Impact of Stroke Team Implementation on Reperfusion Treatment and Workflow Times in Acute Ischemic Stroke: A 13-Year Retrospective Analysis from a Tertiary Center

Impact of Stroke Team Implementation on Reperfusion Treatment and Workflow Times in Acute Ischemic Stroke: A 13-Year Retrospective Analysis from a Tertiary Center | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Stroke Team Implementation on Reperfusion Treatment and Workflow Times in Acute Ischemic Stroke: A 13-Year Retrospective Analysis from a Tertiary Center Mesut Dorukoğlu, Tugay Karaoğlan, Emre Ersegün Günay, Ayşe Güler, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7161247/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Timely reperfusion in acute ischemic stroke (AIS) is critical to minimize irreversible brain damage. Intravenous tissue plasminogen activator (IV tPA) and endovascular thrombectomy (EVT) are the current standard treatments. This study aimed to evaluate the impact of stroke team implementation on treatment rates and workflow efficiency in a tertiary hospital. Methods: This retrospective, cross-sectional study included patients diagnosed with AIS and treated with IV tPA and/or EVT between January 2009 and January 2022. Demographic data, treatment-related time metrics, and admission characteristics were recorded. Patients were categorized based on admission time (weekday/weekend, working hours/off-hours) and according to whether they were treated before or after the stroke team was implemented in 2014. Optimal workflow targets were defined according to international guidelines. Statistical analysis was conducted using SPSS v26, with significance set at p<0.05. Results: A total of 396 patients were included (53.8% male). IV tPA was administered to 68.2% and EVT to 31.8% of the patients. After 2014, EVT procedures expanded from limited weekday hours to 24/7 coverage (p=0.006). Significant improvements were observed in door-to-neurologist (p=0.042), door-to-imaging (p=0.013), and door-to-needle (p=0.021) times after stroke team organization. However, door-to-stroke unit transfer time increased (p=0.003). The pandemic period was associated with delays in transfer time (p<0.001). Time metrics were less optimal during off-hours and weekends. Conclusions: The establishment of a dedicated stroke team significantly improved access to EVT and reduced several critical treatment delays. However, challenges remain in optimizing night-shift and inter-hospital referral processes. Stroke systems of care should include regular workflow monitoring and public awareness campaigns to enhance early recognition and access. Acute ischemic stroke Stroke team Door-to-needle time Workflow optimization Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Acute ischemic stroke (AIS) is a clinical syndrome characterized by sudden-onset focal neurological dysfunction due to the occlusion of a cerebral artery. Ischemic strokes account for approximately 85% of all stroke cases and remain one of the leading causes of long-term morbidity in developed countries, as well as a top-three global cause of death ( 1 ). The prolonged treatment and rehabilitation processes associated with AIS create a substantial economic burden on healthcare systems. However, effective treatment in the acute phase increases the likelihood of functional independence and reduces the need for long-term care, underscoring the individual and societal importance of early intervention ( 2 ). Time is the most critical factor in determining the prognosis of ischemic stroke. The success of treatment largely depends on the awareness of patients and caregivers, the efficiency of emergency services, and the coordination of in-hospital stroke care workflows. According to international guidelines and quality standards, key benchmark times include: initial physician assessment within ≤ 10 minutes of arrival, stroke team evaluation ≤ 15 minutes, initiation of neuroimaging ≤ 25 minutes, interpretation of imaging ≤ 45 minutes, treatment initiation ≤ 60 minutes, and admission to the stroke unit ≤ 180 minutes ( 3 ). To achieve these benchmarks, many healthcare systems have adopted dedicated stroke team models. These multidisciplinary structures improve coordination among departments and promote adherence to evidence-based timelines. In addition to enhancing diagnostic and therapeutic efficiency, such organizational models contribute to overall improvements in care quality. In this context, the present study evaluates the effect of stroke team implementation on the utilization of reperfusion therapies (IV tPA and EVT) and workflow time metrics in a tertiary university hospital. We aimed to determine whether this organizational change improved access to therapy and adherence to guideline-recommended time targets. Materials and Methods Study Design and Setting This retrospective and cross-sectional study was conducted at the Emergency Department of Ege University Faculty of Medicine. The study included patients diagnosed with acute ischemic stroke (AIS) between January 1, 2009, and January 1, 2022, who were treated with IV tPA and/or EVT. All patients were treated according to the national stroke guidelines issued by the Turkish Neurological Society. Patient Selection Patients aged 18 years and older who were diagnosed with AIS and treated with IV tPA and/or EVT were included. Patients with insufficient medical records or a final diagnosis other than AIS were excluded. Data Collection Demographic variables (e.g., age, sex) and comorbidities (including hypertension, diabetes mellitus, coronary artery disease, valvular heart disease, atrial fibrillation, hyperlipidemia, carotid artery stenosis, and prior stroke) were obtained from electronic hospital records. Treatment-related time metrics were grouped as follows: Symptom-to-door time Door-to-initial evaluation Door-to-neurologist assessment Door-to-imaging Door-to-needle Door-to-laboratory results Time spent in the emergency department Door-to-stroke unit admission Admission times were categorized as weekday vs. weekend and working hours (08:00–16:00) vs. off-hours (16:00–08:00). The year 2014, marking the implementation of a formal stroke team at our institution, was used as a reference point. Accordingly, patients were divided into two groups: pre-stroke team (≤2013) and post-stroke team (≥2014) for comparative analysis. Ethical Approval The study was approved by the Ethics Committee of Ege University Faculty of Medicine (Approval Code: 24-8T/112, Date: Jan 22, 2024). Due to the retrospective nature of the study, the requirement for informed consent was waived. Statistical Analysis All statistical