thrombolysis with recombinant tissue plasminogen activator ( rtpa , alteplase ) is the only effective specific treatment for acute ischemic stroke patients coming in window ( 4.5 h from onset of symptoms ) .
a milestone study of national institute of neurological disorders and stroke in 1995 , demonstrated the benefits of rtpa in to patients of acute ischemic stroke ( ais ) who came within window period .
these patients of ais who were thrombolysed were 30% more likely to survive with minimal disability resulting in a 12% absolute increase in the proportion having excellent functional outcomes at 3 months .
stroke study iii trail ( 2008 ) window period was extended to 4.5 h. for every 15 min reduction in door to needle time ( dtnt ) there is 5% reduction in odds of in hospital mortality ( odd ratio , 0.95 ; 95% confidence interval , 0.92 - 0.98 : p = 0.0007 ) .
all patients who presented with stroke to emergency department ( er ) from january 2011 to december 2013 were included in the study .
after initial assessment by causality personnel a medical / neuro - resident evaluated the patient .
radiological diagnosis was obtained with noncontrasted brain computed tomography and/or diffusion weighted magnetic resonance imaging ( dwi ) .
after neuro physician opinion or after telephonic discussion by neuro - resident with neuro physician ( telestroke ) the treatment plan was decided . for the patients who presented within window period thrombolysis was planned .
severity of stroke was documented by the national institutes of health stroke scale ( nihss )
contra - indications for thrombolysis were checked and consent of relatives / patient was taken .
those patients who presented out of window period ( > 4.5 h after onset of symptom / symptom to door time [ std ] > 4.5 h ) , or patients who had hemorrhagic stroke and those who were not willing for giving consent were excluded [ figure 1 ] .
algorithm for patient presenting with stroke in emergency room ( protocol used in the study ) patients record files and charts were used to extract retrospective data .
the collected data use to evaluate er to needle [ door to needle time-(dtnt ) ] time and reasons for delay in thrombolysis therapy in acute stroke patients .
the following parameters were studied 
 onset of symptoms to er time , assessment by physician / medical chief resident time ( door to physician time [ dtpt])er to imaging time ( door to imaging time [ dtit]),er to needle time ( dtnt)contraindications for thrombolysis . 
 
onset of symptoms to er time , assessment by physician / medical chief resident time ( door to physician time [ dtpt ] ) er to imaging time ( door to imaging time [ dtit ] ) , er to needle time ( dtnt ) contraindications for thrombolysis .
the onset of symptom time for patients with wake up was accepted as last time the patient was seen as healthy .
the baseline characteristics of patient with acute ischemic stroke brought / admitted to er , clinical features , arrival time ( door time ) to er , severity of stroke , imaging time , radiological findings , contraindication for thrombolytic treatment , time of starting recombinant tissue plasminogen activator ( rt - pa ) and thereafter complications were recorded [ table 2 ] .
the data abstracted were transferred to the spss 17.0 program ( spss statistics is a software package used for statistical analysis .
it is statistical package for social science and is produced by spss inc . ) of the computer for statistical analysis .
six hundred and ninety - five patients with symptoms of stroke were presented to our emergency department in the study period . out of these five hundred and forty seven ( 78.7% )
were excluded as they had come out of window period that is , they had arrived 4.5 h after the onset of stroke symptoms .
algorithm for patient presenting with stroke in er ( protocol used in the study ) .
further after imaging of these one hundred and forty eight patients , one hundred four ( 70.27% ) were excluded .
sixty - two ( 59.6% ) had intra cerebral bleed , 1 ( 0.9% ) had hemoglobin - 3.1 g , 13 ( 13% ) of them had transient ischemic attack ( neurological symptoms improved ) and dwi images of these patient were normal .
6 ( 5.7 ) patients were diagnosed to have metabolic de - rrangement ( hypoglycemia , hyperglycemia , hyponatremia ) .
other reasons for exclusion in our study were post - ictal status , financial problem , recent thrombolysis , recent surgery , and delay in contacting senior radiologist [ table 1 ] .
distribution of contraindications for thrombolytic therapy of patients baseline clinical characteristics of thrombolysed patients ( n=44 ) total 44 ( 29.7% ) patients with ais were thrombolysed .
thirty - four ( 79.5% ) were male and nine ( 20.45% ) were female .
