Emergency Medicine Pharmacist Impact on Door-to-Needle Time in Patients With Acute Ischemic Stroke

Jacoby, Joshua S.; Draper, Heather; Dumkow, Lisa E.; Farooq, Muhammad Umar; DeYoung, G. Robert; Brandt, Kasey L.

doi:10.1177/1941874417729982

Cited by 19 publications

(31 citation statements)

References 14 publications

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“…Expedited administration of rTPA for AIS remains an ongoing quality improvement initiative for many stroke centers across the country. The utilization of pharmacists in stroke teams has been shown to improve overall DTN administration times, but this is one of the first studies to examine the impact pharmacist have on the guideline specific recommendation of a DTN administration time of less than 60 minutes . Reduction in overall administration times can prove controversial given that the “time is brain” concept is not universally endorsed in the medical community.…”

Section: Discussionmentioning

confidence: 99%

“…Previous literature have shown some of the beneficial impact that including an ED pharmacist into the stroke team can provide . Most of the literature with regard to pharmacist involvement in AIS have been with a reduction in DTN administration times and more accurate dosing of rTPA, without focusing on the overall goal metric of a DTN administration time of 60 minutes or less . Debate will continue as to whether faster administration of rTPA leads to better functional outcomes, but for now, the standard for stroke centers is rapid rTPA administration based on the AHA guideline of a DTN administration time of 60 minutes or less .…”

Section: Introductionmentioning

confidence: 99%

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Effect on door‐to‐needle recombinant tissue plasminogen activator administration times for acute ischemic stroke with and without an emergency department pharmacist

Gilbert

Huffman

2019

J Am Coll Clin Pharm

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Study Objective: A paucity of data exists on the impact emergency department (ED) pharmacists have on a stroke team's door-to-needle (DTN) administration time of recombinant tissue plasminogen activator (rTPA). The purpose of this study was to assess the odds of achieving a DTN administration time for rTPA of 60 minutes or less with an ED pharmacist present.Methods: This was a retrospective, cohort study of patients who received rTPA for acute ischemic stroke (AIS) from May 2017 to May 2018. Patients were included if they were at least 18 years old and received tPA for AIS in the ED. The primary outcome for this study was the likelihood of patients receiving a DTN administration time of 60 minutes or less with or without an ED pharmacist present during a stroke alert at a primary stroke center.Results: The electronic medical record of 184 stroke alert patients was reviewed, and 65 patients were included in the final analysis. Baseline characteristics were similar in all aspects.The odds ratio was 3.3 (95% confidence interval [CI]: 1.1-9.6; P = 0.04) to achieve a DTN administration time of 60 minutes or less when an ED pharmacist was present. The ED pharmacist present group had faster median (47 minutes vs 60 minutes; P = 0.001) and average (49 minutes vs 63 minutes; P = 0.003) DTN administration times compared with the ED pharmacist not present group.Conclusion: An ED pharmacists present during a stroke alert at our faculty resulted in reduced overall DTN rTPA administration times and increased the odds of a patient receiving rTPA less than 60 minutes from arrival for AIS. Further study is required to determine if this finding can be replicated in other EDs. K E Y W O R D Sclinical pharmacist, stroke, thrombolytic

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Effect on door‐to‐needle recombinant tissue plasminogen activator administration times for acute ischemic stroke with and without an emergency department pharmacist

Gilbert

Huffman

2019

J Am Coll Clin Pharm

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“…A retrospective cohort of patients receiving tissue plasminogen activator (tPA) for acute ischemic stroke found a pharmacist's presence at the bedside decreased median door‐to‐needle time by 23.5 minutes . This finding was confirmed by other studies as well . Although no data currently quantify the CA associated with having a pharmacist on the stroke team, a cost‐economic analysis found that delivery of tPA within 3–4.5 hours was associated with $1495 saved per patient compared with no tPA .…”

Section: Results Of Scoping Reviewmentioning

confidence: 82%

“…63 This finding was confirmed by other studies as well. 64,65 Although no data currently quantify the CA associated with having a pharmacist on the stroke team, a cost-economic analysis found that delivery of tPA within 3-4.5 hours was associated with $1495 saved per patient compared with no tPA. 65 Taking into account that pharmacist involvement in stroke care increased the proportion of patients meeting the door-toneedle goal by 42%, CA is estimated at $627.90 per patient.…”