analyses were performed using IBM SPSS Statistics version 26.0. The Shapiro–Wilk test was used to assess the normality of continuous variables. Normally distributed continuous variables were presented as mean ± standard deviation (SD), while non-normally distributed variables were reported as median (minimum–maximum). For comparison between two independent groups, Student’s t-test was used for normally distributed variables and the Mann–Whitney U test for non-normal data. Categorical variables were analyzed using the Chi-square test or Fisher’s exact test, as appropriate. A p-value <0.05 was considered statistically significant. Results A total of 484 patients were retrospectively evaluated. After excluding 88 patients due to insufficient medical records or non-acute ischemic stroke (AIS) diagnoses, 396 patients were included in the final analysis. Of these, 53.8% (n=213) were male and 46.2% (n=183) were female. IV tPA was administered to 68.2% (n=270), while 31.8% (n=126) underwent EVT. Among patients treated after 2014 (n=322), 52.5% were male (n=169), 47.5% were female (n=153), and the mean age was 66.7 ± 12.4 years. In contrast, patients treated before 2014 (n=74) had a male predominance of 59.5% (n=44), with a mean age of 63.2 ± 13.1 years. Prior to 2014, 87.8% of patients (n=65) received IV tPA and only 12.2% (n=9) received EVT. After 2014, IV tPA was administered to 63.7% (n=205), while EVT was performed in 36.3% (n=117). There was no statistically significant difference in sex distribution or comorbid conditions between the groups (Table 1). Before 2014, EVT was only performed during working hours (08:00–16:00) on weekdays. Following the establishment of the stroke team, EVT procedures expanded to 24/7 availability. This shift was statistically significant (p=0.006). Non-contrast cranial CT was performed in all patients throughout the study period. After 2014, there was a marked increase in the use of cranial and cervical CT angiography in EVT candidates (from 80% to over 90%) and a significant increase in MRI usage as well (p<0.001). Several workflow parameters showed statistically significant or borderline changes after stroke team implementation. Symptom-to-door time increased from 54 minutes to 64 minutes (p=0.076), door-to-imaging time decreased from 24 to 20 minutes (p=0.081), and door-to-stroke unit transfer time increased significantly from 114 to 137 minutes (p=0.003). Importantly, the proportion of patients meeting guideline-defined optimal workflow targets improved significantly after 2014: door-to-neurologist time improved from 14 to 12.5 minutes (p=0.042), door-to-imaging time decreased from 24 to 20 minutes (p=0.013), and door-to-needle time shortened from 67 to 64 minutes (p=0.021) (Figure 1). When analyzed according to time of admission, 70.5% of patients (n=279) presented on weekdays and 29.5% (n=117) on weekends. Within the 08:00–16:00 interval, 180 patients were treated, of whom 19.4% (n=35) belonged to the pre-stroke team period and 80.6% (n=145) to the post-period. In this interval, IV tPA was administered to 16.7% pre-2014 vs. 49.4% post-2014; EVT was applied to 2.8% vs. 31.1%, respectively. Similar patterns were observed in the 16:00–00:00 and 00:00–08:00 intervals, with EVT procedures during overnight hours (00:00–08:00) occurring exclusively after 2014 (Figure 2). Comparisons between weekday and weekend admissions revealed the most prominent difference in the door-to-stroke unit transfer time, particularly during the 00:00–08:00 interval on weekends (p=0.018). While most other workflow parameters did not reach statistical significance, they tended to be longer during off-hours and weekends (Figure 3). In terms of mode of arrival, 78.0% (n=309) of patients arrived via emergency medical services (EMS/112), 11.6% (n=46) by self-transport, and 10.4% (n=41) via referral from another medical center. When stratified by arrival method, symptom-to-door time was significantly longer in patients referred from other institutions (p<0.001), while no significant differences were observed in other workflow metrics (Figure 4). To assess the impact of the COVID-19 pandemic, the years 2018–2019 were defined as the pre-pandemic period, and 2020–2021 as the pandemic period. During the pandemic, door-to-stroke unit transfer time was significantly prolonged (p<0.001), likely due to infection control protocols and delays while awaiting SARS-CoV-2 PCR test results (Figure 5). Discussion The primary goal in the treatment of acute ischemic stroke (AIS) is to achieve early recanalization of the occluded vessel and restore perfusion to the ischemic region. The ultimate aim is to salvage the penumbra, a dynamic zone of potentially reversible ischemia surrounding the infarct core (4). While the severity of ischemia is not modifiable, time to reperfusion is a controllable factor, and thus represents a critical determinant of prognosis. Currently, IV tPA and EVT are widely accepted as standard treatments for AIS. IV tPA received FDA approval in 1996 and was licensed in Türkiye in 2006. It is now recommended as a first-line therapy within 4.5 hours of symptom onset (5). However, only about 25% of patients reach the hospital within 3.5 hours, and fewer than 65% arrive within 8 hours (6,7). EVT has been validated through randomized controlled trials in large-vessel occlusions, such as those involving the internal carotid artery (ICA), middle cerebral artery (MCA), or basilar artery (BA). According to international guidelines by AHA/ASA and ESO, time benchmarks in AIS management include initial physician assessment within 10 minutes, neuroimaging initiation within 20 minutes, and treatment onset within 60 minutes (8,9). Early treatment dramatically influences functional outcomes: 1 in every 3.5 patients treated within the first 90 minutes achieves functional independence, compared to 1 in 7 when treatment is initiated between 91–180 minutes, and 1 in 14 for 181–270 minutes (9). This underlines the critical need for process optimization in AIS care. Many strategies aimed at improving these outcomes have been established in national and international studies, most notably the "Target: Stroke" initiative by the AHA/ASA in 2010. This campaign defined evidence-based strategies for reperfusion, including EMS prenotification, hospital-specific stroke protocols, rapid triage, expedited imaging access and interpretation, accelerated laboratory workflows, predefined decision algorithms, team-based approaches, and real-time feedback systems. These efforts reduced door-to-needle times from 77 to 67 minutes and improved in-hospital and long-term outcomes (10). Our study examined how