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Article ; Online: Implementation of thrombolysis for ischaemic stroke.

Dirks, Maaike / Dippel, Diederik Wj

2013 Volume 12, Issue 2, Page(s) 120–121

MeSH term(s)	Female ; Fibrinolytic Agents/therapeutic use ; Hospitals, Community ; Humans ; Male ; Stroke/drug therapy ; Tissue Plasminogen Activator/therapeutic use
Chemical Substances	Fibrinolytic Agents ; Tissue Plasminogen Activator (EC 3.4.21.68)
Language	English
Publishing date	2013-02
Publishing country	England
Document type	Comment ; Journal Article
ZDB-ID	2079704-7
ISSN	1474-4465 ; 1474-4422
ISSN (online)	1474-4465
ISSN	1474-4422
DOI	10.1016/S1474-4422(12)70304-6
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Article ; Online: Unequal access to treatment with intravenous alteplase for women with acute ischemic stroke.

de Ridder, Inger / Dirks, Maaike / Niessen, Louis / Dippel, Diederik

Stroke

2013 Volume 44, Issue 9, Page(s) 2610–2612

Abstract: Background and purpose: A recent meta-analysis showed that women with acute ischemic stroke are less likely to receive treatment with intravenous alteplase than men. The aim of this study was to assess sex differences in treatment with intravenous ... ...

Abstract	Background and purpose: A recent meta-analysis showed that women with acute ischemic stroke are less likely to receive treatment with intravenous alteplase than men. The aim of this study was to assess sex differences in treatment with intravenous alteplase and to explore the reasons for these differences. Methods: We analyzed data from the Promoting Acute Thrombolysis for Ischaemic Stroke (PRACTISE) study. We applied a multiple logistic regression model and expressed the association between sex and treatment with an age-adjusted odds ratio with 95% confidence interval. Results: In total, 5515 patients were included in PRACTISE. Women were an average of 4 years older than men. The median National Institutes of Health Stroke Scale score was 6 in women and 5 in men. Fewer women were treated with intravenous alteplase (11% versus 14%; adjusted odds ratio, 0.8; 95% confidence interval, 0.7-1.0). However, fewer women arrived within 4 hours after onset (27% versus 33%; adjusted odds ratio, 0.8; 95% confidence interval, 0.7-0.9). Conclusions: Fewer women present themselves within 4 hours from stroke onset than men and consequently less often receive thrombolytic treatment. This difference may be caused by the older age of women on average and consequently women more often living alone. Clinical trial registration url: http://www.controlled-trials.com. Unique identifier: ISRCTN20405426.
MeSH term(s)	Administration, Intravenous ; Aged ; Aged, 80 and over ; Brain Ischemia/drug therapy ; Clinical Trials as Topic ; Female ; Fibrinolytic Agents/therapeutic use ; Health Services Accessibility/statistics & numerical data ; Humans ; Male ; Middle Aged ; Severity of Illness Index ; Sex Factors ; Stroke/drug therapy ; Thrombolytic Therapy/statistics & numerical data ; Tissue Plasminogen Activator/therapeutic use ; Treatment Outcome
Chemical Substances	Fibrinolytic Agents ; Tissue Plasminogen Activator (EC 3.4.21.68)
Language	English
Publishing date	2013-09
Publishing country	United States
Document type	Comparative Study ; Journal Article ; Randomized Controlled Trial ; Research Support, Non-U.S. Gov't
ZDB-ID	80381-9
ISSN	1524-4628 ; 0039-2499 ; 0749-7954
ISSN (online)	1524-4628
ISSN	0039-2499 ; 0749-7954
DOI	10.1161/STROKEAHA.113.002263
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Article ; Online: Development and validation of the Dutch Stroke Score for predicting disability and functional outcome after ischemic stroke: A tool to support efficient discharge planning.

de Ridder, Inger R / Dijkland, Simone A / Scheele, Maaike / den Hertog, Heleen M / Dirks, Maaike / Westendorp, Willeke F / Nederkoorn, Paul J / van de Beek, Diederik / Ribbers, Gerard M / Steyerberg, Ewout W / Lingsma, Hester F / Dippel, Diederik Wj

European stroke journal

2018 Volume 3, Issue 2, Page(s) 165–173

Abstract: Introduction: We aimed to develop and validate a prognostic score for disability at discharge and functional outcome at three months in patients with acute ischemic stroke based on clinical information available on admission.: Patients and methods: ... ...

