Can emergency department physicians safely and effectively initiate thrombolysis for acute ischemic stroke?

Background and Purpose-Thrombolysis for treatment of acute ischemic stroke should be administered as fast as possible after symptom onset. The aim of this study was to examine, in our tertiary care center, the time intervals preceding intra-arterial thrombolysis in order to accelerate and optimize the management of acute strokes. Methods-Between January 1, 2000, and April 30, 2002, 597 patients with acute stroke were admitted to our stroke center.One hundred forty-eight patients underwent diagnostic arteriography, and 100 (16.8%) received intra-arterial thrombolysis. For all patients, we prospectively recorded and analyzed the time of symptom onset, admission, CT and/or MRI scan, diagnostic arteriography, and, if performed, intra-arterial thrombolysis. Results-The mean time to arrival in the emergency department was 99 minutes for patients who were admitted directly (Bern patients), 127 minutes for those who were referred from community hospitals without a CT scanner (non-Bern/ϪCT patients), and 210 minutes for patients from hospitals with imaging facilities (non-Bern/ϩCT patients).The mean delay from symptom onset to treatment was 234 minutes for Bern patients, 269 minutes for non-Bern/ϪCT patients, and 302 minutes for non-Bern/ϩCT patients. The patients from the last group needed longer to receive intra-arterial thrombolysis than did patients who were admitted directly (Pϭ0.002) or who were transferred from a hospital without a CT scanner (Pϭ0.03). Conclusions-This prospective study indicates that direct referral without prior imaging at community hospitals shortens the time until intra-arterial thrombolysis. In addition, our in-hospital delay preceding intra-arterial thrombolysis is longer than the delays reported for intravenous thrombolysis and indicates potential for improvement.

Section: Discussionmentioning

confidence: 99%

Pre- and In-Hospital Delays From Stroke Onset to Intra-arterial Thrombolysis

Nedeltchev

Arnold

Brekenfeld

et al. 2003

“…Although emergency physicians exhibit high sensitivity and positive predictive value in identifying patients with stroke, 110,111 only 6 studies [112][113][114][115][116][117] have identified instances of fibrinolytic delivery in the setting of acute stroke by an emergency or primary care physician (either alone or in telephone consultation with a neurologist). The number of patients treated by nonneurologists in these studies was small, ranging from 6 to 53.…”

Section: Access To Neurological Expertisementioning

confidence: 99%

Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Jauch¹,

Saver²,

Adams³

et al. 2013

5,374

1,801

Background and Purpose-The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. Methods-Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. Results-The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. Guidelines for the Early Management of PatientsThis statement was approved by the American Heart Association Science Advisory and Coordinating Committee on December 12, 2012. A copy of the document is available at http://my.americanheart.org/statements by selecting either the "By Topic" link or the "By Publication Date" link. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.The Executive Summary is available as an online-only Data Supplement with this article at http://stroke.ahajournals.org/lookup/suppl/ doi:10.1161/STR.0b013e318284056a/-/DC1.The American Heart Association requests that this document be cited as follows: Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; on behalf of the American Heart Association Stroke Council, Council on Cardio...

“…31,32 Others have shown that lowering of hemorrhage rates can be achieved with significant educational support, quality monitoring, and experience. 16,[33][34][35][36] Our study suggests that tPA administration is safe in community settings, although efficacy and outcome postthrombolysis were not measured.…”

Section: Wojner-alexandrov Et Al Hopsto Studymentioning

confidence: 99%

Houston Paramedic and Emergency Stroke Treatment and Outcomes Study (HoPSTO)

Wojner-Alexandrov

Alexandrov

Rodriguez

et al. 2005

207

175

Background and Purpose-Establishment of stroke centers, combined with accurate paramedic diagnosis and rapid transport, is essential to deliver acute stroke therapy. We wanted to measure and improve paramedic and hospital performance through implementation of the Brain Attack Coalition and American Stroke Association guidelines. Methods-Pre-intervention and active-intervention phases with parallel data measurement points were used. The study involved six hospitals comprising the majority of acute-stroke admissions in Houston, Tex. Hospital, paramedic, and patient data were collected prospectively pre-intervention and during the active-intervention phase on all suspected acute-stroke patients admitted by Houston Fire Department-Emergency Medical Services. A multilevel educational intervention included paramedic, hospital, and community education. Paramedic diagnostic accuracy, hospitalperformance efficiency, and thrombolytic treatment rates were the main outcome measures of the study. Results-Four hundred forty-six patients (74 per month) were transported in the pre-intervention phase to participating hospitals (59.8% of all suspected stroke patients transported city wide by Houston Fire Department-Emergency Medical Services), compared with 1072 patients (89 per month, or 68.7%) transported in the active-intervention phase (PϽ0.001). Accuracy of paramedic diagnosis of stroke increased from 61% to 79%. Admission within 2 hours of symptom onset increased from 58% to 62% (Pϭ0.002). Thrombolysis rates increased in 4 of 6 centers, with 1 posttissue plasminogen activator hemorrhage (3.7%) reported. Conclusions-A multilevel educational program improves rapid hospitalization and paramedic diagnostic accuracy and increases the number of patients presenting for evaluation within the 3-hour tissue plasminogen activator window.