the implementation of a stroke team in a tertiary university hospital in 2014 influenced AIS treatment processes over a 13-year period. We observed statistically significant reductions in door-to-imaging, door-to-needle, and door-to-neurologist times following stroke team organization, in accordance with prior reports emphasizing the "time is brain" paradigm (11,12). Unlike some previous studies, we also assessed EVT trends and found that prior to 2014, EVT was only performed during weekday working hours, whereas afterward it became available 24/7—highlighting the real-world impact of multidisciplinary coordination. Despite these improvements, symptom-to-door time actually increased after 2014, consistent with previous research that emphasizes the persistent issue of pre-hospital delays (13). This suggests a need for national and local efforts to raise public awareness about stroke symptoms and the importance of early hospital presentation. In terms of arrival method, our findings revealed no significant difference in workflow times between patients arriving via EMS and those presenting independently. However, patients referred from other medical centers experienced significantly prolonged symptom-to-door times, underlining ongoing limitations in the regional stroke referral network (14,15). Once at our center, however, all patients received comparable care, suggesting robust in-hospital workflows regardless of referral status. An analysis based on admission times revealed significantly longer door-to-stroke unit transfer times between 00:00 and 08:00 hours, especially on weekends. This "off-hour effect"—a well-documented factor in stroke outcomes—is likely due to reduced staffing, slower imaging access, and delayed neurological evaluation during nighttime hours (16). Finally, our study included patients treated during the COVID-19 pandemic. During this period, door-to-stroke unit transfer times were significantly prolonged, likely reflecting the impact of infection control protocols, including patient isolation and the need to await PCR test results. These findings are consistent with previous reports emphasizing the need for safe yet efficient stroke care pathways during pandemics (17). Several limitations of our study should be acknowledged. First, its retrospective and single-center design may limit generalizability. Second, due to limited access to older electronic records, we were unable to analyze clinical outcome measures (e.g., modified Rankin Scale, mortality). Third, relevant clinical and radiological data—such as NIHSS scores, occlusion sites, and infarct volume—could not be evaluated. Future multicenter, prospective studies are needed to validate our findings and explore their implications on patient outcomes. Conclusion This study demonstrates that the implementation of a dedicated stroke team significantly improved the timeliness and accessibility of reperfusion therapies, particularly EVT, in the management of acute ischemic stroke. The observed reductions in door-to-imaging, door-to-needle, and door-to-neurologist times reflect enhanced in-hospital coordination and workflow efficiency. However, challenges remain in optimizing care during off-hours and reducing pre-hospital and inter-facility referral delays. Our findings support the integration of stroke team models, routine performance monitoring, and public education initiatives to strengthen stroke systems of care and promote timely access to treatment. Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of Ege University Faculty of Medicine (Approval Code: 24-8T/112; Date: 22.08.2024). Due to the retrospective nature of the study, the requirement for informed consent to participate was waived by the ethics committee. The study was conducted in accordance with the principles of the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors received no specific funding for this study. Authors’ contributions Dorukoğlu MM: Conceptualization, data collection, formal analysis, writing – original draft. Karaoğlan T: Data curation, literature review, writing – review and editing. Ersegün E: Methodology support, results interpretation, writing – review and editing. Güler A: Supervision, administrative support, critical review of the manuscript. Karbek Akarca F: Study design guidance, senior supervision, manuscript revision. Şirin H: Senior supervision, validation of methodology, critical revision for intellectual content. All authors read and approved the final version of the manuscript. Acknowledgements The authors would like to thank the Emergency Department and Neurology Clinic staff of Ege University Faculty of Medicine for their assistance in patient care and data acquisition. References Johnson CO, Nguyen M, Roth GA, Nichols E, Alam T, Abate D, et al. Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18(5):439–58. Blackham KA, Meyers PM, Abruzzo TA, Albuquerque FC, Fiorella D, Fraser J, et al. Endovascular therapy of acute ischemic stroke: Report of the Standards of Practice Committee of the Society of NeuroInterventional Surgery. J Neurointerv Surg. 2012;4(2):87–93. Çabalar M. Akut iskemik inmede acil yaklaşımlar: intravenöz trombolitik tedavi. In: Soysal A, editor. Akut İskemik İnmede Güncel Tedavi Yaklaşımları. Ankara: Türkiye Klinikleri; 2023. pp. 14–8. Yemişçi M, Gürer G, Dalkara T. Akut iskemik inmede erken tedavi. Turkiye Klinikleri J Neurol. 2004;2(1):22–30. Wahlgren N, Ahmed N, Dávalos A, et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. 2007;369(9558):275–82. Kapoor I. Randomized assessment of rapid endovascular treatment of ischemic stroke: The ESCAPE Trial Investigators. J Neuroanaesth Crit Care. 2015;2(2):149–50. Tong D, Reeves MJ, Hernandez AF, et al. Times from symptom onset to hospital arrival in the Get With the Guidelines–Stroke Program 2002 to 2009: temporal trends and implications. Stroke. 2012;43(7):1912–7. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46–110. Turc G, Bhogal P, Fischer U, Khatri P, Lobotesis K, Mazighi M, et al. European Stroke Organisation (ESO) guidelines on mechanical thrombectomy in acute ischaemic stroke. Eur Stroke J. 2019;4(1):6–12. Fonarow GC, Zhao X, Smith EE, et al. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA. 2014;311(16):1632–40. Tveiten A, Mygland A, Ljøstad U, Thomassen L. Intravenous thrombolysis for ischaemic stroke: short delays and high community-based treatment rates after organisational changes in a previously inexperienced centre. Emerg Med J. 2009;26(5):324–6. Lindsberg PJ, Häppölä O, Kallela M, Valanne L, Kuisma M, Kaste M. Door to thrombolysis: ER reorganization and reduced delays to acute stroke treatment. Neurology. 