a critical part of treating an adult patient suspected of stroke and time is key when administering this

medication.

● Transporting patients to CT laboratory within the limited timeframe has been shown to improve patient outcomes

drastically.

● Level of evidence for these results range between levels I and IV. This included cohort studies, quasi-randomized,

and randomized controls studies.

● As a result, gaining IV access prior to CT scan positively affects the door-to-needle time of a patient receiving tPA,

leading to improved patient outcomes.

(American stroke Association, 2018, Bhatt, Lesko, Lucas, Kansara, & Baraban, 2016, Deline, Doyle, Lail, Mowla,

Rajabzadeh, Sawer, Shirrani, 2017, Gurav, et al. 2018, Hansen et al., 2017, Mowla et al., 2017, Thortveit et al., 2014)
Discussion/Conclusions

● The studies analyzed were conducted in a variety of institutes, such as emergency departments, hospital clinics

and stroke centers

● There were no sociodemographic differences among participants/population involved. Likely, there were no

notable differences between the studies analyzed.

● One’s various ages and gender analyzed was not taken into consideration for the chosen studies. All participants

had experienced an acute ischemic stroke.

● The findings showed vast improvements in patients who had gained IV access prior to arrival. According to

Mowla et al., (2017), this allowed for quicker treatment time in patients suffering from acute ischemic strokes

● In a present article written by Gurav et al., (2018) implementation of “stroke code” displayed greater than 60

minute improvement in door-to-imagine time which contributed to reducing DTN time

● The major conclusion drawn from the literature review is that reduced door-to-needle time resulted more effective

outcomes for patients suffering from acute ischemic strokes.

Matrix Study title / Type of Comparison Outcome Summary of
authors / year study Participant Variables Variables Results
of publication s/ (Independent (Dependent)
Population or Co-
variables)

CT and MRI- LOE III: Acute Patients DNT to CT, “DNT were 8
based door- Quasi- stroke experiencing DNT to MRI min shorter for
needle-times Randomized patients acute stroke CT-allocated
for acute symptoms patients
compared to
stroke patients
MRI-allocated
a quasi-
patients; a time-
randomized difference that by
clinical trial / simulated
Hansen et al. / prediction
(2017) decreased the
chance of
independent
living at 3
months with 1%
in 16.9% of the
MRI-allocated iv-
tPA-treated
patients.”
(Hansen, et al.
2017)
Matrix
Study title / Type of Comparison Outcome Summary of
authors / year study Participant Variables Variables Results
of publication s/ (Independent (Dependent)
Population or Co-
variables)

Impact of LOE IV: Acute Patient Pre-”stroke The average

“stroke code”- Case ischemic suffering code” and DTN time was
rapid response control/coho stroke from acute implementati higher during
team: An rt study patients ischemic on of “stroke
the pre-“stroke
attempt to stroke (AIS) code”
improve code” stage as
intravenous opposed to
thrombolysis implementation/
rate and to post-”stroke-
shorten door- code”(Gurav, et
to-needle time al. 2018).
in acute
ischemic
stroke / Gurav
et al. / (2018)
Matrix
Study title / Type of Comparison Outcome Summary of
authors / year study Participant Variables Variables Results
of publication s/ (Independent (Dependent)
Population or Co-
variables)

Improvement LOE IV: Patients Protocol 1: DNT and The reduction

in door to Case with acute direct Door-to-CT in DNT was
needle time in control/coho ischemic transfer from time mostly due to
rt study stroke ambulance to the reduction in
patients with
CT and fast door-to-CT
acute ischemic neuro time.
stroke via a assessment Additionally,
simple stroke by CT-to-needle
activation neurologist time showed
protocol / and that there was
Tan et al. / emergency no significant
physician reduction after
(2018)
Protocol 2: protocol
stroke nurse amendment 2.
accompanies
patient to the
various steps
in the Tx
pathway
Matrix
Study title / Type of Comparison Outcome Summary of
authors / year study Participant Variables Variables Results
of publication s/ (Independent (Dependent)
Population or Co-
variables)

