Standard of Care for tPA for Stroke Has Evolved
Although some ED physicians remain opposed to the idea of using tPA, the consideration of the use of thrombolytics such as tPA for stroke patients who are eligible candidates has become the public expectation.
"Two years ago, you could argue whether this is the right or wrong thing to do, but now that argument is pretty much behind us," says John Burton, MD, chair of the Department of Emergency Medicine at Carilion Clinic in Roanoke, VA. "People will be held to a standard that pretty much dictates that if the patient meets the treatment criteria, considering this is the right thing to do."
However, Robert B. Takla, MD, MBA, FACEP, chief of the Emergency Center at St. John Hospital and Medical Center in Detroit, MI, says, "As ED doctors, we don't see the long-term benefitwe see the immediate catastrophic effect. A lot of us will question the studies, but the current standard of care is to provide the lytic therapy option for a subset of patients who present with a stroke."
Whether science supports this practiceand some ED physicians strongly feel that it does notis a separate issue. "For ten years we have argued that the science just doesn't support treatment with tPA. But it is increasingly becoming the standard of care that you consider therapy," says Burton. "Protocols for CTs and stroke assessments and evaluations are old hat. EDs have moved beyond that."
The evolution of ED stroke care is very different from the "time is muscle" approach now taken with heart attack patients in the ED, adds Burton. "With heart attack, ED physicians could at least see that there was science and evidence that this is something that would make a difference every single time," he says.
In contrast, some ED physicians are very disappointed at the evidence that tPA translates into scientifically proven differences in outcomes. "It's easy for them to get caught up in that disappointment, but they should not," says Burton. "We all need to realize that there is a certain standard of care and processes that have evolved."
Matthew Rice, MD, JD, FACEP, an ED physician with Northwest Emergency Physicians of TEAMHealth in Federal Way, WA, says that the best way to approach this dilemma, medicolegally, is for ED physicians to think through how they are going to evaluate stroke patients. Then, patients must be informed of their options to either receive, or not receive, the drug.
"Have the patient and family participate as to whether they want to accept the risk," says Rice. "Then, document in the chart the decision-making process and what the patient and family have chosen to do. "
While tPA is still not universally considered as standard of care, says Hartmut Gross, MD, a professor of emergency medicine at Medical College of Georgia in Augusta, if your hospital has protocols in place you have now made it standard of care in your institution and will have to comply with those guidelines.
"It used to be that standard of care was determined on the local level, but now with access to information on the Internet, there is no reason to limit it to locality anymore," says Gross. "By the same token, if you don't have certain resources or certain levels of expertise available, you shouldn't be held to the same standard as another facility with a whole stroke team in place to expedite care."
Having a neurologist at the bedside in the ED as one would do at a stroke center, is just not realistic or even possible in a small, community ED. "However, even the small community ED would be held to a standard of having an assessment and treatment protocol/process in place for the stroke patient," says Burton. "This would include consideration for the timely administration of tPA."
In a stroke center, the protocol may well dictate that the decision will be made by a neurologist, either in direct consultation or physically present. "In the latter, the community ED, the decision will more often than not rest with the emergency physician at the bedside, unless there has been some prearranged process for neurology consultation at a distance," says Burton.
Although some ED physicians remain opposed to the idea of using tPA, the consideration of the use of thrombolytics such as tPA for stroke patients who are eligible candidates has become the public expectationYou have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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