Acute ischemic stroke is a neurological emergency in which early restoration of cerebral blood flow determines the extent of salvageable brain tissue and subsequent functional recovery. Intravenous thrombolysis has remained a cornerstone of reperfusion treatment for eligible patients, with benefit demonstrated in the original National Institute of Neurological Disorders and Stroke trial and subsequent randomized evidence supporting treatment within accepted therapeutic windows [2,3]. Contemporary stroke guidelines emphasize that eligible patients should receive intravenous thrombolytic therapy as early as possible after arrival, following rapid clinical assessment and exclusion of intracranial haemorrhage by neuroimaging [1].

The biological basis for urgent treatment is reflected in the concept of ‘time is brain’. Quantitative modelling has shown that neuronal, synaptic and myelinated fibre loss progresses rapidly during untreated large-vessel ischemic stroke, reinforcing the need for coordinated emergency response [5]. Meta-analytic evidence further demonstrates that shorter treatment delay is associated with greater benefit from alteplase across clinically relevant age and severity groups [4]. Therefore, the interval from hospital arrival to initiation of thrombolytic therapy, commonly termed door-to-needle time, has become a measurable indicator of acute stroke care quality.

Door-to-needle performance is influenced by multiple linked processes, including recognition at triage, activation of the stroke team, neurological assessment, point-of-care glucose testing, blood pressure control, rapid computed tomography, interpretation of imaging, consent or shared decision-making, drug preparation and bedside administration. The American Heart Association/American Stroke Association Target: Stroke initiative highlighted several practical strategies for improving door-to-needle time, including emergency medical service prenotification, single-call stroke team activation, rapid brain imaging, standard protocols, premixing or early preparation of thrombolytic agents and real-time data feedback [6]. Large registry analyses have shown that improvements in door-to-needle time are associated with better clinical outcomes, supporting door-to-needle monitoring as both a quality metric and a patient-centred intervention [7,8].

Despite clear treatment targets, achieving timely thrombolysis remains difficult in many emergency departments. Barriers include delayed patient arrival, incomplete prehospital notification, limited imaging prioritization, uncertainty regarding eligibility, uncontrolled blood pressure, laboratory-related delays and attendant decision-making. Indian reports also indicate that thrombolysis workflows often require further streamlining even in tertiary care settings [12,13]. Department-level audits are useful because they identify site-specific delays that can be corrected through protocol modification, staff training and multidisciplinary coordination.

The present study was conducted to evaluate door-to-needle time among acute ischemic stroke patients presenting to the Emergency Department of KIMS Saveera Hospital, Anantapur. The objectives were to describe baseline demographic and clinical characteristics, assess major stroke workflow intervals, determine the proportion of patients achieving door-to-needle time of ≤60 minutes, identify factors associated with thrombolysis delay and document early neurological and in-hospital outcomes.

