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Meta-analysis of interventions to reduce door to needle times in acute ischaemic stroke patients

  • Siarkowski, Michael1
  • Lin, Katie2
  • Li, Shari S3
  • Al Sultan, Abdulaziz2
  • Ganshorn, Heather2
  • Kamal, Noreen4
  • Hill, Michael2
  • Lang, Eddy2
  • 1 The University of British Columbia, Vancouver, British Columbia, Canada , Vancouver (Canada)
  • 2 University of Calgary, Calgary, Alberta, Canada , Calgary (Canada)
  • 3 Queen's University, Kingston, Ontario, Canada , Kingston (Canada)
  • 4 Dalhousie University, Halifax, Nova Scotia, Canada , Halifax (Canada)
Published Article
BMJ Open Quality
BMJ Publishing Group
Publication Date
Aug 03, 2020
DOI: 10.1136/bmjoq-2020-000915
PMID: 32747390
PMCID: PMC7401993
PubMed Central


Background Door-to-needle time (DTN) has an important impact on thrombolysis and reperfusion outcomes in the treatment of acute ischaemic stroke. This systematic review is a critical synthesis of studies evaluating DTN reduction strategies. Method Ovid MEDLINE, PubMed, Cochrane Database of Systematic Reviews, CINAHL, ProQuest dissertations and LILACS were used as bibliographic databases for primary literature. CIHI, Health Quality Council of Alberta, Health Quality Ontario and websites of heart and stroke associations in Canada, USA, 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. Articles quality was evaluated using National Institute of Health’s Study Quality Assessment tools. Methods for improving DTN were categorised under 13 DTN reduction strategies, primarily adapted from the Target: Stroke Phase II recommendations, and including two additional categories: Strategies not encompassed by any Target: Stroke recommendation, and Combinations of Interventions. Results 96 studies (4 randomised control trials, 1 review, 91 observational pre/post studies) were included in the review. All strategies and interventions resulted in a reduction of DTN. Approaches using combinations of interventions were the most effective at reducing DTN (33.77% DTN reduction, standard mean difference=1.857, 95% CI=1.510–2.205), and were more effective than approaches using only a single strategy (p=0.040). DTN reduction was associated with the duration of the DTN reduction programme at each facility (p=0.006). Interpretation The greatest reductions in DTN were observed when implementing combinations of DTN reduction strategies, although there was no significant advantage to implementing more than two strategies simultaneously. PROSPERO registration number 42016036215.

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