co - morbid illness in the form of hypertension 6 ( 13.6% ) , diabetes 2 ( 4.5% ) , ischemic heart diseases ( ihd ) 2 ( 4.5% ) , previous stroke cva 3 ( 6.5% ) , > 1 co - morbidity ( ht / cva / dm / ihd / hypothyriod ) 19 ( 43% ) , seizure 1 ( 2% ) and alcoholic liver diseases 1 ( 2% ) patients respectively .
the mean time for arrival of patients from onset of symptoms to hospital ( std ) 1.23 h ( 15 min-3 h ) .
the mean door to neuro - physician time dtpt was 32 min ( 5 min-2.23 h ) .
the mean dtnt 1.44 h ( 40 min-3.3 h ) [ tables 3 and 4 ] , [ figures 24 ] .
our study dtpt , dtit and dtnt compared with aha guideline interval number of patients thrombolysed per hour door to physician time door to imaging time ( recommended standard time :  45 min )
analysis of our study clearly states that stdt , dtpt , dtit , and dtnt time are significantly more .
thus , we had many hurdles in delivering thrombolysis therapy to these 44 patients . only 7 ( 15% ) patients had dtnt  60 min .
the problems / barriers in our study were categorized into three factors : mean symptom to door time was 83 min ( median : 69 ) .
poor recognition of stroke signs , especially in older patients caused delay in arrival time to hospital .
public and emergency medical services staff education play important role in shortening the pre hospital period . in our study - door to physician ,
door to imaging and door to needle time were significantly ore compared to standard recommendations ( aha ) [ table 3 ] .
there was lack of handling stroke patients with high priority at each level er , imaging unit , stroke unit .
thus lack of triaging stroke patient at all level of intervention was our weakest point .
in one of the patients the on call doctor was very busy attending emergency calls so causing increase in dtpt time . the concept of having second on call doctor who takes care only of patients with acute stroke has being recommended by kobayashi et al .
lack of triaging at radiology unit and performing entire sequences of magnetic resonance imaging ( mri ) scan lead to increase in dtit . thus again
dwi has high sensitivity ( 88 - 100% ) and specificity ( 95 - 100% ) for detecting infarcted regions , within minutes of onset of symptoms .
study suggested  brain attack team mri sequence  of < 10 min to confirm acute ischemia stroke and assess candidacy for iv - rtpa .
lack of triaging of bed for stroke patients resulted in increase in dtnt time . to prevent these delay we started thrombolysing ais patient in er . to prevent delay due to inavailability of drug
, we have started keeping rtpa in our drug stock our dtnt was 104 min ( door to needle time median - 100 ) .
relatives with geriatric patient ( 79 years ) took longer time to give consent due to age of the patient and secondly due to financial burden .
one of our patients had liver diseases so we had to wait for international normal ratio report for prothrombin time ( international normalized ratio ) .
transient ischemic attack patients were not thrombolysed , but in latter half of study dwi images helped us to prevent delay .
poor recognition of stroke signs , especially in older patients caused delay in arrival time to hospital .
public and emergency medical services staff education play important role in shortening the pre hospital period . in our study - door to physician ,
door to imaging and door to needle time were significantly ore compared to standard recommendations ( aha ) [ table 3 ] .
there was lack of handling stroke patients with high priority at each level er , imaging unit , stroke unit .
thus lack of triaging stroke patient at all level of intervention was our weakest point .
education of emergency medical services of stroke symptoms will help to triage stroke patient . in one of the patients the on call doctor was very busy attending emergency calls so causing increase in dtpt time .
the concept of having second on call doctor who takes care only of patients with acute stroke has being recommended by kobayashi et al .
lack of triaging at radiology unit and performing entire sequences of magnetic resonance imaging ( mri ) scan lead to increase in dtit . thus again
dwi has high sensitivity ( 88 - 100% ) and specificity ( 95 - 100% ) for detecting infarcted regions , within minutes of onset of symptoms .
study suggested  brain attack team mri sequence  of < 10 min to confirm acute ischemia stroke and assess candidacy for iv - rtpa .
lack of triaging of bed for stroke patients resulted in increase in dtnt time . to prevent these delay we started thrombolysing ais patient in er . to prevent delay due to inavailability of drug
, we have started keeping rtpa in our drug stock our dtnt was 104 min ( door to needle time median - 100 ) .
relatives with geriatric patient ( 79 years ) took longer time to give consent due to age of the patient and secondly due to financial burden .