2006;67(2):334–6. Evenson KR, Foraker RE, Morris DL, Rosamond WD. A comprehensive review of prehospital and in-hospital delay times in acute stroke care. Int J Stroke. 2009;4(3):187–99. Alabdali A, Yousif S, Alsaleem A, Aldhubayb M, Aljerian N. Can Emergency Medical Services (EMS) shorten the time to stroke team activation, computed tomography (CT), and the time to receiving antithrombotic therapy? A prospective cohort study. Prehosp Disaster Med. 2020;35(2):148–51. Fassbender K, Balucani C, Walter S, Levine SR, Haass A, Grotta JC. Streamlining of prehospital stroke management: the golden hour. Lancet Neurol. 2013;12(6):585–96. Albright KC, Savitz SI, Raman R, Martin-Schild S. Impact of off-hour arrival on stroke evaluation and treatment. J Stroke Cerebrovasc Dis. 2017;26(4):963–8. Rodríguez-Pardo J, Fuentes B, De Leciñana M, et al. Acute stroke care during the COVID-19 pandemic: Ictus Madrid Program recommendations. Neurología (Engl Ed). 2020;35(4):258–63. Table Table 1. Patient Characteristics and Treatment Modalities Before and After Stroke Team Implementation Characteristic 2009–2013 (n=74) 2014–2022 (n=322) Male, n (%) 44 (59.5%) 169 (52.5%) Female, n (%) 30 (40.5%) 153 (47.5%) Mean age ± SD (years) 63.2 ± 13.1 66.7 ± 12.4 IV tPA administered, n (%) 65 (87.8%) 205 (63.7%) EVT performed, n (%) 9 (12.2%) 117 (36.3%) Note: There were no statistically significant differences between the two periods regarding sex distribution or comorbidities (p>0.05). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 06 Sep, 2025 Reviewers agreed at journal 28 Aug, 2025 Reviewers agreed at journal 28 Aug, 2025 Reviewers invited by journal 28 Aug, 2025 Editor assigned by journal 13 Aug, 2025 Editor invited by journal 24 Jul, 2025 Submission checks completed at journal 24 Jul, 2025 First submitted to journal 24 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7161247","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":509276680,"identity":"99b3ce02-586b-4d4b-849d-8c9dd3924e55","order_by":0,"name":"Mesut Dorukoğlu","email":"","orcid":"","institution":"Ege University","correspondingAuthor":false,"prefix":"","firstName":"Mesut","middleName":"","lastName":"Dorukoğlu","suffix":""},{"id":509276682,"identity":"40ae875f-0fd6-4475-9a15-49673533b8dc","order_by":1,"name":"Tugay Karaoğlan","email":"","orcid":"","institution":"Ege University","correspondingAuthor":false,"prefix":"","firstName":"Tugay","middleName":"","lastName":"Karaoğlan","suffix":""},{"id":509276684,"identity":"a9d31f9f-ec9d-4e3b-a3a9-463adbb91d35","order_by":2,"name":"Emre Ersegün Günay","email":"","orcid":"","institution":"Kyrenia University","correspondingAuthor":false,"prefix":"","firstName":"Emre","middleName":"Ersegün","lastName":"Günay","suffix":""},{"id":509276686,"identity":"287a56bc-0506-48ad-a100-97cd608a2e92","order_by":3,"name":"Ayşe Güler","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYHACxgMMDP/r7Y83HwNz2diJ0APUwpzAcOZYGgNDAlALM9FabviYgbUwENLC37/G4MDHPWx5jDN4vj34+GObPB8zA+OHjzm4tUjceGNwcMYznmJm6d7thjMSbhu2MTMwS87chseaG2cMDvMckGBskzm7TZon4TYjUAsbMy8eLfIgLX8OGDD2SOQ8A2mxJ6jF4HyPwWGGAwmJMyRy2EBaEglqMbzBVnCw58ABYwOeY2aSM9JuJ7cxMzbj9Yvc+cMbH/w4cEDOgL35mcQHm9u289ubD374iM/7EgkYQowNeNQDAf8B/PKjYBSMglEwChgAIGlWhk5Ll20AAAAASUVORK5CYII=","orcid":"","institution":"Ege University","correspondingAuthor":true,"prefix":"","firstName":"Ayşe","middleName":"","lastName":"Güler","suffix":""},{"id":509276688,"identity":"a1024bab-06e1-48fd-98ac-9d075bb22c01","order_by":4,"name":"Funda Karbek Akarca","email":"","orcid":"","institution":"Ege University","correspondingAuthor":false,"prefix":"","firstName":"Funda","middleName":"Karbek","lastName":"Akarca","suffix":""},{"id":509276690,"identity":"4d6384cc-8ace-4179-8525-7f7f57776b47","order_by":5,"name":"Hadiye Şirin","email":"","orcid":"","institution":"Ege University","correspondingAuthor":false,"prefix":"","firstName":"Hadiye","middleName":"","lastName":"Şirin","suffix":""}],"badges":[],"createdAt":"2025-07-19 02:08:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7161247/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7161247/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90804504,"identity":"d64ffa5d-eb49-49ef-a8e5-28ddd22e37fd","added_by":"auto","created_at":"2025-09-08 10:39:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":776135,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of mean workflow time parameters before (2009–2013) and after (2014–2022) stroke team implementation. Statistically significant differences are labeled with p-values.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7161247/v1/e44de06b308d7aec6e4c2caa.png"},{"id":90804634,"identity":"c69c3dcb-c38a-49f1-a2f5-d578f87a0f5d","added_by":"auto","created_at":"2025-09-08 10:39:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":396137,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of IV thrombolysis (tPA) and endovascular thrombectomy (EVT) procedures before (≤2013) and after (≥2014) stroke team implementation across different admission time intervals.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7161247/v1/8b4ab3ce080ba2ebec0aaa6d.png"},{"id":90804593,"identity":"e996bab0-dd42-48d8-898c-d4710e80c428","added_by":"auto","created_at":"2025-09-08 10:39:14","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1242414,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of mean workflow times across seven time categories based on weekday and weekend admission intervals\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7161247/v1/9ef15cda47c368817bd81a4b.png"},{"id":90804470,"identity":"e73e5183-ad11-4c58-b35e-b581b356f14e","added_by":"auto","created_at":"2025-09-08 10:39:08","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":343602,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of workflow times among stroke patients based on arrival mode\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7161247/v1/993fd433fd8e9c2eb2d43980.jpeg"},{"id":90804491,"identity":"f94f76dc-3262-4f22-a026-a5401a81e9fc","added_by":"auto","created_at":"2025-09-08 10:39:10","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":326981,"visible":true,"origin":"","legend":"\u003cp\u003eMean workflow times compared between the pre-pandemic period (2018–2019) and the COVID-19 pandemic period (2020–2021)\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7161247/v1/717e4c147f6c2fb21213a5f8.jpeg"},{"id":90804675,"identity":"34d953e5-6ee2-4c22-9f48-9a181663496a","added_by":"auto","created_at":"2025-09-08 10:39:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3241910,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7161247/v1/0a72225b-a2ac-4581-a2a1-859353cf6abe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Stroke