Good is not Good Enough: The Benchmark Stroke Door-to-Needle Time Should be 30 Minutes

The importance of treating ischemic stroke patients quickly has long been recognized, and the mantra "Time is brain", is now ubiquitous.1,2 Unfortunately, the thinking "We still have time in the treatment window..." is occurring too often during the acute stroke code. The treatment window from time of onset is 4.5 hours[3] in most guidelines,[4,5] yet there is declining benefit as time elapses. A 1997 National Institute of Neurological Disorders and Stroke (NINDS) Symposium and the subsequent Brain Attack Coalition[6] set the standard of 60 minute door-to-needle time.7 This door-to-needle time was arbitrary but designed to provide a useful metric. It has now been incorporated into both national guidelines and accreditation standards[8-10] but has been treated more like a guide or a range rather than a hard target. Parkinson's law - "The job expands to fit the time available" - is as true in stroke care as it is in economics.11 We argue that to change this mentality we must revise our target downward to a 30-minute median door-to-needle time.