Study design and setting: This hospital-based observational study was conducted in the Department of Emergency Medicine, KIMS Saveera Hospital, Anantapur, Andhra Pradesh, India, over a 12-month period from March 2025 to February 2026. The study evaluated emergency department workflow among patients with acute ischemic stroke who underwent intravenous thrombolysis. Study population: The study included 100 consecutive patients diagnosed with acute ischemic stroke who presented within the thrombolysis-eligible time window and received intravenous thrombolytic therapy after standard clinical and radiological evaluation. Patients were included when clinical features were consistent with acute ischemic stroke, non-contrast computed tomography excluded intracranial haemorrhage, and treatment eligibility was confirmed according to institutional stroke protocol based on accepted guideline recommendations [1,3]. Patients with intracranial haemorrhage, stroke mimics, incomplete time records, contraindications to thrombolysis, or non-thrombolysed ischemic stroke were excluded from analysis. Study size: The sample size was calculated using the formula n = Z²p(1-p)/d². Considering an expected proportion of 50% for achieving door-to-needle time within 60 minutes, 95% confidence level and 10% absolute precision, the minimum required sample size was 96. This was rounded to 100 patients to improve completeness and allow practical analysis of workflow intervals. Data collection and variables: Data were collected using a structured case record form. Baseline variables included age, sex, vascular risk factors, previous stroke or transient ischemic attack, and baseline National Institutes of Health Stroke Scale score. NIHSS documented initial stroke severity [14]. Workflow variables included onset-to-door time, door-to-physician assessment time, door-to-CT initiation time, CT completion-to-reporting time, CT-to-needle time and overall door-to-needle time. Door-to-needle time was defined as the interval between emergency department arrival and initiation of intravenous thrombolytic bolus or infusion. Outcome measures: The primary outcome was the proportion of patients achieving door-to-needle time of ≤60 minutes, consistent with widely used stroke care quality benchmarks [1,6]. Secondary outcomes included distribution of door-to-needle time categories, delay-related factors, early neurological improvement, functional independence at discharge, symptomatic intracranial haemorrhage, discharge status and in-hospital mortality. Bias control: Potential selection bias was minimized by consecutive inclusion of all eligible thrombolysed patients during the study period. Information bias was reduced by using predefined time points from emergency department records, imaging logs and treatment charts. Observer variation in neurological assessment was limited by use of the standardized NIHSS format. Missing or inconsistent time documentation was checked against source records before final analysis. Statistical analysis: Data were analyzed using descriptive statistics. Continuous variables were expressed as mean with standard deviation or median with interquartile range, depending on distribution. Categorical variables were presented as frequency and percentage. Patients were descriptively grouped according to door-to-needle time ≤60 minutes and >60 minutes to compare workflow delay factors. Ethical considerations: The study was conducted after approval from the Institutional Ethics Committee. Patient confidentiality was maintained by anonymizing clinical data before analysis. No intervention beyond standard institutional management was performed. Informed consent was obtained wherever applicable according to institutional policy.

A total of 100 patients with acute ischemic stroke presenting to the Emergency Department and receiving intravenous thrombolysis were included in the study. The mean age of the study population was 61.8 ± 12.4 years. Most patients were aged ≥60 years, and males constituted 62.0% of the sample. Hypertension was the most common vascular risk factor, followed by diabetes mellitus, dyslipidaemia, smoking and atrial fibrillation. The mean baseline NIHSS score was 12.6 ± 4.1, indicating moderate stroke severity at presentation. The baseline demographic and clinical profile is shown in Table 1.

Table 1. Baseline demographic and clinical characteristics of the study population

The median onset-to-door time was 130 minutes, while the median door-to-physician assessment time was 8 minutes. The median door-to-CT initiation time was 24 minutes, and the median CT-to-needle time was 28 minutes. The overall median door-to-needle time was 58 minutes. Door-to-needle time of ≤60 minutes was achieved in 56 patients, whereas 44 patients had door-to-needle time of >60 minutes. The distribution of stroke workflow intervals is presented in Table 2.

Table 2. Time intervals in acute stroke workflow

Among the study participants, 56.0% received thrombolysis within the recommended door-to-needle target of ≤60 minutes. A door-to-needle time of ≤45 minutes was achieved in 24.0% of patients, while 20.0% had door-to-needle time between 61 and 75 minutes. Door-to-needle time exceeded 90 minutes in 10.0% of patients. The categorical distribution of door-to-needle time is shown in Table 3.

Table 3. Distribution of door-to-needle time among thrombolysed patients

Patients who achieved door-to-needle time ≤60 minutes had a lower median door-to-CT time and shorter CT-to-needle interval compared with those who had delayed thrombolysis. The most common reasons for delay were delayed neuroimaging, uncontrolled blood pressure requiring stabilization, delayed laboratory clearance and delay in consent or decision-making by attendants. Off-hour presentation was also more frequent among patients with door-to-needle time >60 minutes, as shown in Table 4.

Table 4. Factors associated with door-to-needle delay

Clinical improvement was assessed using NIHSS score at 24 hours and at discharge. The mean NIHSS score decreased from 12.6 ± 4.1 at admission to 9.1 ± 4.8 at 24 hours and 7.4 ± 5.0 at discharge. Functional independence at discharge, defined as modified Rankin Scale score of 0–2, was observed in 42.0% of patients. Symptomatic intracranial haemorrhage occurred in 4.0% of patients. The in-hospital mortality rate was 8.0%. Patients treated within 60 minutes had better early neurological improvement and lower mortality than those with delayed door-to-needle time. Clinical outcomes are summarized in Table 5.