Team Implementation on Reperfusion Treatment and Workflow Times in Acute Ischemic Stroke: A 13-Year Retrospective Analysis from a Tertiary Center","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute ischemic stroke (AIS) is a clinical syndrome characterized by sudden-onset focal neurological dysfunction due to the occlusion of a cerebral artery. Ischemic strokes account for approximately 85% of all stroke cases and remain one of the leading causes of long-term morbidity in developed countries, as well as a top-three global cause of death (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe prolonged treatment and rehabilitation processes associated with AIS create a substantial economic burden on healthcare systems. However, effective treatment in the acute phase increases the likelihood of functional independence and reduces the need for long-term care, underscoring the individual and societal importance of early intervention (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTime is the most critical factor in determining the prognosis of ischemic stroke. The success of treatment largely depends on the awareness of patients and caregivers, the efficiency of emergency services, and the coordination of in-hospital stroke care workflows. According to international guidelines and quality standards, key benchmark times include: initial physician assessment within \u0026le;\u0026thinsp;10 minutes of arrival, stroke team evaluation\u0026thinsp;\u0026le;\u0026thinsp;15 minutes, initiation of neuroimaging\u0026thinsp;\u0026le;\u0026thinsp;25 minutes, interpretation of imaging\u0026thinsp;\u0026le;\u0026thinsp;45 minutes, treatment initiation\u0026thinsp;\u0026le;\u0026thinsp;60 minutes, and admission to the stroke unit\u0026thinsp;\u0026le;\u0026thinsp;180 minutes (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo achieve these benchmarks, many healthcare systems have adopted dedicated stroke team models. These multidisciplinary structures improve coordination among departments and promote adherence to evidence-based timelines. In addition to enhancing diagnostic and therapeutic efficiency, such organizational models contribute to overall improvements in care quality.\u003c/p\u003e\u003cp\u003eIn this context, the present study evaluates the effect of stroke team implementation on the utilization of reperfusion therapies (IV tPA and EVT) and workflow time metrics in a tertiary university hospital. We aimed to determine whether this organizational change improved access to therapy and adherence to guideline-recommended time targets.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003ch3\u003e\u003cstrong\u003eStudy Design and Setting\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis retrospective and cross-sectional study was conducted at the Emergency Department of Ege University Faculty of Medicine. The study included patients diagnosed with acute ischemic stroke (AIS) between January 1, 2009, and January 1, 2022, who were treated with IV tPA and/or EVT. All patients were treated according to the national stroke guidelines issued by the Turkish Neurological Society.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003ePatient Selection\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003ePatients aged 18 years and older who were diagnosed with AIS and treated with IV tPA and/or EVT were included. Patients with insufficient medical records or a final diagnosis other than AIS were excluded.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eDemographic variables (e.g., age, sex) and comorbidities (including hypertension, diabetes mellitus, coronary artery disease, valvular heart disease, atrial fibrillation, hyperlipidemia, carotid artery stenosis, and prior stroke) were obtained from electronic hospital records. Treatment-related time metrics were grouped as follows:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eSymptom-to-door time\u003c/li\u003e\n \u003cli\u003eDoor-to-initial evaluation\u003c/li\u003e\n \u003cli\u003eDoor-to-neurologist assessment\u003c/li\u003e\n \u003cli\u003eDoor-to-imaging\u003c/li\u003e\n \u003cli\u003eDoor-to-needle\u003c/li\u003e\n \u003cli\u003eDoor-to-laboratory results\u003c/li\u003e\n \u003cli\u003eTime spent in the emergency department\u003c/li\u003e\n \u003cli\u003eDoor-to-stroke unit admission\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAdmission times were categorized as weekday vs. weekend and working hours (08:00\u0026ndash;16:00) vs. off-hours (16:00\u0026ndash;08:00). The year 2014, marking the implementation of a formal stroke team at our institution, was used as a reference point. Accordingly, patients were divided into two groups: pre-stroke team (\u0026le;2013) and post-stroke team (\u0026ge;2014) for comparative analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of Ege University Faculty of Medicine (Approval Code: 24-8T/112, Date: Jan 22, 2024). Due to the retrospective nature of the study, the requirement for informed consent was waived.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eAll statistical analyses were performed using IBM SPSS Statistics version 26.0. The Shapiro\u0026ndash;Wilk test was used to assess the normality of continuous variables. Normally distributed continuous variables were presented as mean \u0026plusmn; standard deviation (SD), while non-normally distributed variables were reported as median (minimum\u0026ndash;maximum). For comparison between two independent groups, Student\u0026rsquo;s t-test was used for normally distributed variables and the Mann\u0026ndash;Whitney U test for non-normal data. Categorical variables were analyzed using the Chi-square test or Fisher\u0026rsquo;s exact test, as appropriate. A p-value \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 484 patients were retrospectively evaluated. After excluding 88 patients due to insufficient medical records or non-acute ischemic stroke (AIS) diagnoses, 396 patients were included in the final analysis. Of these, 53.8% (n=213) were male and 46.2% (n=183) were female. IV tPA was administered to 68.2% (n=270), while 31.8% (n=126) underwent EVT.\u003c/p\u003e\n\u003cp\u003eAmong patients treated after 2014 (n=322), 52.5% were male (n=169), 47.5% were female (n=153), and the mean age was 66.7 ± 12.4 years. In contrast, patients treated before 2014 (n=74) had a male predominance of 59.5% (n=44), with a mean age of 63.2 ± 13.1 years. Prior to 2014, 87.8% of patients (n=65) received IV tPA and only 12.2% (n=9) received EVT. After 2014, IV tPA was administered to 63.7% (n=205), while EVT was performed in 36.3% (n=117). There was no statistically significant difference in sex distribution or comorbid conditions between the groups (Table 1).