one of our patients had liver diseases so we had to wait for international normal ratio report for prothrombin time ( international normalized ratio ) .
transient ischemic attack patients were not thrombolysed , but in latter half of study dwi images helped us to prevent delay .
poor recognition of stroke signs , especially in older patients caused delay in arrival time to hospital .
public and emergency medical services staff education play important role in shortening the pre hospital period .
in our study - door to physician , door to imaging and door to needle time were significantly ore compared to standard recommendations ( aha ) [ table 3 ] .
there was lack of handling stroke patients with high priority at each level er , imaging unit , stroke unit .
thus lack of triaging stroke patient at all level of intervention was our weakest point .
education of emergency medical services of stroke symptoms will help to triage stroke patient . in one of the patients the on call doctor was very busy attending emergency calls so causing increase in dtpt time .
the concept of having second on call doctor who takes care only of patients with acute stroke has being recommended by kobayashi et al .
lack of triaging at radiology unit and performing entire sequences of magnetic resonance imaging ( mri ) scan lead to increase in dtit . thus again
dwi has high sensitivity ( 88 - 100% ) and specificity ( 95 - 100% ) for detecting infarcted regions , within minutes of onset of symptoms .
study suggested  brain attack team mri sequence  of < 10 min to confirm acute ischemia stroke and assess candidacy for iv - rtpa .
lack of triaging of bed for stroke patients resulted in increase in dtnt time . to prevent these delay we started thrombolysing ais patient in er . to prevent delay due to inavailability of drug
our dtnt was 104 min ( door to needle time median - 100 ) . patient with raised blood pressure requiring labetalol infusion caused delay .
relatives with geriatric patient ( 79 years ) took longer time to give consent due to age of the patient and secondly due to financial burden .
one of our patients had liver diseases so we had to wait for international normal ratio report for prothrombin time ( international normalized ratio ) .
transient ischemic attack patients were not thrombolysed , but in latter half of study dwi images helped us to prevent delay .
the barriers of thrombolysis in our study included : 
 lack of public awareness and inaccessiblity to emergency medical serviceslack of prioritizing triage system at er , radiology unit and stroke unitlack of a multi - disciplinary stroke care team . 
 
lack of public awareness and inaccessiblity to emergency medical services lack of prioritizing triage system at er , radiology unit and stroke unit lack of a multi - disciplinary stroke care team .
a multi - disciplinary stroke care team consists of well - established emergency medical services , physicians , neurologist , nurses , radiology staff , neuro - radiologist , and pharmacist . forming a one - call comprehensive  stroke code  will help in co - ordination at all level .
time to time audit of quality indicator of stroke code team may help to overcome the factors for delay in dtnt .
 aim:(1 ) to evaluate the number of patients thrombolysed within 1 h of arrival to emergency room ( er ) ( 2 ) to identify reasons for delay in thrombolysis of acute stroke patients.materials and methods : all patients admitted to er with symptoms suggestive of stroke from january 2011 to november 2013 were studied . 
 retrospective data were collected to evaluate er to needle ( door to needle time [ dtnt ] ) time and reasons for delay in thrombolysis . 
 the parameters studied ( 1 ) onset of symptoms to er time , ( 2 ) er to imaging time ( door to imaging time [ dtit ] ) , ( 4 ) er to needle time ( door to needle ) and ( 5 ) contraindications for thrombolysis.results:a total of 695 patients with suspected stroke were admitted during study period . 
 547 ( 78% ) patients were out of window period . 
 148 patients ( 21% , m = 104 , f = 44 ) arrived within window period ( < 4.5 h. ) . 
 104 ( 70.27% ) were contraindicated for thrombolysis . 
 majority were intracerebral bleeds . 
 44 ( 29.7% ) were eligible for thrombolysis . 
 7 ( 15.9% ) were thrombolysed within 1 h. the mean time for arrival of patients from onset of symptoms to hospital ( symptom to door ) 83 min ( median - 47 ) . 
 the mean door to neuro - physician time ( dtpt ) was 32 min ( median - 15 min ) . 
 the mean dtit was 58 min ( median - 50 min ) . 
 the mean dtnt 104 ( median - 100 min).conclusion : reasons for delay in thrombolysis are : absence of stroke education program for common people . 
 lack of priority for triage and imaging for stroke patients . 
Introduction
Materials and Methods
Results
Discussion
None
Pre-hospital
Hospital factors
Patient factors
Conclusions