Table 5. Clinical outcomes of the study population

Figure 1: Clinical Outcomes of Study Population

Overall, the study showed that slightly more than half of acute ischemic stroke patients received thrombolysis within the recommended door-to-needle time of 60 minutes. Delays were mainly related to neuroimaging workflow, blood pressure stabilization, laboratory processing, consent-related factors and off-hour presentation. Shorter door-to-needle time was associated with better early neurological improvement and more favourable discharge outcomes.

The present observational study evaluated door-to-needle time among 100 thrombolysed acute ischemic stroke patients presenting to the Emergency Department. The median door-to-needle time was 58 minutes, and 56.0% of patients achieved treatment within 60 minutes. This finding indicates that the department reached the initial Target: Stroke benchmark of treating at least half of eligible patients within 60 minutes, but it also shows that a substantial proportion continued to experience avoidable in-hospital delay [6]. Current guideline-driven stroke systems emphasize that every eligible patient should move rapidly from recognition to imaging and thrombolysis because treatment benefit declines with time [1,4].

The observed median door-to-CT time of 24 minutes was close to recommended rapid imaging expectations, yet delayed neuroimaging remained an important contributor among patients with door-to-needle time above 60 minutes. International registry data have shown that reducing door-to-needle time improves discharge outcomes and mortality profiles after thrombolysis [7,8]. A later JAMA analysis also demonstrated that longer door-to-needle time was associated with higher one-year mortality and readmission, emphasizing that in-hospital delay has consequences beyond the index admission [10]. In the present study, patients treated within 60 minutes showed better early neurological improvement and lower mortality than those with delayed treatment, supporting the clinical relevance of maintaining efficient emergency stroke pathways.

Several operational barriers were identified. Off-hour presentation was more frequent in the delayed group, suggesting that staffing patterns, imaging readiness and specialist availability influence workflow. Referred patients also had longer delays, possibly due to incomplete referral documentation, repeat assessment, uncertainty regarding exact onset time, or the need to re-establish eligibility. Blood pressure control was another common cause of delay, which is expected because uncontrolled hypertension requires stabilization before thrombolysis. Consent-related delay remained clinically relevant, highlighting the need for simple counselling scripts, early family engagement and clear explanation of benefit-risk balance.

Indian studies have reported that thrombolysis workflows often fall short of ideal targets because of delays in recognition, imaging, decision-making and treatment initiation [12,13]. The findings of this study are therefore consistent with the wider challenge of implementing time-sensitive stroke care in busy emergency settings. A mobile application-based Indian strategy improved door-to-needle performance by improving team communication and workflow visibility, suggesting that digital alerts, predefined roles and parallel processing can be effective in comparable settings [13]. Narrative reviews also support prenotification, direct transfer to CT, point-of-care testing, treatment in the imaging area and regular audit-feedback cycles as practical measures to shorten door-to-needle time [11].

The study reinforces the need for a protocol-driven stroke pathway at the emergency department level. A single-call stroke activation system, triage-based pre-alert, direct-to-CT movement, rapid blood pressure protocol, early thrombolytic preparation, reduced dependence on nonessential laboratory results and continuous staff training can further improve performance. Continuous monitoring of door-to-CT, CT-to-needle and total door-to-needle intervals will help identify whether future delays are patient-related, imaging-related, decision-related, or drug-administration-related.

Limitations

This single-centre study included only 100 thrombolysed patients, limiting broader generalization. Non-thrombolysed ischemic stroke patients were not analyzed, so pre-treatment exclusion patterns were not captured. Long-term post-discharge functional outcomes were unavailable. Delay factors were derived from routine hospital records, and their accuracy depended on complete emergency time documentation during a busy workflow. Multivariable analysis was not performed because only descriptive data were available.

This observational study showed that 56.0% of acute ischemic stroke patients receiving intravenous thrombolysis achieved a door-to-needle time of ≤60 minutes, with an overall median door-to-needle time of 58 minutes. Delays were mainly linked to neuroimaging workflow, blood pressure stabilization, laboratory processing, consent-related issues and off-hour presentation. Patients treated within the target window showed better early neurological improvement and more favourable discharge outcomes. Regular audit of stroke workflow, direct-to-CT protocols, rapid team activation, early thrombolytic preparation and continuous emergency staff training are essential to improve reperfusion timelines and strengthen acute stroke care quality in emergency departments. These measures can improve treatment consistency across duty shifts and referral pathways locally.

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