Is Door-to-Needle Time Reduced for Emergency Medical Services Transported Stroke Patients Routed Directly to the Computed Tomography Scanner on Emergency Department Arrival?

J Stroke Cerebrovasc Dis. 2020 Jan;29(1):104477. doi: 10.1016/j.jstrokecerebrovasdis.2019.104477. Epub 2019 Nov 4.


Background: A nationally recommended practice to accelerate thrombolytic therapy for acute ischemic stroke is to route emergency medical services (EMS)-transported stroke patients directly to the computed tomography (CT) scanner on arrival. We evaluated door-to-needle time with direct-to-CT routing versus emergency department (ED)-bed first routing.

Methods: This was a retrospective analysis from a large regionalized stroke system. Paramedics utilize the modified Los Angeles Prehospital Stroke Screen and transport acute stroke patients to Approved Stroke Centers. Individual stroke centers postarrival protocols vary, with some routing patients directly to CT. Stroke centers report treatment and outcomes to a registry, from which data were abstracted from May 2015 through April 2016. Adult patients transported by EMS and treated with thrombolytic therapy were included. The primary outcome was door-to-needle time. Secondary outcome was door-to-imaging time.

Results: EMS transported 6315 patients for suspected stroke and 789 (13%) were treated with thrombolysis at 41 stroke centers, 171 (22%) at hospitals with direct-to-CT routing and 618 (78%) at hospitals with ED-bed routing. Patient characteristics were similar between groups. Door-to-needle time was not different in the 2 groups, median 57 minutes (interquartile range [IQR] 44-76) for CT routing versus 54 minutes (IQR 40-74) for ED routing, median difference 3 (95% CI -1, 7), P == .2. Door-to-imaging time was shorter with CT routing compared to ED routing, median 13 minutes (IQR 8-21) and 16 minutes (IQR 10-24), respectively.

Conclusions: In this regional stroke system, hospitals with protocols for routing EMS-transported stroke patients directly to CT did not have reduced door-to-needle compared to hospitals without such protocols.

Keywords: Stroke; emergency medical services; neuroimaging; thrombolytic therapy.

Publication types

  • Comparative Study

MeSH terms

  • Administration, Intravenous
  • Aged
  • Aged, 80 and over
  • Critical Pathways
  • Emergency Service, Hospital*
  • Female
  • Fibrinolytic Agents / administration & dosage*
  • Humans
  • Los Angeles
  • Male
  • Middle Aged
  • Predictive Value of Tests
  • Registries
  • Retrospective Studies
  • Stroke / diagnostic imaging*
  • Stroke / drug therapy*
  • Thrombolytic Therapy*
  • Time Factors
  • Time-to-Treatment*
  • Tomography Scanners, X-Ray Computed*
  • Tomography, X-Ray Computed / instrumentation*
  • Transportation of Patients*


  • Fibrinolytic Agents