Abstract	Introduction: We aimed to develop and validate a prognostic score for disability at discharge and functional outcome at three months in patients with acute ischemic stroke based on clinical information available on admission. Patients and methods: The Dutch Stroke Score (DSS) was developed in 1227 patients with ischemic stroke included in the Paracetamol (Acetaminophen) In Stroke study. Predictors for Barthel Index (BI) at discharge ('DSS-discharge') and modified Rankin Scale (mRS) at three months ('DSS-3 months') were identified in multivariable ordinal regression. The models were internally validated with bootstrapping techniques. The DSS-3 months was externally validated in the PRomoting ACute Thrombolysis in Ischemic StrokE study (1589 patients) and the Preventive Antibiotics in Stroke Study (2107 patients). Model performance was assessed in terms of discrimination, expressed by the area under the receiver operating characteristic curve (AUC), and calibration. Results: At model development, the strongest predictors of Barthel Index at discharge were age per decade over 60 (odds ratio = 1.55, 95% confidence interval (CI) 1.41-1.68), National Institutes of Health Stroke Scale (odds ratio = 1.24 per point, 95% CI 1.22-1.26) and diabetes (odds ratio = 1.62, 95% CI 1.32-1.91). The internally validated AUC was 0.76 (95% CI 0.75-0.79). The DSS-3 months, additionally consisting of previous stroke and atrial fibrillation, performed similarly at internal (AUC 0.75, 95% CI 0.74-0.77) and external validation (AUC 0.74 in PRomoting ACute Thrombolysis in Ischemic StrokE (95% CI 0.72-0.76) and 0.69 in Preventive Antibiotics in Stroke Study (95% CI 0.69-0.72)). Observed outcome was slightly better than predicted. Conclusion: If further validated, the DSS may contribute to efficient stroke unit discharge planning alongside patients' contextual factors and therapeutic needs.
Language	English
Publishing date	2018-01-25
Publishing country	England
Document type	Journal Article
ZDB-ID	2851287-X
ISSN	2396-9881 ; 2396-9873
ISSN (online)	2396-9881
ISSN	2396-9873
DOI	10.1177/2396987318754591
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Article ; Online: Elevated pretreatment blood pressure and IV thrombolysis in stroke.

Dirks, Maaike / Zonneveld, Thomas P / Dippel, Diederik W J / Nederkoorn, Paul J / van de Beek, Diederik / van Oostenbrugge, Robert J / Kruyt, Nyika D

Neurology

2015 Volume 84, Issue 14, Page(s) 1419–1425

Abstract: Objectives: We investigated whether an active blood pressure-lowering strategy is associated with more patients receiving thrombolytics compared with a conservative "watch and measure" strategy, and assessed safety and functional outcome of these 2 ... ...

Abstract	Objectives: We investigated whether an active blood pressure-lowering strategy is associated with more patients receiving thrombolytics compared with a conservative "watch and measure" strategy, and assessed safety and functional outcome of these 2 treatment strategies. Methods: This is a post hoc analysis in 2 randomized controlled stroke trials, the PRACTISE (Promoting Acute Thrombolysis in Ischemic Stroke) and the PASS (Preventive Antibiotics in Stroke Study). We included all patients with elevated pretreatment blood pressure above 185/110 mm Hg at presentation but otherwise eligible for IV thrombolysis (IVT). The decision to use an active or conservative strategy was in accordance with local hospital treatment guidelines. The primary outcome was the proportion of patients treated with IVT. Secondary outcomes were (1) symptomatic intracranial hemorrhage (increased neurologic deficit with a concomitant hemorrhage on neuroimaging), (2) functional outcome at 3 months, and (3) the door-to-needle time. Results: We included 224 patients, 66 (29%) received the active and 158 (71%) the conservative strategy. In the active group, 55 patients (83%) received thrombolytics vs 87 (55%) in the conservative group, an increase of 28% (95% confidence interval: 16%-40%). If only patients actually treated with IVT were considered, the rate of symptomatic intracranial hemorrhage was 7% in both groups. There was no difference in door-to-needle time. Conclusions: Active blood pressure lowering was associated with an increased proportion of patients treated with IVT compared with a conservative strategy, without a difference in symptomatic hemorrhage rate.
MeSH term(s)	Aged ; Aged, 80 and over ; Antihypertensive Agents/therapeutic use ; Female ; Humans ; Hypertension/drug therapy ; Intracranial Hemorrhages/epidemiology ; Male ; Middle Aged ; Randomized Controlled Trials as Topic ; Stroke/drug therapy ; Stroke/epidemiology ; Stroke/therapy ; Thrombolytic Therapy/statistics & numerical data ; Time-to-Treatment/statistics & numerical data ; Treatment Outcome
Chemical Substances	Antihypertensive Agents
Language	English
Publishing date	2015-04-07
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	207147-2
ISSN	1526-632X ; 0028-3878
ISSN (online)	1526-632X
ISSN	0028-3878
DOI	10.1212/WNL.0000000000001445
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Article: Measuring Quality Improvement in Acute Ischemic Stroke Care: Interrupted Time Series Analysis of Door-to-Needle Time.