Section: Emergency Code Stroke Participation (Loe Iii)mentioning

confidence: 99%

Scoping Review of Interventions Associated with Cost Avoidance Able to Be Performed in the Intensive Care Unit and Emergency Department

et al. 2019

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A framework for evaluating pharmacists’ impact on cost avoidance in the intensive care unit (ICU) and emergency department (ED) has not been established. This scoping review was registered (CRD42018091217) and conducted to identify, aggregate, and qualitatively describe the highest quality evidence for cost avoidance generated by clinical pharmacists on interventions performed in an ICU or ED. Searches were conducted in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from inception until April 2018. The level of evidence (LOE) for each specific category of intervention was evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation evidence‐to‐decision framework. The risks of bias for articles were evaluated using Newcastle Ottawa and Cochrane Collaboration tools. The values from all interventions were inflated to 2018 U.S. dollars using the consumer price index for medical care. Of the 464 articles initially identified, 371 were excluded and 93 were included. After reviewing references from the articles included, an additional 71 articles were also reviewed. The 38 cost intervention categories were supported by varying LOEs: IA (0 categories), IB (1 category), IIA (4 categories), IIB (0 categories), III (27 categories), and IV (6 categories), and articles mostly displayed low to moderate risks of bias. Pharmacists generate cost avoidance through a variety of interventions in critically and emergently ill patients. The quality of evidence supporting specific cost avoidance values is generally low. Quantification of and factors associated with the cost avoidance generated from pharmacists caring for these patients are of paramount importance.

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“…Improve the people's understanding of the necessity of thrombolysis, time urgency and safety, and fully understand that the benefits of early thrombolysis far outweigh the risks [52,53]. Secondly, at the hospital level, 1) popularize the knowledge of cerebral infarction, improve the awareness of early thrombolytic therapy for patients and medical staff; 2) establish a referral mechanism for network hospitals; 3) open a green channel for thrombolytic therapy in patients with acute ischemic cerebral infarction; 4) train relevant professionals to improve clinical execution; 5) take a door-to-needle time (DNT) thrombolysis management system to shorten or eliminate in-hospital delay time and improve the response rate of thrombolytic therapy [54,55]. Third, in terms of doctors, 1) fully understand the importance of thrombolysis in AIS; 2) quickly identify patients with acute stroke, and grasp the emergency thrombolysis time window, indications and contraindications; 3) for patients with unknown onset time, IP can be determined by imaging; 4) be skilled in arterial thrombolysis and endovascular treatment and other related technologies, and can successfully complete bridging treatment; 5) can have the ability to cope with hemor-rhagic transformation after thrombolysis.…”

Section: Before Thrombolysismentioning

confidence: 99%

Progress in the Treatment of Acute Ischemic Stroke, Current Challenges and the Establishment of Clinical Decision-Making System

Yang¹,

Du²,

Zhang³

et al. 2019

J Neurol Res

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Ischemic stroke often occurs in middle-aged and elderly people, leading to brain tissue ischemia, hypoxia and necrosis. The clinical manifestations are a series of neurological deficits, such as aphasia, hemiplegia and disturbance of consciousness, with high morbidity, mortality, disability rate, recurrence rate and multiple complications. This article aims to review current treatment advances, analyze current challenges and propose coping strategies. The literature on stroke treatment and the latest technological progress were reviewed. Combined with clinical and epidemiological to analyze the current challenges, the coping strategies were proposed before, during and after thrombolysis. Early intravenous thrombolysis and bridging treatment can restore blood perfusion in time and save the ischemic penumbra of brain tissue. However, the current proportion of patients receiving thrombolytic therapy is very low. The main challenges are as follows: easy to miss the time window, door-to-needle time is too long and there is a lack of understanding of the safety and efficacy of thrombolysis, especially the hemorrhagic transformation. A clinical decision-making system is established for stroke rescue by improving the popularization rate of stroke thrombolytic therapy, optimizing the green channel process of stroke and improving the executive ability of clinicians, to shorten the rescue time. Advanced imaging techniques are used to identify potential patients for thrombolysis. Acute intravascular bridge therapy is used to improve the efficacy of thrombolysis. Screening before thrombolysis, timely thrombolytic therapy, reexamination after thrombolysis and active response to hemorrhagic transformation can effectively improve the safety and acceptability of treatment.

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Emergency Medicine Pharmacist Impact on Door-to-Needle Time in Patients With Acute Ischemic Stroke

Abstract: The EMP involvement in initial stroke care was associated with a significant improvement in DTN time.

Cited by 19 publications

References 14 publications

Effect on door‐to‐needle recombinant tissue plasminogen activator administration times for acute ischemic stroke with and without an emergency department pharmacist

Effect on door‐to‐needle recombinant tissue plasminogen activator administration times for acute ischemic stroke with and without an emergency department pharmacist

Scoping Review of Interventions Associated with Cost Avoidance Able to Be Performed in the Intensive Care Unit and Emergency Department

Progress in the Treatment of Acute Ischemic Stroke, Current Challenges and the Establishment of Clinical Decision-Making System

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