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Every day you may make progress. Every step may be fruitful. Yet there will stretch out before you an ever-lengthening, ever-ascending and ever-improving path. You know you will never get to the end of the journey. But this, so far from discouraging, only adds to the joy and glory of the climb.

Winston Churchill (1874–1965)

Organized Stroke care and delivery of health services in a timely manner is a challenge worldwide [1,2]. New therapeutic opportunities are available for patients with ischaemic stroke [3,4]. However, it requires the multilevel coordination of different services/health care providers [from emergency medical and transportation services (EMS) system to emergency physicians and CT technicians].

In the present article, Kim [5] examined the relationship between pre-hospital notification and processes of recombinant Alteplase (t-PA) administration/stroke outcomes. They compared time with t-PA delivery between pre- (n = 44) versus post-notification (n = 47) (table 1 Kim [5]) approach. They also evaluated stroke patients treated with (n = 30) and without (n = 61) (table 2 Kim [5]) pre-hospital notification policy. They found an increased iv t-PA rate from 6.5% to 14.3% after the implementation of the notification system. Door-to-needle time was significantly reduced in the pre-notification group. No significant differences in stroke outcomes were observed [5].

What are the limitations of the present article?

  1. Top of page
  2. What are the limitations of the present article?
  3. What have we learned?
  4. Where are we going?
  5. Acknowledgement
  6. References

Readers are to be cautioned when interpreting the results of this study. First, this is a single centre study. Second, the sample size is small. Third, the role of confounding also needs to be considered. For example, interhospital transfers were not reported. It is well-known that t-PA administration is longer for patients transferred from other institutions. This is probably the explanation for longer time from symptoms onset reported for patients with notification 121.5 min vs. 74.7 min; P < 0.01). It is not surprising, the lack of differences in stroke outcomes (disability at 90 days), considering the study was not powered to detect a difference between groups.

What have we learned?

  1. Top of page
  2. What are the limitations of the present article?
  3. What have we learned?
  4. Where are we going?
  5. Acknowledgement
  6. References

Briefly, the understanding of two concepts as background information may help put this into perspective. First, the use of deadlines (known as ‘deadline’ tactic in marketing) is an effective way in achieving a desired result. For example, students are usually more compliant when given a deadline for their assignments than leaving it to their own discretion. This is also known as the ‘Student syndrome.’ When they have more than enough time to complete the task, students start the task late, consuming all the ‘safety time’ they had. It is the extra time that has the opposite effect – guaranteeing the task will run full term or late [6]. Second, the fear of missing a short-time available ‘good’ option/offer (perceived by customers as a potential lost opportunity) has served different companies to sell products either more quickly or make them more profit.

The underlying principle is that people seem to be more motivated by the thought of losing something than by the thought of gaining something of similar value [7]. This is not unique to marketing. Some of these principles could be applied to stroke care. As known, the higher the organization of the health system/delivery of stroke care, the better the outcomes (measured as the number of stroke patients with access to thrombolysis, shorter door-to-needle times, etc). In my personal view, an important take home message from Kim’s [5] article is given by the fact that door-to-needle time was significantly shorter when the 3 h time window was closer. This may highlight an interesting aspect in human nature – we seem to work faster under time pressure. The fear of missing a unique opportunity to contribute to a meaningful clinical recovery when just a few minutes are left may explain these results. This is even more relevant with the results of the European Cooperative Acute Stroke Study (ECASS) 3 trial following the pooled analysis of t-PA trials that confirmed benefit when extended up to 4.5 h from symptoms onset [8,9]. Therefore, we may observe an absolute higher number of patients receiving thrombolytic therapy after an acute ischaemic stroke. However, if the finding reported by Kim [5] is proven true, it is possible that the increasing number patients receiving thrombolytic therapy would be accompanied by a longer door-to-needle time just because some colleagues may erroneously feel they have ‘more time’ under the newly accepted time window of 4.5 h (similar to the ‘safety time’ described for the student syndrome).

Where are we going?

  1. Top of page
  2. What are the limitations of the present article?
  3. What have we learned?
  4. Where are we going?
  5. Acknowledgement
  6. References

Different strategies can be implemented to proactively engage the public in managing vascular risk factors, optimizing awareness of the signs and symptoms of stroke and improving access to thrombolytic therapy. Now, it is our turn to contribute to improve the internal processes of acute stroke care. The nihilistic era of ischaemic stroke care has ended. It requires not only our expertise but also our commitment. Time is brain and brain is efficient time management of in-hospital resources and services. Paraphrasing Benjamin Franklin: ‘Lost time is never found again’.

Acknowledgement

  1. Top of page
  2. What are the limitations of the present article?
  3. What have we learned?
  4. Where are we going?
  5. Acknowledgement
  6. References

Dr. Saposnik appreciates the feedback provided by Dr. Neville Bayer.

References

  1. Top of page
  2. What are the limitations of the present article?
  3. What have we learned?
  4. Where are we going?
  5. Acknowledgement
  6. References