van Dishoeck, Anne Margreet / Dippel, Diederik W J / Dirks, Maaike / Looman, Caspar W N / Mackenbach, Johan P / Steyerberg, Ewout W

Cerebrovascular diseases extra

2014 Volume 4, Issue 2, Page(s) 149–155

Abstract: Background: In patients with acute ischemic stroke, early treatment with recombinant tissue plasminogen activator (rtPA) improves functional outcome by effectively reducing disability and dependency. Timely thrombolysis, within 1 h, is a vital aspect of ...

Abstract	Background: In patients with acute ischemic stroke, early treatment with recombinant tissue plasminogen activator (rtPA) improves functional outcome by effectively reducing disability and dependency. Timely thrombolysis, within 1 h, is a vital aspect of acute stroke treatment, and is reflected in the widely used performance indicator 'door-to-needle time' (DNT). DNT measures the time from the moment the patient enters the emergency department until he/she receives intravenous rtPA. The purpose of the study was to measure quality improvement from the first implementation of thrombolysis in stroke patients in a university hospital in the Netherlands. We further aimed to identify specific interventions that affect DNT. Methods: We included all patients with acute ischemic stroke consecutively admitted to a large university hospital in the Netherlands between January 2006 and December 2012, and focused on those treated with thrombolytic therapy on admission. Data were collected routinely for research purposes and internal quality measurement (the Erasmus Stroke Study). We used a retrospective interrupted time series design to study the trend in DNT, analyzed by means of segmented regression. Results: Between January 2006 and December 2012, 1,703 patients with ischemic stroke were admitted and 262 (17%) were treated with rtPA. Patients treated with thrombolysis were on average 63 years old at the time of the stroke and 52% were male. Mean age (p = 0.58) and sex distribution (p = 0.98) did not change over the years. The proportion treated with thrombolysis increased from 5% in 2006 to 22% in 2012. In 2006, none of the patients were treated within 1 h. In 2012, this had increased to 81%. In a logistic regression analysis, this trend was significant (OR 1.6 per year, CI 1.4-1.8). The median DNT was reduced from 75 min in 2006 to 45 min in 2012 (p < 0.001 in a linear regression model). In this period, a 12% annual decrease in DNT was achieved (CI from 16 to 8%). We could not find a significant association between any specific intervention and the trend in DNT. Conclusion and implications: The DNT steadily improved from the first implementation of thrombolysis. Specific explanations for this improvement require further study, and may relate to the combined impact of a series of structural and logistic interventions. Our results support the use of performance measures for internal communication. Median DNT should be used on a monthly or quarterly basis to inform all professionals treating stroke patient of their achievements.
Language	English
Publishing date	2014-06-24
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2651613-5
ISSN	1664-5456
ISSN	1664-5456
DOI	10.1159/000363535
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Article ; Online: Effectiveness of thrombolysis with intravenous alteplase for acute ischemic stroke in older adults.