Delays in LOE: I Adult Patient Door- to - Initiating stroke

door-to- Quantitative patients experiencing needle time protocol with
needle time for approach suspected an acute of patient EMS and
acute ischemic of an acute ischemic receiving having EMS
stroke in the ischemic stroke tPA gaining IV
emergency stroke access prior to
department: A hospital arrival
comprehensive has decreased
stroke center delay of
experience / initiating IVT,
Mowla et al. / with an increase
(2017) of patients
receiving IVT
from 30% to
50%.
Matrix Study title / Type of Comparison Outcome Summary of
authors / year study Participant Variables Variables Results
of publication s/ (Independent (Dependent)
Population or Co-
variables)

Patients with LOE: II Patients Patients with Time In acute

low National One well with acute acute differences ischemic stroke
Institutes of designed ischemic ischemic with door-to- patients
RCT from stroke who strokes that needle receiving IV-
Health Stroke
multiple received were either (DTN) times tPA, lower
Scale scores sites IV- tPA low or high and door-to- NIHSS scores
have longer within 4.5 on the CT (DCT) were associated
door-to-needle hours of National times with longer
times: last- Institutes of between the DTN and DCT
Analysis of a known- Health low and high times
telestroke well Stroke Scale NIHSS
(NIHSS) scores
network /
scores
Bhatt, Lesko,
Lucas,
Kansara, &
Baraban /
(2016)
Matrix Study title / Type of Comparison Outcome Summary of
authors / year study Participant Variables Variables Results
of publication s/ (Independent (Dependent)
Population or Co-
variables)

Organizational LOE IV: All stroke Patients Door-to- Out of the 243
changes Case patients experiencing needle time patients
aiming to control/Coh treated an ischemic analyzed, 22%
ort study with IV stroke were admitted
reduce iv tPA
tPA to the hospital
door-to-needle with an
time / ischemic stroke
Thortveit, Bøe, attack. DNT
Ljøstad, time was
Mygland, & decreased from
Tveiten / 36 minutes to
28 minutes.
(2014)
References
Bhatt, A., Lesko, A., Lucas, L., Kansara, A., & Baraban, E. (2016). Patients with low
National Institutes of Health Stroke Scale Scores have longer
door-to-needle times: Analysis of a telestroke network. Journal of Stroke
and Cerebrovascular Diseases, 25, 2253–2258.
https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.05.005

Gurav, S. K., Zirpe, K. G., Wadia, R. S., Naniwadekar, A., Pote, P. U., Tungenwar,
A., …Surywanshi, P. (2018). Impact of “stroke code”-rapid response team: An attempt
to improve intravenous thrombolysis rate and to shorten door-to-needle time in
acute ischemic stroke. Indian Journal of Critical Care Medicine, 22(4), 243–248.
https://doi-org.lp.hscl.ufl.edu/10.4103/ijccm.IJCCMpass

Hansen, C. K., Christensen, A., Rodgers, H., Havsteen, I., Kruuse, C., Nybing, J., . .
Christensen, H. (2017). CT and MRI-based door-needle-times for acute
stroke patients a quasi-randomized clinical trial. Clinical Neurology and
Neurosurgery. doi: 10.1016/j.clineuro.2017.05.011
 References
Mowla, A., Doyle, J., Lail, N. S., Rajabzadeh-Oghaz, H., Deline, C., Shirani, P., . . .
Sawyer, R.N. (2017). Delays in door-to-needle time for acute ischemic stroke in the
emergency department: A comprehensive stroke center experience. Journal of the
Neurological Sciences,376, 102-105. doi:10.1016/j.jns.2017.03.003
Retrieved from
http://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/Ischemi
cClots/Ischemic-Strokes-Clots_UCM_310939_Article.jsp#.W_g1KRNKgWo

Tan, B. Y. Q., Ngiam, N. J. H., Sunny, S., Kong, W. Y., Tam, H., Sim, T. B., … Yeo, L. L.
(2018). Improvement in door-to-needle time in patients with acute ischemic stroke
via a simple stroke activation protocol. Journal of Stroke and Cerebrovascular
Diseases, 27, 1539–1545. https://doi-
org.lp.hscl.ufl.edu/10.1016/j.jstrokecerebrovasdis.2018.01.005

Thortveit, E. T., Bøe, M. G., Ljøstad, U., Mygland, Å., & Tveiten, A. (2014).
Organizational changes aiming to reduce iv tPA door-to-needle time. Acta
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