Implementation of a physician-directed emergency stroke protocol resulted in decreased door-to-needle time and onset-to-treatment time, without increases in rates of symptomatic intracerebral hemorrhage, according to a study published in Annals of Emergency Medicine.

Researchers in this retrospective before-after intervention analysis evaluated the efficacy of an emergency physician-based stroke protocol designed for use in an urban hospital when no neurologist is available. Outcomes evaluated were symptomatic intracerebral hemorrhage, time delay, and clinical recovery of patients, as well as change in door-to-needle time, as estimated by multivariable linear regression.

From 2009 to 2012, 107 comparable patients were treated with tissue plasminogen activator; 46 comparable patients were treated from 2013 to 2014 (group 1 and group 2, respectively). Median door-to-needle time decreased from 54 minutes to 20 minutes after reorganization (statistical estimate of difference, 32 minutes; 95% CI, 26-38 minutes), median onset-to-treatment time decreased from 135 minutes to 119 minutes (statistical estimate of difference, 23 minutes; 95% CI, 6-39 minutes), and incidence of symptomatic intracerebral hemorrhage decreased from 4.7% to 2.2% (difference, 2.5%; 95% CI, -8.7%-9.2%).

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Approximately 70% of patients treated post-reorganization were functionally independent (modified Rankin Scale scores 0-2), but pre-reorganization Rankin Scale score data were not available, as the hospital did not previously assess 90-day outcomes as standard practice.

Study investigators concluded that improvements in door-to-needle and onset-to-treatment times are possible “once the acute ischemic stroke protocol has been created, with cooperation between neurologists, radiologists, and emergency physicians.”


Heikkilä I, Kuusisto H, Holmberg M, Palomäki A. Fast protocol for treating acute ischemic stroke by emergency physicians [published online September 17, 2018]. Ann Emerg Med. doi:10.1016/j.annemergmed.2018.07.019.