Dirks, Maaike / Koudstaal, Peter J / Dippel, Diederik W J / Niessen, Louis W / van Wijngaarden, Jeroen D H / Franke, Cees L / van Oostenbrugge, Robert J

Journal of the American Geriatrics Society

2011 Volume 59, Issue 11, Page(s) 2169–2171

MeSH term(s)	Aged, 80 and over ; Fibrinolytic Agents/administration & dosage ; Humans ; Injections, Intravenous ; Stroke/drug therapy ; Thrombolytic Therapy/methods ; Tissue Plasminogen Activator/administration & dosage ; Treatment Outcome
Chemical Substances	Fibrinolytic Agents ; Tissue Plasminogen Activator (EC 3.4.21.68)
Language	English
Publishing date	2011-11
Publishing country	United States
Document type	Letter ; Research Support, Non-U.S. Gov't
ZDB-ID	80363-7
ISSN	1532-5415 ; 0002-8614
ISSN (online)	1532-5415
ISSN	0002-8614
DOI	10.1111/j.1532-5415.2011.03707.x
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Article ; Online: The effectiveness of thrombolysis with intravenous alteplase for acute ischemic stroke in daily practice.

Dirks, Maaike / Niessen, Louis W / van Wijngaarden, Jeroen / Koudstaal, Peter J / Franke, Cees L / van Oostenbrugge, Robert J / Dippel, Diederik W J

International journal of stroke : official journal of the International Stroke Society

2012 Volume 7, Issue 4, Page(s) 289–292

Abstract: Background: Thrombolysis with intravenous alteplase has been proven an effective treatment for patients with acute ischemic stroke in randomized clinical trials. In daily practice, the effect of thrombolysis may be less, and complications may occur more ...

Abstract	Background: Thrombolysis with intravenous alteplase has been proven an effective treatment for patients with acute ischemic stroke in randomized clinical trials. In daily practice, the effect of thrombolysis may be less, and complications may occur more often. Aims: The aim of this study was to assess effectiveness and safety of thrombolysis in an unselected observational cohort of patients. Methods: During a two-year period, all patients over 18 years with acute stroke who were admitted within four-hours from onset of symptoms in 12 centers were registered. We compared outcomes in patients who were treated with alteplase with patients who were not treated with alteplase. The primary outcome was good functional outcome at three-months measured with the modified Rankin Scale ≤2). The safety end point was symptomatic intracranial hemorrhage and mortality. We used a multivariable logistic regression model to adjust for baseline imbalances and multilevel analysis to take into account within center correlations. Results: Overall, 1657 patients with ischemic stroke were admitted within four-hours from onset of symptoms and 696 (42%) were treated with alteplase. Treatment with alteplase was associated with a favorable outcome (adjusted odds ratio 1·3; 95% confidence interval 1·0 to 1·7). After further adjustment for potential clustering effects, the adjusted odds ratio for good outcome was 1·4 (95% confidence interval 1·0 to 1·8). Thirty-six (5%) of the 696 patients treated with alteplase had a symptomatic intracranial bleeding complication. Conclusions: Thrombolysis for ischemic stroke with intravenous alteplase is an effective treatment also in an unselected observational cohort of patients.
MeSH term(s)	Aged ; Aged, 80 and over ; Brain Ischemia/drug therapy ; Female ; Fibrinolytic Agents/administration & dosage ; Humans ; Infusions, Intravenous ; Male ; Stroke/drug therapy ; Tissue Plasminogen Activator/administration & dosage ; Treatment Outcome
Chemical Substances	Fibrinolytic Agents ; Tissue Plasminogen Activator (EC 3.4.21.68)
Language	English
Publishing date	2012-06
Publishing country	United States
Document type	Journal Article ; Randomized Controlled Trial ; Research Support, Non-U.S. Gov't
ZDB-ID	2303728-3
ISSN	1747-4949 ; 1747-4930
ISSN (online)	1747-4949
ISSN	1747-4930
DOI	10.1111/j.1747-4949.2011.00709.x
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Article ; Online: Outcomes of Nonagenarians with Acute Ischemic Stroke Treated with Intravenous Thrombolytics.

Behrouz, Réza / Masjuán-Vallejo, Jaime / Vera, Rocío / Willey, Joshua Z / Zedet, Mickael / Moulin, Solène / Cordonnier, Charlotte / Klijn, Catharina J M / Kanselaar, Karin / Dirks, Maaike / Silver, Brian / Khan, Muhib / Azarpazhooh, Mahmoud R / Godoy, Daniel A / Roffe, Christine / Paley, Lizz / Bray, Benjamin D / Smith, Craig J / Di Napoli, Mario

Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association

2018 Volume 27, Issue 1, Page(s) 246–256

Abstract: Background: Nonagenarians are under-represented in thrombolytic trials for acute ischemic stroke (AIS). The effectiveness of intravenous thrombolytics in nonagenarians in terms of safety and outcome is not well established.: Materials and methods: We ...

