Do centres with well-developed protocols, training and infrastructure have higher rates of thrombolysis for acute ischaemic stroke?

QJM. 2011 Sep;104(9):785-91. doi: 10.1093/qjmed/hcr075. Epub 2011 May 24.


Background: The introduction of intravenous thrombolysis with recombinant tissue Plasminogen Activator (rt-PA) has greatly improved the effectiveness of acute ischaemic stroke care. However, in most hospitals only 2-10% of all admitted stroke patients are treated with thrombolysis.

Aim: The purpose of this study is to identify if available protocols, training and infrastructure influence the thrombolysis rate.

Design: Cohort study of 12 hospitals in the Netherlands.

Methods: In a cohort of patients admitted with acute stroke within 24 h from onset of symptoms, data were obtained. Stroke service characteristics of 12 hospitals were acquired through structured interviews with intra- and extramural representatives, in order to asses (i) protocols, (ii) training and (iii) complexity of infrastructure. Data were analysed with multi-level logistic regression to relate the likelihood of treatment with thrombolysis to availability and completeness of protocols, training and infrastructure both outside (extramural) and inside (intramural) each centre.

Results: Overall 5515 patients were included in the study. Thrombolysis rates varied from 5.7% to 21.7%. An association was observed between thrombolysis rates and extramural training [odds ratio (OR): 1.11; 95% confidence interval (CI): 0.99-1.25] and availability of intramural protocols (OR: 1.46; 95% CI: 1.12-1.91). After adjustment for hospital size and teaching vs. nonteaching hospital, these associations became stronger; extramural training [adjusted OR (aOR): 1.14; 95% CI: 1.01-1.30] and availability of intramural protocols (aOR: 1.77; 95% CI: 1.30-2.39).

Conclusions: Extramural training and intramural protocols are important tools to increase thrombolysis rates for acute ischaemic stroke in hospitals. Intramural protocols and extramural training should be aimed at all relevant professionals.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Brain Ischemia / drug therapy*
  • Clinical Protocols / standards*
  • Cohort Studies
  • Delivery of Health Care / organization & administration
  • Education, Medical, Continuing / statistics & numerical data
  • Female
  • Humans
  • Male
  • Middle Aged
  • Netherlands
  • Neurology / education
  • Recombinant Proteins / therapeutic use
  • Stroke / drug therapy*
  • Thrombolytic Therapy / methods
  • Thrombolytic Therapy / standards
  • Thrombolytic Therapy / statistics & numerical data*
  • Tissue Plasminogen Activator / therapeutic use


  • Recombinant Proteins
  • Tissue Plasminogen Activator