\u003c/p\u003e\n\u003cp\u003eBefore 2014, EVT was only performed during working hours (08:00–16:00) on weekdays. Following the establishment of the stroke team, EVT procedures expanded to 24/7 availability. This shift was statistically significant (p=0.006). Non-contrast cranial CT was performed in all patients throughout the study period. After 2014, there was a marked increase in the use of cranial and cervical CT angiography in EVT candidates (from 80% to over 90%) and a significant increase in MRI usage as well (p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eSeveral workflow parameters showed statistically significant or borderline changes after stroke team implementation. Symptom-to-door time increased from 54 minutes to 64 minutes (p=0.076), door-to-imaging time decreased from 24 to 20 minutes (p=0.081), and door-to-stroke unit transfer time increased significantly from 114 to 137 minutes (p=0.003). Importantly, the proportion of patients meeting guideline-defined optimal workflow targets improved significantly after 2014: door-to-neurologist time improved from 14 to 12.5 minutes (p=0.042), door-to-imaging time decreased from 24 to 20 minutes (p=0.013), and door-to-needle time shortened from 67 to 64 minutes (p=0.021) (Figure 1).\u003c/p\u003e\n\u003cp\u003eWhen analyzed according to time of admission, 70.5% of patients (n=279) presented on weekdays and 29.5% (n=117) on weekends. Within the 08:00–16:00 interval, 180 patients were treated, of whom 19.4% (n=35) belonged to the pre-stroke team period and 80.6% (n=145) to the post-period. In this interval, IV tPA was administered to 16.7% pre-2014 vs. 49.4% post-2014; EVT was applied to 2.8% vs. 31.1%, respectively. Similar patterns were observed in the 16:00–00:00 and 00:00–08:00 intervals, with EVT procedures during overnight hours (00:00–08:00) occurring exclusively after 2014 (Figure 2).\u003c/p\u003e\n\u003cp\u003eComparisons between weekday and weekend admissions revealed the most prominent difference in the door-to-stroke unit transfer time, particularly during the 00:00–08:00 interval on weekends (p=0.018). While most other workflow parameters did not reach statistical significance, they tended to be longer during off-hours and weekends (Figure 3).\u003c/p\u003e\n\u003cp\u003eIn terms of mode of arrival, 78.0% (n=309) of patients arrived via emergency medical services (EMS/112), 11.6% (n=46) by self-transport, and 10.4% (n=41) via referral from another medical center. When stratified by arrival method, symptom-to-door time was significantly longer in patients referred from other institutions (p\u0026lt;0.001), while no significant differences were observed in other workflow metrics (Figure 4).\u003c/p\u003e\n\u003cp\u003eTo assess the impact of the COVID-19 pandemic, the years 2018–2019 were defined as the pre-pandemic period, and 2020–2021 as the pandemic period. During the pandemic, door-to-stroke unit transfer time was significantly prolonged (p\u0026lt;0.001), likely due to infection control protocols and delays while awaiting SARS-CoV-2 PCR test results (Figure 5).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe primary goal in the treatment of acute ischemic stroke (AIS) is to achieve early recanalization of the occluded vessel and restore perfusion to the ischemic region. The ultimate aim is to salvage the penumbra, a dynamic zone of potentially reversible ischemia surrounding the infarct core (4). While the severity of ischemia is not modifiable, time to reperfusion is a controllable factor, and thus represents a critical determinant of prognosis.\u003c/p\u003e\n\u003cp\u003eCurrently, IV tPA and EVT are widely accepted as standard treatments for AIS. IV tPA received FDA approval in 1996 and was licensed in Türkiye in 2006. It is now recommended as a first-line therapy within 4.5 hours of symptom onset (5). However, only about 25% of patients reach the hospital within 3.5 hours, and fewer than 65% arrive within 8 hours (6,7). EVT has been validated through randomized controlled trials in large-vessel occlusions, such as those involving the internal carotid artery (ICA), middle cerebral artery (MCA), or basilar artery (BA).\u003c/p\u003e\n\u003cp\u003eAccording to international guidelines by AHA/ASA and ESO, time benchmarks in AIS management include initial physician assessment within 10 minutes, neuroimaging initiation within 20 minutes, and treatment onset within 60 minutes (8,9). Early treatment dramatically influences functional outcomes: 1 in every 3.5 patients treated within the first 90 minutes achieves functional independence, compared to 1 in 7 when treatment is initiated between 91–180 minutes, and 1 in 14 for 181–270 minutes (9). This underlines the critical need for process optimization in AIS care.\u003c/p\u003e\n\u003cp\u003eMany strategies aimed at improving these outcomes have been established in national and international studies, most notably the \"Target: Stroke\" initiative by the AHA/ASA in 2010. This campaign defined evidence-based strategies for reperfusion, including EMS prenotification, hospital-specific stroke protocols, rapid triage, expedited imaging access and interpretation, accelerated laboratory workflows, predefined decision algorithms, team-based approaches, and real-time feedback systems. These efforts reduced door-to-needle times from 77 to 67 minutes and improved in-hospital and long-term outcomes (10).\u003c/p\u003e\n\u003cp\u003eOur study examined how the implementation of a stroke team in a tertiary university hospital in 2014 influenced AIS treatment processes over a 13-year period. We observed statistically significant reductions in door-to-imaging, door-to-needle, and door-to-neurologist times following stroke team organization, in accordance with prior reports emphasizing the \"time is brain\" paradigm (11,12). Unlike some previous studies, we also assessed EVT trends and found that prior to 2014, EVT was only performed during weekday working hours, whereas afterward it became available 24/7—highlighting the real-world impact of multidisciplinary coordination.\u003c/p\u003e\n\u003cp\u003eDespite these improvements, symptom-to-door time actually increased after 2014, consistent with previous research that emphasizes the persistent issue of pre-hospital delays (13). This suggests a need for national and local efforts to raise public awareness about stroke symptoms and the importance of early hospital presentation.