Abstract	Background: Nonagenarians are under-represented in thrombolytic trials for acute ischemic stroke (AIS). The effectiveness of intravenous thrombolytics in nonagenarians in terms of safety and outcome is not well established. Materials and methods: We used a multinational registry to identify patients aged 90 years or older with good baseline functional status who presented with AIS. Differences in outcomes-disability level at 90 days, frequency of symptomatic intracerebral hemorrhage (sICH), and mortality-between patients who did and did not receive thrombolytics were assessed using multivariable logistic regression, adjusted for prespecified prognostic factors. Coarsened exact matching (CEM) was utilized before evaluating outcome by balancing both groups in the sensitivity analysis. Results: We identified 227 previously independent nonagenarians with AIS; 122 received intravenous thrombolytics and 105 did not. In the unmatched cohort, ordinal analysis showed a significant treatment effect (adjusted common odds ratio [OR]: .61, 95% confidence interval [CI]: .39-.96). There was an absolute difference of 8.1% in the rate of excellent outcome in favor of thrombolysis (17.4% versus 9.3%; adjusted ratio: .30, 95% CI: .12-.77). Rates of sICH and in-hospital mortality were not different. Similarly, in the matched cohort, CEM analysis showed a shift in the primary outcome distribution in favor of thrombolysis (adjusted common OR: .45, 95% CI: .26-.76). Conclusions: Nonagenarians treated with thrombolytics showed lower stroke-related disability at 90 days than those not treated, without significant difference in sICH and in-hospital mortality rates. These observations cannot exclude a residual confounding effect, but provide evidence that thrombolytics should not be withheld from nonagenarians because of age alone.
MeSH term(s)	Age Factors ; Aged, 80 and over ; Argentina ; Brain Ischemia/diagnosis ; Brain Ischemia/drug therapy ; Brain Ischemia/mortality ; Brain Ischemia/physiopathology ; Cerebral Hemorrhage/chemically induced ; Chi-Square Distribution ; Clinical Decision-Making ; Disability Evaluation ; Europe ; Female ; Fibrinolytic Agents/administration & dosage ; Fibrinolytic Agents/adverse effects ; Hospital Mortality ; Humans ; Infusions, Intravenous ; Logistic Models ; Male ; Multivariate Analysis ; North America ; Odds Ratio ; Patient Selection ; Registries ; Risk Factors ; Stroke/diagnosis ; Stroke/drug therapy ; Stroke/mortality ; Stroke/physiopathology ; Thrombolytic Therapy/adverse effects ; Time Factors ; Tissue Plasminogen Activator/administration & dosage ; Tissue Plasminogen Activator/adverse effects ; Treatment Outcome
Chemical Substances	Fibrinolytic Agents ; Tissue Plasminogen Activator (EC 3.4.21.68)
Language	English
Publishing date	2018-01
Publishing country	United States
Document type	Journal Article ; Multicenter Study
ZDB-ID	1131675-5
ISSN	1532-8511 ; 1052-3057
ISSN (online)	1532-8511
ISSN	1052-3057
DOI	10.1016/j.jstrokecerebrovasdis.2017.08.031
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Article ; Online: Lifetime health effects and medical costs of integrated stroke services - a non-randomized controlled cluster-trial based life table approach.

Baeten, Stefan A / van Exel, N Job A / Dirks, Maaike / Koopmanschap, Marc A / Dippel, Diederik Wj / Niessen, Louis W

Cost effectiveness and resource allocation : C/E

2010 Volume 8, Page(s) 21

Abstract: Background: Economic evaluation of stroke services indicates that such services may lead to improved quality of life at affordable cost. The present study assesses lifetime health impact and cost consequences of stroke in an integrated service setting.!# ...