\u003c/p\u003e\n\u003cp\u003eIn terms of arrival method, our findings revealed no significant difference in workflow times between patients arriving via EMS and those presenting independently. However, patients referred from other medical centers experienced significantly prolonged symptom-to-door times, underlining ongoing limitations in the regional stroke referral network (14,15). Once at our center, however, all patients received comparable care, suggesting robust in-hospital workflows regardless of referral status.\u003c/p\u003e\n\u003cp\u003eAn analysis based on admission times revealed significantly longer door-to-stroke unit transfer times between 00:00 and 08:00 hours, especially on weekends. This \"off-hour effect\"—a well-documented factor in stroke outcomes—is likely due to reduced staffing, slower imaging access, and delayed neurological evaluation during nighttime hours (16).\u003c/p\u003e\n\u003cp\u003eFinally, our study included patients treated during the COVID-19 pandemic. During this period, door-to-stroke unit transfer times were significantly prolonged, likely reflecting the impact of infection control protocols, including patient isolation and the need to await PCR test results. These findings are consistent with previous reports emphasizing the need for safe yet efficient stroke care pathways during pandemics (17).\u003c/p\u003e\n\u003cp\u003eSeveral limitations of our study should be acknowledged. First, its retrospective and single-center design may limit generalizability. Second, due to limited access to older electronic records, we were unable to analyze clinical outcome measures (e.g., modified Rankin Scale, mortality). Third, relevant clinical and radiological data—such as NIHSS scores, occlusion sites, and infarct volume—could not be evaluated. Future multicenter, prospective studies are needed to validate our findings and explore their implications on patient outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that the implementation of a dedicated stroke team significantly improved the timeliness and accessibility of reperfusion therapies, particularly EVT, in the management of acute ischemic stroke. The observed reductions in door-to-imaging, door-to-needle, and door-to-neurologist times reflect enhanced in-hospital coordination and workflow efficiency. However, challenges remain in optimizing care during off-hours and reducing pre-hospital and inter-facility referral delays. Our findings support the integration of stroke team models, routine performance monitoring, and public education initiatives to strengthen stroke systems of care and promote timely access to treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of Ege University Faculty of Medicine (Approval Code: 24-8T/112; Date: 22.08.2024). Due to the retrospective nature of the study, the requirement for informed consent to participate was waived by the ethics committee.\u003cbr\u003e\u0026nbsp;The study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors received no specific funding for this study.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/h3\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eDorukoğlu MM:\u003c/strong\u003e Conceptualization, data collection, formal analysis, writing – original draft.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eKaraoğlan T:\u003c/strong\u003e Data curation, literature review, writing – review and editing.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eErsegün E:\u003c/strong\u003e Methodology support, results interpretation, writing – review and editing.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eGüler A:\u003c/strong\u003e Supervision, administrative support, critical review of the manuscript.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eKarbek Akarca F:\u003c/strong\u003e Study design guidance, senior supervision, manuscript revision.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eŞirin H:\u003c/strong\u003e Senior supervision, validation of methodology, critical revision for intellectual content.\u003cbr\u003e\u0026nbsp;\u0026nbsp;All authors read and approved the final version of the manuscript.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors would like to thank the Emergency Department and Neurology Clinic staff of Ege University Faculty of Medicine for their assistance in patient care and data acquisition.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJohnson CO, Nguyen M, Roth GA, Nichols E, Alam T, Abate D, et al. Global, regional, and national burden of stroke, 1990\u0026ndash;2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18(5):439\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBlackham KA, Meyers PM, Abruzzo TA, Albuquerque FC, Fiorella D, Fraser J, et al. Endovascular therapy of acute ischemic stroke: Report of the Standards of Practice Committee of the Society of NeuroInterventional Surgery. J Neurointerv Surg. 2012;4(2):87\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u0026Ccedil;abalar M. Akut iskemik inmede acil yaklaşımlar: intraven\u0026ouml;z trombolitik tedavi. In: Soysal A, editor. Akut İskemik İnmede G\u0026uuml;ncel Tedavi Yaklaşımları. Ankara: T\u0026uuml;rkiye Klinikleri; 2023. pp. 14\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYemiş\u0026ccedil;i M, G\u0026uuml;rer G, Dalkara T. Akut iskemik inmede erken tedavi. Turkiye Klinikleri J Neurol. 2004;2(1):22\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWahlgren N, Ahmed N, D\u0026aacute;valos A, et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. 2007;369(9558):275\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKapoor I. Randomized assessment of rapid endovascular treatment of ischemic stroke: The ESCAPE Trial Investigators. J Neuroanaesth Crit Care. 2015;2(2):149\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTong D, Reeves MJ, Hernandez AF, et al. Times from symptom onset to hospital arrival in the Get With the Guidelines\u0026ndash;Stroke Program 2002 to 2009: temporal trends and implications. Stroke. 2012;43(7):1912\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePowers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46\u0026ndash;110.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTurc G, Bhogal P, Fischer U, Khatri P, Lobotesis K, Mazighi M, et al. European Stroke Organisation (ESO) guidelines on mechanical thrombectomy in acute ischaemic stroke. Eur Stroke J. 2019;4(1):6\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFonarow GC, Zhao X, Smith EE, et al. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA. 2014;311(16):1632\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTveiten A, Mygland A, Lj\u0026oslash;stad U, Thomassen L. Intravenous thrombolysis for ischaemic stroke: short delays and high community-based treatment rates after organisational changes in a previously inexperienced centre. Emerg Med J. 2009;26(5):324\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLindsberg PJ, H\u0026auml;pp\u0026ouml;l\u0026auml; O, Kallela M, Valanne L, Kuisma M, Kaste M. Door to thrombolysis: ER reorganization and reduced delays to acute stroke treatment. Neurology. 2006;67(2):334\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEvenson KR, Foraker RE, Morris DL, Rosamond WD. A comprehensive review of prehospital and in-hospital delay times in acute stroke care. Int J Stroke. 2009;4(3):187\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlabdali A, Yousif S, Alsaleem A, Aldhubayb M, Aljerian N. Can Emergency Medical Services (EMS) shorten the time to stroke team activation, computed tomography (CT), and the time to receiving antithrombotic therapy? A prospective cohort study. Prehosp Disaster Med. 2020;35(2):148\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFassbender K, Balucani C, Walter S, Levine SR, Haass A, Grotta JC. Streamlining of prehospital stroke management: the golden hour. Lancet Neurol. 2013;12(6):585\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlbright KC, Savitz SI, Raman R, Martin-Schild S. Impact of off-hour arrival on stroke evaluation and treatment. J Stroke Cerebrovasc Dis. 2017;26(4):963\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRodr\u0026iacute;guez-Pardo J, Fuentes B, De Leci\u0026ntilde;ana M, et al. Acute stroke care during the COVID-19 pandemic: Ictus Madrid Program recommendations. Neurolog\u0026iacute;a (Engl Ed). 2020;35(4):258\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003ePatient Characteristics and Treatment Modalities Before and After Stroke Team Implementation\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e2009\u0026ndash;2013 (n=74)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e2014\u0026ndash;2022 (n=322)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44 (59.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e169 (52.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 (40.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e153 (47.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMean age \u0026plusmn; SD (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e63.2 \u0026plusmn; 13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e66.7 \u0026plusmn; 12.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIV tPA administered, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65 (87.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e205 (63.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEVT performed, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (12.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e117 (36.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote: There were no statistically significant differences between the two periods regarding sex distribution or comorbidities (p\u0026gt;0.05).\u003c/em\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acute ischemic stroke, Stroke team, Door-to-needle time, Workflow optimization","lastPublishedDoi":"10.21203/rs.3.rs-7161247/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7161247/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eTimely reperfusion in acute ischemic stroke (AIS) is critical to minimize irreversible brain damage. Intravenous tissue plasminogen activator (IV tPA) and endovascular thrombectomy (EVT) are the current standard treatments. This study aimed to evaluate the impact of stroke team implementation on treatment rates and workflow efficiency in a tertiary hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis retrospective, cross-sectional study included patients diagnosed with AIS and treated with IV tPA and/or EVT between January 2009 and January 2022. Demographic data, treatment-related time metrics, and admission characteristics were recorded. Patients were categorized based on admission time (weekday/weekend, working hours/off-hours) and according to whether they were treated before or after the stroke team was implemented in 2014. Optimal workflow targets were defined according to international guidelines. Statistical analysis was conducted using SPSS v26, with significance set at p\u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 396 patients were included (53.8% male). IV tPA was administered to 68.2% and EVT to 31.8% of the patients. After 2014, EVT procedures expanded from limited weekday hours to 24/7 coverage (p=0.006). Significant improvements were observed in door-to-neurologist (p=0.042), door-to-imaging (p=0.013), and door-to-needle (p=0.021) times after stroke team organization. However, door-to-stroke unit transfer time increased (p=0.003). The pandemic period was associated with delays in transfer time (p\u0026lt;0.001). Time metrics were less optimal during off-hours and weekends.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe establishment of a dedicated stroke team significantly improved access to EVT and reduced several critical treatment delays. However, challenges remain in optimizing night-shift and inter-hospital referral processes. Stroke systems of care should include regular workflow monitoring and public awareness campaigns to enhance early recognition and access.\u003c/p\u003e","manuscriptTitle":"Impact of Stroke Team Implementation on Reperfusion Treatment and Workflow Times in Acute Ischemic Stroke: A 13-Year Retrospective Analysis from a Tertiary Center","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-08 10:38:38","doi":"10.21203/rs.3.rs-7161247/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-06T07:59:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"267181850662037205356844056000261858124","date":"2025-08-29T02:34:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"105376824092950669622002048304949238968","date":"2025-08-28T22:50:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-28T18:01:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-13T04:32:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-24T09:38:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-24T05:05:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2025-07-24T05:02:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e089461f-200b-4725-884d-00f73f696047","owner":[],"postedDate":"September 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-08T10:38:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-08 10:38:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7161247","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7161247","identity":"rs-7161247","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}