Abstract	Background: Economic evaluation of stroke services indicates that such services may lead to improved quality of life at affordable cost. The present study assesses lifetime health impact and cost consequences of stroke in an integrated service setting. Methods: The EDISSE study is a prospective non-randomized controlled cluster trial that compared stroke services (n = 151 patients) to usual care (n = 187 patients). Health status and cost trial-data were entered in multi-dimensional stroke life-tables. The tables distinguish four levels of disability which are defined by the modified Rankin scale. Quality-of-life scores (EuroQoL-5D), transition and survival probabilities are based on concurrent Dutch follow-up studies. Outcomes are quality-adjusted life years lived and lifetime medical cost by disability category. An economic analysis compares outcomes from a successful stroke service to usual care, by bootstrapping individual costs and effects data from patients in each arm. Results: Lifetime costs and QALYs after stroke depend on age-of-onset of first-ever stroke. Lifetime QALYs after stroke are 2.42 (90% CI - 0.49 - 2.75) for male patients in usual care and 2.75 (-0.61; 6.26) for females. Lifetime costs for men in the usual care setting are €39,335 (15,951; 79,837) and €42,944 (14,081; 95,944) for women. A comparison with the stroke service results in an ICER of €11,685 saved per QALY gained (€14,211 and €7,745 for men and women respectively). This stroke service is with 90% certainty cost-effective. Conclusions: Our analysis shows the potential of large health benefits and cost savings of stroke services, taking a lifetime perspective, also in other European settings.
Language	English
Publishing date	2010-11-17
Publishing country	England
Document type	Journal Article
ZDB-ID	2119372-1
ISSN	1478-7547 ; 1478-7547
ISSN (online)	1478-7547
ISSN	1478-7547
DOI	10.1186/1478-7547-8-21
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Article: Measuring Quality Improvement in Acute Ischemic Stroke Care: Interrupted Time Series Analysis of Door-to-Needle Time

van Dishoeck, Anne Margreet / Dippel, Diederik W.J. / Dirks, Maaike / Looman, Caspar W.N. / Mackenbach, Johan P. / Steyerberg, Ewout W.

Cerebrovascular Diseases Extra

2014 Volume 4, Issue 2, Page(s) 149–155

Institution	Departments of Public Health and Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
Abstract	Background: In patients with acute ischemic stroke, early treatment with recombinant tissue plasminogen activator (rtPA) improves functional outcome by effectively reducing disability and dependency. Timely thrombolysis, within 1 h, is a vital aspect of acute stroke treatment, and is reflected in the widely used performance indicator ‘door-to-needle time' (DNT). DNT measures the time from the moment the patient enters the emergency department until he/she receives intravenous rtPA. The purpose of the study was to measure quality improvement from the first implementation of thrombolysis in stroke patients in a university hospital in the Netherlands. We further aimed to identify specific interventions that affect DNT. Methods: We included all patients with acute ischemic stroke consecutively admitted to a large university hospital in the Netherlands between January 2006 and December 2012, and focused on those treated with thrombolytic therapy on admission. Data were collected routinely for research purposes and internal quality measurement (the Erasmus Stroke Study). We used a retrospective interrupted time series design to study the trend in DNT, analyzed by means of segmented regression. Results: Between January 2006 and December 2012, 1,703 patients with ischemic stroke were admitted and 262 (17%) were treated with rtPA. Patients treated with thrombolysis were on average 63 years old at the time of the stroke and 52% were male. Mean age (p = 0.58) and sex distribution (p = 0.98) did not change over the years. The proportion treated with thrombolysis increased from 5% in 2006 to 22% in 2012. In 2006, none of the patients were treated within 1 h. In 2012, this had increased to 81%. In a logistic regression analysis, this trend was significant (OR 1.6 per year, CI 1.4-1.8). The median DNT was reduced from 75 min in 2006 to 45 min in 2012 (p < 0.001 in a linear regression model). In this period, a 12% annual decrease in DNT was achieved (CI from 16 to 8%). We could not find a significant association between any specific intervention and the trend in DNT. Conclusion and Implications: The DNT steadily improved from the first implementation of thrombolysis. Specific explanations for this improvement require further study, and may relate to the combined impact of a series of structural and logistic interventions. Our results support the use of performance measures for internal communication. Median DNT should be used on a monthly or quarterly basis to inform all professionals treating stroke patient of their achievements.
Keywords	Acute ischemic stroke ; Acute stroke care ; Door-to-needle time ; Recombinant tissue plasminogen activator ; Performance indicator ; Quality of care ; Quality improvement ; Process indicators
Language	English
Publishing date	2014-06-24
Publisher	S. Karger AG
Publishing place	Basel, Switzerland
Document type	Article
ZDB-ID	2651613-5
ISSN	1664-5456 ; 1664-5456
ISSN (online)	1664-5456
ISSN	1664-5456
DOI	10.1159/000363535
Database	Karger publisher's database

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